Saiqa Mullick[1] is a senior associate with the Population Council's Reproductive Health program. She coordinates operations research on reproductive tract infections (RTIs) and the integration of HIV and AIDS into reproductive health services in east and southern Africa. Mullick is currently participating in the development of two World Health Organization (WHO) global strategies: control of sexually transmitted infections and elimination of congenital syphilis. She was also a core team member in the development of evidence-based WHO guidelines for the integration of RTIs into reproductive health.

MM: We did the HIV and FP integration project in the Northwest Province of South Africa. It’s a two-phase project; in phase 1 we’re looking at the feasibility, acceptability, and cost of the model of participating in integration of services. This phase has been completed, and from that we determined it is possible to integrate. The information from the providers and the department of health actually informs phase 2, the effectiveness of the first phase model of integrating. 

 

In phase 1, a provider would offer Voluntary Counseling and Testing (VCT) and either refer a client to a counselor for testing or maybe do the testing themselves. The outcome from this project was that actually it depends on the setting, and it is advisable that it should be client driven. So in the best model we are looking at doing just that, depending on the setting but in the same possibility both options should be available to the client and the client should be given a choice. The whole thing is directed by the client’s’ choice. The choice of either you as the provider testing the client, or you as a provider, referring. You counsel, you offer the VCT, then the client actually guides you whether he/she wants you to test or if she wants to be referred to a facility which could be on site or a referral to outside.

 

SM: In both instances, these are FP clients, both new and repeat clients that we’re talking about. Many of the clients in South Africa are on hormonal contraception. They’re coming every 2 or 3 months. The model would be that you as a FP provider would be having a discussion of HIV risk and serostatus and offering VCT. So it would be a routine provider-initiated offer of testing. It would then be up to you. So where the difference is that whether you as a FP client would want your FP provider testing you or whether you would have that person refer you to an onsite or another facility to be tested by someone else, and in most instances that would be a lay counselor at another facility or at the same facility.

 

 

SM: It was USAID funded and PEPFAR funded through the South Africa USAID mission, although there was a considerable time contribution from staff at the Department of Health. In fact, staff from the Department of Health were often involved in the training and conducting a number of sessions in the training on the policies and the strategic direction of the department. It was a considerable time contribution from the Department of Health. 

 

SM: Phase 1 began at the end of 2004. Phase 1 is completed particularly looking at acceptability, feasibility and cost. The baseline has been done, the intervention is actually in place, and we’re hoping to evaluate that and to follow up the same clients very shortly. We’re about to go out for training field workers in the next couple of weeks. So in the next few months we should have the results of the effectiveness evaluation.

 

 

SM: We know that FP services are the most highly utilized public sector service in South Africa and we know that many women are on hormonal contraception, so they’re actually visiting these facilities every few months. And we also know from other isolated research data that the prevalence of STIs, including HIV, are relatively high in FP populations. So given the high prevalence of HIV and the high utilization of FP services, it was really felt that it would be a good opportunity or that there was a rationale to really integrate the two services. We discussed this with the National Department of Health which has a policy supporting integrated care, but I think that there existed an issue with the policy. How to implement that or what would be a good way to implement the policy was the issue. And so it was discussed with the National Department of Health.

 

SM: Initially it was the National Department of Health, but when you’re working in facilities, you have to work from national through the provincial structures and then with the facility managers and with the various programs involved. We worked with both the Maternal and Child (MC) and Women’s Health directorate as well as the VCT program, and we’ve also been involving or informing other relevant directorates. Phase 1 was mainly working with government. Phase 2 has been more linking up with others. A lot of the vertical services in the province where we were working were actually contracted out to an NGO by the Department of Health, so we were in communication with them throughout that process.

 

 

MM: The community that was involved were the clients. We conducted the focus group discussions with the providers and the clients, and the implementation itself happened through the community. Initially the service providers were involved in Phase 1, and then we were looking at the gaps that came out. The client is still in contact with a person for information, like a lay counselor. We included lay counselors in our training and service providers as well.

 

 

SM: Not in 2004, but now there’s a lot more talk about integrated services. Part of the training was really aimed at presenting a rationale on why one would want to integrate services and providing clients with tools or integration. These are FP providers and some of them had some HIV-related training or they had certainly MC and Women’s Health/FP training. But when you do those trainings in one block and then another block, it still doesn’t actually get to the issue of how you integrate. You may not have the knowledge, but you need the tools and rationale on why you would want to provide those services at the same time or why it would make sense. There’s a lot more talk about integration. Other people are a lot more interested in it. A lot more motivation as well, compared to a couple of years ago.

 

 

MM: I think the providers are supportive but they need continued support. Obviously in the facilities they have challenges. In South Africa we have a crisis of staff; we have a staff shortage.   We try to make sure the providers are trained. We have identified some champions in the facilities who monitor and evaluate and give us feedback and they serve as a means, and there will be ownership. They know that we are there for them and currently we are in contact with them. We telephone them weekly. We are trying to make sure there is ownership. There are a lot of staff rotations, and there will be spillage of that information. They just need to be supported.

 

 

SM: A tool was developed, which was an adaptation of a tool called the Balanced Counseling Strategy (BCS), which we’re calling the Balanced Counseling Strategy Plus which is really a tool to help FP providers integrate HIV into the FP services. The BCS tool was initially designed by the FRONTIERS project [Population Council] as a tool to help standardize FP consultations, and it was tested in Peru and Guatemala, and found to be effective in improving the quality of care in FP consultations. It had already been validated in Latin America, but it didn’t have an HIV or STI component. And therefore we adapted it further to be used in a high HIV and STI prevalent setting and we used it in both Kenya as well as South Africa. We recently found that there were some components that were very similar across the two countries, but then of course there’s also a discussion with the Department of Health and with what the local needs. We incorporated components in the training for South Africa that we might have not done for Kenya, and vice versa. But there seemed to be some areas of commonality. 

