Paul Perchal - Global HIV/STI Program, EngenderHealth, Brazil, Ethiopia, Ukraine
September 2007
As Director for EngenderHealth’s global HIV/STI program, Paul Perchal provides technical and management oversight to a global HIV/STI team as well as strategic guidance to the organization’s work in the field of HIV/AIDS and other STIs in 13 countries. He is recognized internationally for leading multi and bi-lateral HIV/AIDS projects resulting in expanded HIV/AIDS services and improved approaches to service delivery. He has led the successful introduction of comprehensive Prevention of Mother-to-Child-Transmission (PMTCT) services in Brazil, Ethiopia, and the Ukraine that address the needs of antenatal clients and HIV- positive women.
The HIV/SRH Integration site interviewed Paul about his experiences with providing integrated services in Brazil, Ethiopia, and the Ukraine.
Can you give us a brief introduction to the project you’re going to be speaking about?
It’s a project that we executed on behalf of UNFPA with funding from a UN partnership of organizations to strengthen existing PMTCT services in three countries: Ukraine, Ethiopia, and Brazil, and particularly looking at two core elements of comprehensive PMTCT: addressing the HIV prevention needs of pregnant, postpartum women and also the sexual, reproductive health, and family planning needs of HIV-positive women. These are two areas that—based on a literature review and some formative research that we did—were relatively weak in all three countries. So this project had a two-fold purpose. The first was to implement some pilot projects on integration of HIV prevention with maternal and child health (MCH) services in three countries and the second component was to develop operational guidance on integration of sexual, reproductive health and family planning in HIV services. So we did some formative research and also developed a programming and training manual, and field tested it in three countries.
How did you arrive at those three countries to implement this two part program?
We went through a process of first coming up with some criteria .[1] And then we went through a process of working with our counterparts, if we had them in some of those countries, and UNFPA counterparts, and contacting the Ministry of Health to find out if this was a project that they were interested in supporting, and then based on that, we decided on these three countries. We had a much longer list of countries that we were considering and ended up choosing these based on political realities and a good fit with processes already going on within the country.
When you first developed this project, who was involved with the development?
We went through a series of planning stages. As I mentioned, we did a literature review that looked at what promising practices may have already existed, we did some formative research at the country level with policy makers, providers and clients to find out what some of the needs were and what some of the gaps were. And then once we had chosen the site with the Ministry of Health in each of the countries, we went through a more in-depth planning exercise with each of the sites based on program planning workshops that we had developed. It brought together the Ministry of Health, regional and district officials, program managers and key staff, and community stakeholders to go through a two-day intensive planning exercise that included a rapid assessment of their current situation within their own community. We then helped them decide their priorities in developing a workplan, which eventually ended up being the workplan for the project.
Could you describe the facilities in which the project was implemented? Were they clinics?
It varied from country to country. What we were trying to create, if it didn’t already exist, was a referral network. Often it included a regional or district hospital, clinics, or dispensaries. It varies from country to country. In the case of the Ukraine, it’s a little bit different there because they have HIV/AIDS centers, which were the former STI centers prior to the break of the former Soviet Union, and these have become stand-alone HIV centers. We tried to include them as much as possible, but there was some resistance in the Ukraine because they had a hard time understanding that they even had a role or responsibility to play in terms of addressing other family planning and sexual reproductive health issues. However, the PMTCT programs in the Ukraine are totally integrated into the MCH units or hospitals and they actually have a higher percentage of universal access PMTCT, so it’s a bit different in that country than in the other two because in the Ukraine they have fully integrated PMTCT that is not linked to their HIV centers.
Women who accept testing in ANC and are HIV-positive are referred to PMTCT services on site and encouraged to register with the stand alone HIV centers off-site. When we started working with these facilities, there was no follow-up, so no one knew if the women actually made it there. Many people suspected that they didn’t because there is a lot of stigma and discrimination associated with these HIV centers because everybody knows that that’s exactly what they are. Ukraine was different in terms of the kind of referral network that we had to create there. We had to get the HIV centers on board. Even though they were involved in all the planning exercises and seemed to be on board, there was still some resistance throughout most of the project and implementation to taking on more responsibilities.
