Mantshi Menziwa is a senior program officer with the Population Council's Reproductive Health (RH) program. She implements, initiates and researches various components of RH ensuring that all the technical activities are implemented in a timely manner within the budget, provide technical and training support to beneficiaries and liaise with donors and government agencies. Menziwa has worked as Assistant Director of Medical Services for the National Department of Health in South Africa, where she focused on policy development, training, monitoring and evaluation for the integration of HIV/AIDS services with women's health care.  A nurse by profession, Ms. Menziwa has provided reproductive health services, antenatal and postnatal care, Family Planning (FP), Prevention of Mother-to-Child Transmission (PMTCT) care, mental health care as well as other health services in several hospitals and health centres in South Africa. She currently serves on the South to South Technical Assistance Team on Sexual and Gender Based Violence (SGBV).

 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. She was a core team member in the development of evidence- based WHO guidelines for the integration of RTIs into Reproductive health services. Mullick currently oversees the development, implementation and monitoring of the Population Councils Reproductive Health and HIV and AIDS research agenda for South Africa. A medical doctor by profession Mullick has been involved both in the provision as well as the monitoring and evaluation and strengthening of reproductive health services in the Africa region. Prior to joining the Population Council Mullick was the Deputy Director of the Reproductive Health and HIV Research Unit in Durban.  

The HIV/SRH Integration site interviewed Mantshi and Saiqa about Population Council's provision of integrated services in South Africa.

Can you give us a brief introduction to the project you're going to be speaking about, which integrates HIV/AIDS with SRH services?

MM: PC in collaboration with the Department of Health (National and Provincial), conducted the HIV and FP integration project in the North West Province of South Africa.  It's a two-phase project; in phase 1 we were looking at the feasibility, acceptability, and cost of the HIV/FP integration model. This Phase has been completed, and the results show that it is acceptable and feasible to integrate these services.  The information gathered from a dissemination workshop with the providers and the department of health actually informed the Phase 2, project in terms of the development and the evaluation of the effectiveness of a "better model" of integrating HIV/FP. 

In Phase 1, a provider would discuss HIV and STI risk and offer Counseling and Testing (C & T) and either refer a client to a lay counselor for HIV testing or maybe do the testing themselves. The outcome from this project was that the performance may actually depend on the setting, and it is advisable that it should be client driven so that clients have a choice of who tests them.  In evaluating the better 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 model chosen 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 test, 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 to the clinic.  The model would be that you as a FP provider would be having a discussion of HIV risk and serostatus and offering C & T.  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.

How was this project funded?

SM: It was 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  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. 

When did the program begin?

SM: Phase 1 began at the end of 2004.  Phase 1 is completed particularly looking at acceptability, feasibility and cost.  The baseline for Phase 2 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.

What was the rationale for starting this project?  How did it come about? What was the need that was being responded to when this project was initiated?

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 and not using dual protection, 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, is 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 to reach a large number of sexually active women 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. How to implement that or what would be a good way to implement the policy was the challenge.  And so it was discussed with the National Department of Health.

Were there any other parties that you were in discussion with when planning and implementing this program?

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 additionally involved  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.

Was there any community involvement in the program, from community members or community groups?

MM: The community that was involved was FP clients.  We conducted the focus group discussions with the providers and the clients, and the implementation itself happened at the public health clinics which are accessed by the community.  Phase 1 training targeted service providers only, a gap which was subsequently addressed in Phase 2 by including lay counselors too as people who have contact with the FP client at some point in time   

How much did providers know about integrated services before the program began?  Had many of the providers heard about integration? 

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 providers with tools to help implement integrated services.  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 now.  Other people are a lot more interested in it.  A lot more motivation as well, compared to a couple of years ago.

The providers are more aware of integration now.  Is it something that they are supportive of now?  Currently how do FP providers view integration?

MM: I think the providers are supportive but they need continued support.  Obviously in the facilities they have challenges.  In South Africa we have serious staff shortages.   We try to make sure the providers are trained.  We have identified some champions in the facilities who do monitoring and evaluation and give us feedback on an adhoc and weekly basis. The idea is to promote ownership through active involvement and participation. Staff rotation which occurs in most public health  will allow for  spillage of the integration  information. 

Could you speak a little more about tools you used to educate providers on integration?

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 and STIs into the FP services in high prevalence settings. 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 prevalence settings 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 are.  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. 
 
Could you speak a little more about the training that the providers received?

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 in South Africa was the formal four days, and it was targeted at mainly professional nurses and there were some enrolled nurses as well.  The enrolled nurses didn't perform as well on the pre- and post-tests as the professional nurses.  The professional nurses are 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 post-training 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 conduct and interpret an HIV 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 so that they are able to refer clients who may have FP needs back to the FP services.
Was there a formal evaluation of phase 1?

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.  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.

When is phase 2 slated to end and when does the funding for the second phase of the project end?

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.

A possible third phase - would that involve FP providers providing FP counseling to HIV- positive women as well?

MM: Yes, definitely.

And is that something that is currently starting to be thought about in integration-FP counseling to HIV-positive women?  I know that's an important thing on which some people focus.

MM: It is an idea that we considered.  We recently had a meeting with our Department of Health to propose and explore the possibility of integrating antiretroviral therapy (ART) into family planning.  It was acknowledged that much as the package of HIV care is comprehensive, reproductive health care is not an area of focus at the ART sites  and they know that reproductive health issues are really not talked about.. 

SM: The Population Council has a number of of activities exploring various models of integrated services.  We have one project on sexual assault which really is integration of HIV and reproductive health in collaboration with Tswaranang Legal Advocacy Centre, 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.  Another activity we're working with, again with the provincial department of health, in a province called KwaZulu Natal, at the policy and guideline level is to really to develop antenatal and postnatal guidelines which are evidence based and also look at the different aspects of care required including HIV and AIDS.  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 MTCT.  We'll have reports very shortly.

Were there any other challenges that any of you found when implementing the program, in either the previous phases or the current phase?

MM: There are some of the challenges occurring especially in phase 2.  There was a public sector strike in South Africa for two months and that deterred our program completely.  Facilities have other priorities and it was difficult to send people for training, this caused delays in the  intervention.  Generally there has been a shortage of staff as well.  Good trained people are often lost to other programs or countries.

Do you have any lessons learned from this program that you would want to pass on to other program officers or managers?  Best practices or things that you learned to be important when implementing an integration program?

MM: Integrating HIV into reproductive health is feasible and it is acceptable.  It is important to make sure that it is sustainable and interventions also support your providers.  The SA department of health emphasizes sustainability and capacity building with any intervention conducted in the country. The intervention and best practice from one province should provide conditions for scale up in the other provinces. Of importance as well is to ensure that the intervention impacts positively on program implementation. It is definitely feasible, accessible and effective as well.  The feedback that you get from the clients is also very important.

SM: Also, when designing interventions for integration, 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.

Any other additional comments?

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 but  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.

Contact Information:
Saiqa Mullick
Population Council
PO Box 411744
Craighall 2024
Johannesburg, South Africa
+27 11 438 4400/7200
E-mail: smullick@popcouncil.org