 

 

SM: The training in South Africa was a four-day training and in Kenya it was a nine-day training. The initial round of training was the formal four days, and it was targeted at mainly professional nurses and there were some enrolled nurses as well. They didn’t perform as well on the pre- and post-tests as the professional nurses. The professional nurses would be mainly the ones who are actually providing the FP services, but of course in situations in which clinics are short staffed, enrolled nurses are also involved in providing FP services. There was a need for follow-up and even now in the second phase of training, there has been a need for follow-up training. Everybody in the facility can’t come out and participate in the training, and it is important to make sure that everyone, including the managers, are exposed to some training. The support has been very useful. What we learned from phase 1 was that we should have also involved lay counselors and health informatics people in the training which we have done now in the phase 2. And despite the shortages, many of the professional nurses were very keen to know how to interpret a rapid test even if they had a lay counselor conducting these at their facilities. So we actually provided that training for all of them and even the lay counselors. They obviously are a different cadre of staff and they expressed a need to be exposed to some training on reproductive health. 

 

 

SM: There was, and we are finalizing that report. It should be out very shortly. We did conduct focus group discussions with both clients and providers, pre- and post- intervention, and we also conducted client-provider observation to look at quality of care issues and also client exit interviews, both pre- and post-intervention. I think there were some significant improvements in terms of quality of care. Of course, since it was a cross-sectional study, pre and post for phase 1, we weren’t following up the same individuals so it has some limitations but some of those were to be addressed in phase 2. We’re looking at effectiveness and possibly following up a cohort of clients, both pre- and post-intervention. The Kenya study showed similar findings in the quality of care. They did a longer training, and the quality of care improved significantly across the board, not only in terms of the HIV-related issues but also in the quality of FP.

 

 

SM: We should have that completed by March 2008. As part of the second phase of funding, in addition to completing the evaluation, we have begun to have discussions about scaling up and how we could support two other provinces, so we’re hoping to engage two new provinces because much of this work has been in the Northwest province. But we’ve been requested to begin to work with two more provinces so we would be scaling up to twelve other clinics in two additional provinces. And the funding for that would run out at the end of September 2008.

 

MM: Yes, definitely.

MM: It is an idea that we  considered. We recently had a meeting with our Department of Health onthe idea of integrating antiretroviral therapy (ART) into family planning. And they actually acknowledged that on the ART side, the idea was to make sure that a client gets a comprehensive HIV care management and treatment, and they  are not really being focused on reproductive health. And they know that reproductive health issues are really not talked about, because we had initially said that we need to do a situational analysis. 

 

SM: We’ve got a couple of activities. We have one project on sexual assault which really is integration of HIV and reproductive health, in terms of the medical management of a survivor of sexual assault. We have developed a rural, nurse-driven model which would provide the testing, the ART starter pack, and the 28-day treatment if required and also prophylaxis for STI as well as emergency contraception. And the other activity we’re working with, again with the provincial department of health, in a province called Kwasinudal, at the policy and guideline level is to really look at how many antenatal and postnatal guidelines can be updated to be evidence based and also look at the different aspects of care required. Also, I have two colleagues in Kenya who are working on the HIV/FP integration side and one who’s been working in Lesotho and Swaziland, again on HIV and reproductive health integration but particularly looking at a postpartum intervention, and prevention of MCT. We’ll have reports very shortly.

 

MM: Some of the challenges occur especially in phase 2. There was a public sector strike in South Africa for two months and that deterred our program completely. There have been other priorities and people couldn’t get out for training, which pushed our intervention further. Generally there has been a shortage of staff as well. You might have good people who are trained and willing and able but they often don’t last.

MM: Integrating HIV into reproductive health is feasible and it is accessible. It is important to make sure that it is sustainable and it supports your providers and they see you. The take of the department of health of South Africa is that you do an intervention and you leave us with something. So make sure it is sustainable and applicable. What you do in Northwest, you can do in any other province. Make sure it impacts positively in program implementation as well. It is definitely feasible and accessible and effective as well. The feedback that you get from the clients is also very important.

 

SM: Also, when designing interventions forintegration, don’t assume that after training the providers can automatically integrate these two aspects when they’re faced with a client. There is a real need for tools to help facilitate that. The other issue is flexibility. You may have the same concept which might get implemented differently in one facility compared to another. Client flow may be higher or lower in a particular day. Providers may oscillate from one model to another. One size doesn’t fit all. In terms of making models of integration flexible, that would be a lesson learned.

SM: Just to mention that the integration model evolved as well. We’re now already working on the third phase of that, which is linking up with the ART side in the areas where we weren’t. Yes, you can provide VCT. CD4 counts are very low by the time people are initiating treatment, so we’re trying to link up with the sites and see what’s being discussed in terms of reproductive intentions and trying to improve continuity of care so that we don’t lose people once they’ve tested positive. And also we want to see how to increase the spectrum from HIV prevention and testing to really providing more care and monitoring for both HIV-positive individuals and those of unknown status, as well as those who are on ART, and to also keep those who are negative and offer retesting. We’re actually in that phase of refining the intervention further, and I think the model will keep evolving for a while. 

 

MM: We are also aiming to link those who are positive but not on treatment, with other services other than ART.

Saiqa Mullick
Population Council
PO Box 411744
Craighall 2024
Johannesburg, South Africa
+27 11 438 4400/7200