With which cadres, in terms of providers, were you working?
It varies from country to country. In the Ukraine, only doctors are allowed to do HIV counseling and testing and PMTCT, so there we worked hard to get them to be more receptive to the idea of nurses and nurse attendants doing some of the preliminary counseling. Doctors were so busy and there were so many clients per hour. So what we tried to do was have the women sit down before with a nurse or nurse attendant who provided them with education in HIV prevention and counseling. And the nurse attendant usually does the blood drawing, so that is another opportunity for the nurse attendant to reinforce some of those behavior change communication messages.
In Ethiopia, we looked at community health workers and traditional birth attendants and, of course, in that country nurses are already doing Voluntary Counseling and Testing (VCT) and nurses and midwives are doing PMTCT. In Brazil, we worked a lot with community organizations: again, nurses and midwives are already doing all of that work; it’s not really a role allocated to doctors. When it comes to treatment and care, definitely doctors have responsibility for that. In Brazil, we worked a lot more closely with community organizations because there were so many well established ones. We helped with strengthening outreach and follow-up with women to make sure they were getting all the clinical services that they needed.
Did you involve any other community members in developing the programs?
We made sure that the networks of people would be represented during all planning activities either through a local network or a national one. They were also invited to participate in the project monitoring committee that was set-up at each project site. We also made sure that women’s groups were invited to participate. Depending on the country, we also looked at how other services were being provided, such as social services, and invited officials from that Ministry department and community groups that were providing care and support services.
What links to community support groups did you have? Were there any specific links that these programs made with community support groups?
Yes, there were links to local and national HIV networks. Also, we linked other community groups providing care and support. What we basically tried to do was map out what all the existing services were, both clinical and non-clinical, and then look at how to strengthen the linkages between those services through a more formalized referral mechanism.
In the countries where this project was implemented, was there a high level of unmet need of family planning among people with HIV?
I would say yes. Where family planning was being provided, it was probably being provided in a fairly biased fashion by providers in that there tended to favor condom use only and the providers were not really talking about other family planning methods. In terms of the HIV prevention and MCH, I would say that in Brazil and Ethiopia, this was seen as more the need than in the Ukraine. For some reason, the Ukrainian Ministry of Health was much more interested in the sexual and reproductive health (SRH) integration component of people living with HIV rather than HIV prevention. The Ministry seemed to feel that all the prevention needs of HIV-negative women and women with antenatal care were being addressed through their PMTCT program, and that clearly wasn’t the case based on the needs assessments that we did.
They were really not doing that much HIV prevention counseling before we started implementing this project. However, there was the perception from the Ministry of Health that given they had universal access to PMTCT, they somehow addressed HIV prevention counseling because women were being tested and counseled in ANC. I guess that they assumed that they were getting intense HIV prevention counseling at the same time as ANC. However, it clearly wasn’t possible for providers to provide any in-depth counseling because they just didn’t have enough time according to service delivery guidelines for number of clients providers needed to see.
Was there also perception that HIV-positive women shouldn’t be having children at all?
Oh, absolutely. While that was true in all three countries, it was true to a lesser degree in Brazil because they’ve had PMTCT services and care and treatment services for a relatively longer period of time. I think when Brazilian providers or policy makers were talking about stigma related to fertility choices, for example, I think they talked about it more of something that was experienced in the past whereas in Ethiopia and Ukraine it was still very much a issue in present day.
When you were talking about family planning and the bias about only using condoms – did your program introduce the concept of dual protection?
Yes, we introduced dual protection both in the HIV prevention work that we were doing in MCH as well as SRH counseling and family planning counseling for HIV-positive women in the PMTCT services, as well as other services. Depending on the site and the way the services are delivered, the integration of SRH for HIV-positive women looks a little bit different. Some HIV-positive women who weren’t pregnant received counseling through the family planning services, or ART services while those who were pregnant got the counseling through MCH and PMTCT services.
Aside from the funding that UNFPA gave you, did you need any other resources to start this program? Particularly in terms of other consultants?
Absolutely, we hired a project coordinator in each country and there were some other equipment and supplies that we had to purchase. We developed BCC materials, so we hired a consultant to develop those and then printed all of those. We did some facility upgrades, where sites did not have a confidential counseling space, to ensure that they did. We did a cost-analysis that provides a breakdown of what the costs were in one country versus the other for introducing HIV prevention interventions in MCH services. It worked out to approximately $6 per client to introduce a package of HIV prevention interventions including HIV testing and counseling, risk reduction counseling, STI screening, and distribution of condoms and BCC materials. We also did some modeling of the cost savings for these HIV prevention interventions. When you also you look at the cost savings pertaining to averted infections and PMTCT and care and treatment services , it is very significant. It’s quite a worthwhile investment.
How long were the trainings that the providers received?
There were two main types of training that we did, and we also paid for the providers to go through some of the specialized trainings through the Ministry of Health.
The first training that we offered was a whole site training, an introduction to PMTCT. It was offered to doctors, nurses, and to other facility staff from security guards to cleaning attendants. The idea behind this was to ensure that everyone had a baseline understanding of what PMTCT was, what VCT was, as well as addressing some of those other issues such as values clarification, stigma, human rights, getting them to understand the complexities of the lives these women are leading, and other underlying factors contributing to their vulnerability. That was a 3-day training. It was supplemented by specialized training for key staff providing those services. We did that through the national curricula, PMTCT curricula, and VCT curricula. That varied from country to country.
I think in Ethiopia it was a 7-day training. In Ukraine we didn’t do any specialized training because it wasn’t readily available. There was one organization that was doing most of the training, and they already did their trip to the region, so it was difficult to piggyback on other national trainings that were being offered. Given that doctors were the ones doing most of the work, many of them, through either technical updates they had done on their own or through their pre-service training, seemed to have a fairly good understanding of what was involved in offering VCT, what was offered in providing PMTCT. So in that country we didn’t do any additional training.
And then the other major training curricula that we field-tested was the 5-day training on SRH for HIV-positive women and adolescent girls. Again, it was offered more as a whole site training, so that everybody had the same baseline knowledge and then it was supplemented by more specialized training either on specifically focusing on the family planning needs of HIV-positive women.
Did the training address attitudes and beliefs? How did you attempt to counter those beliefs in the training?
If you go through the two training manuals, there’s a number of exercises dealing with value clarification, beliefs and attitudes about sexuality, about fertility. There are also a lot of exercises dealing with human rights and stigma and the importance of reducing stigma and other exercises dealing with confidentiality and disclosure and partner notification because those are still gray areas in the countries that we worked in. These issues were less of a problem in Brazil because there are stated policies on how providers are supposed to deal with those issues.
It became a really good opportunity to actually have an open and frank discussion about how they’re handling some of these things and some of the beliefs and values. Another important aspect of stigma reduction is infection prevention, so we tried to address some of the provider’s fears around transmission at work and also working with other people who might be HIV-positive. We were trying to bring all these issues out and have an open and frank discussion about it. Ultimately though, I think on some level, it needs to be followed up through some kind of supervisory structure, such as was done in Ethiopia where they had facilitative supervision and had been exposed to quality improvement activities in the past. There seemed to be more of a willingness of providers to let go of their own values and beliefs or at least put their personal values and beliefs aside and deal with the client in a professional manner.
What type of job aids did you provide for people to use in counseling settings, as they went forward and they added these responsibilities?
We developed a counseling algorithm, and a providers’ checklist of important topics and issues as a reminder to discuss with clients. And we developed a key messages card for providers, again, to trigger them in terms of the key behavior changes messages to convey to women when they’re counseling them.
What was the process of evaluating the project? How did you see if your goals and objectives were being achieved?
There were three major components to the evaluation. We did baseline and end-line facility surveys, in which we talked to key providers. We took a snapshot of services before we started the project and at the end of the project so we could see what kinds of services were introduced and referral linkages were made. We also did pre and post-training questionnaires. We also did a six month follow-up to see how well they had retained the knowledge. And then we did client surveys, before and after to gauge the kinds of changes. Given the project was so short, we weren’t really looking at changes in behaviors, we were looking more at intentions to change behavior or to adapt any other health behaviors based on the counseling received. And the client surveys also included a section on client satisfaction.
Since certain concepts were relatively new, how did everyone feel when this program started? How did providers and clients react to the implementation of this programming?
We did some client surveys and they demonstrated the clients were very satisfied with the services and they didn’t perceive the quality of services had suffered in any way. In terms of the providers, even though theoretically they saw the value and importance of doing this, there was some resistance obviously because they’re being asked to take on more work or organize their work differently. In the sites where they already had exposure to facilitative or supportive supervision and quality improvement processes, the providers were much more readily able to take on this integrated service or the additional services, compared to sites that hadn’t. The sites in Ethiopia had it and the sites in the Ukraine didn’t. There was some resistance from providers to actually following through. There were some significant problems in providers with their attitudes and beliefs.
What was the very biggest obstacle that you encountered with these programs?
Stigma was a very big problem. How it also manifested itself though, for some HIV-positive women, particularly in Ethiopia, was the whole issue dealing with infant feeding choices and the fact that the government doesn’t provide formula to mothers because it’s just not budgeted for. It’s very difficult to develop a supportive kind of relationship with the women and so one of the things we looked at doing, actually because it was clear in Ethiopia that there was a lot of breastfeeding and maybe some formula feeding and other types of infant feeding choices being used, was to try to work with one of the PL HIV organizations to try to set up a support group with the HIV-positive women. Because there’s a lot of stigma around using formula a lot of women chose to breastfeed because they didn’t want to deal with the stigma, so that was an issue that we were not able to grapple with entirely alone, and we had to work with community groups and organizations to figure out the best way to approach that.
There were other obstacles that we weren’t able to solve because some of it just had to do with lack of availability of certain commodities, and I guess it’s a lesson learned for anybody doing this. I would not only look at what’s available at the service site you’re supporting, I would look at procurement issues much more broadly than that, in terms of what kind of stock outs happened in the past in the countries you’re working in. A good example is condoms. We were never able to procure male condoms in the Ukraine for all the health facilities that we were supporting.
And some of it is political, because of the gatekeepers for condoms. We as an organization were not a procurement agency so we had to collaborate with other organizations who were procuring and this is where it became a little political.
What do you see as some of your shining successes in overcoming the obstacles?
One of the greatest accomplishments at all the sites was improving access to comprehensive PMTCT services by integrating SRH and HIV services and strengthening the referral networks. Because a lot of people assume that when they send a client somewhere, that they actually end up going to that other service. We tried to build up some of a formal mechanism, including referral forms and a way to follow up with the receiving health facility to make sure the client made it there. We also developed more formal relationships between services by having one type of service provider come to a health facility and talk more about what their services are and vice versa. So that’s one aspect I think was quite successful. In all, compared to how they began, we did baseline and end-line surveys and in all the health facilities that were supported through this project, they had much stronger referrals and linkages. In the beginning, that was challenging, like in the Ukraine example they didn’t really know what was happening with the HIV-positive women, once they delivered their child and went home and were referred to these HIV center. By developing a more formal relationship between the MCH units in hospitals and the HIV centers, I think they were looking a lot more at some of these issues to deal with follow-up or with women not coming back for their follow up appointments.
Did you have to make adjustments to your approach as you went along with the program?
Absolutely. We went in with an idea, for example a package of training that we could offer; however, we had to make adjustments to the training plan. Where that came in was to ensure that some providers also had the necessary specialized training on things such as PMTCT or VCT. Maybe I should take a step back. In the case of Ethiopia, we started this project with the idea that we were going to strengthen the HIV prevention component in their PMTCT program. However, they didn’t have a PMTCT program to begin with, so introducing VCT as one of the components of HIV prevention in this project, they ended up setting up the PMTCT program during the life of the project. And they also introduced care and treatment services as well in their health facilities. We weren’t anticipating that but it seemed to be a logical evolution. So we had to be more flexible in terms of the types of training needs, the types of commodities that were needed, and we had to adapt. What started off as HIV prevention and SRH family planning for HIV-positive women led to a need to support some of the sites in terms of being able to establish and maintain some of these other integral services.
We involved community groups and organizations in the planning phase, and as members in the implementation and monitoring and evaluation teams. Program managers, key staff, and community members monitored the progress of the pilots in each country. I think the relationship grew much stronger between the health facilities and the community organizations so as the projects evolved, we needed to be more flexible in terms of supporting these community organizations or collaborating with them more directly than we had anticipated. Many of them don’t have many resources or they haven’t had a lot of opportunities for capacity building. So one of the things we tried to ensure was we always invited them to participate in all the trainings that were available. Almost every time, they sent two or three people to go through the trainings. So those were some of the adjustments we had to make.
Can you offer words of wisdom to give to other programs, setting up integration programs? What’s the big message based on your experience with this program?
Having local buy-in is really key, and there are different ways of doing that. You certainly need buy-in from the Ministry of Health. Fairly early on before you’re thinking of introducing something, you need to have meetings to orient them about integration. Integration is being talked about a lot; however, district and regional health officials don’t understand what it looks like on the ground. And it’s also a good opportunity to identify with them what some of the challenges are in introducing integrated services. I mentioned the issues to do with procurement—you have to make sure you have all the commodities you need and that’s where district and regional health officials can come in.
You also want to make sure you have buy-in from the community, community groups and organizations because you can do all you want to strengthen health systems and health facilities, however, if the community still perceives that there’s either problems with the services or that there’s stigma, or that they’re just not welcome, they’re not going to be using those services. I think that ensuring that there’s good collaboration with community groups and especially organizations of people living with HIV is critical.
Another piece that people might not think about, this is working back and forth between the health facility and the MOH and the district or regional level. Indicators are not geared towards integrated services—what we ended up doing is actually creating some new fields and tracking some of these indicators ourselves that weren’t necessarily required, either on the family planning or HIV side of things. They were just additional indicators we needed to track to be able to determine what the accomplishments of the pilot interventions.
There’s also a disconnect between national guidelines and how services are provided in an integrated fashion. In many countries, there aren’t guidelines on integration, so you run into these operational disconnects. VCT guidelines say that you counsel a person for this number of minutes; however, there may be another national guideline that says that providers need to see this number of clients within an hour, so it presents the people that are delivering the services with a bit of dichotomy. They look for direction in terms of what to do. If it’s at all possible to try to iron some of that stuff out, I know some of it will take some advocacy. If somebody is implementing something at a service delivery level, it might not have the mandate or resources to do that kind of advocacy. It’s something somebody should keep in mind, if they’re looking to integrate—national policies, management guidelines or health facilities are not geared towards integration. You can anticipate there will be a lot of challenges and obstacles that you may not have thought about, and we touched upon some in our conversation. If you want to successfully implement something, you have to find a way to deal with those challenges.
And the whole issue of sustainability is something people need to think about fairly early on. A lot of people talk about integration, but there isn’t really money in ministry budgets to support integration. So before the end of the project, we share some of the preliminary results and lessons learned with key MOH officials to try to get on-going support for some of the services to be introduced into the budget. So after the pilot project ends, the services won’t all of a sudden dry up and cease to be offered.
Contact Information
Paul Perchal
EngenderHealth
440 Ninth Avenue
New York, NY USA 10001
Phone: 212-993-9831
pperchal@engenderhealth.org
[1] Strong relationships between local partners and potential project sites; Availability of a range of HIV/AIDS service delivery models and/or interventions along the prevention to care continuum; Presence of integrated or stand alone services for adolescent girls; Presence of strong national or local networks of People Living with HIV and/or women’s groups; Availability of essential commodities/supplies; Capacity to mobilize quickly for project start-up; Willingness and commitment in countries by national (government) staff especially Ministry of Health to support SRH-HIV integration.