Resources for HIV/AIDS & Sexual and Reproductive Health Integration

Dr. James Shelton of USAID raises an important point about some of the barriers to integrating of HIV and family planning services. Providers are being asked to do more and need to know how they will benefit. He also outlined some potential approaches and asked for comments about the practical aspects of successful integration from providers who have had experience with HIV and family planning integration.

1. What is the benefit to the providers? Is the question “How do we get providers see a benefit to themselves?”

Adequately meeting the needs clients/patients is gratifying. However, it is important that providers feel equipped to meet those needs. Additional training gives providers additional skills to improve their ability to deliver care in their current and future jobs. However, it is important to understand that FP providers and HIV providers cannot be expected to deliver the full scope of both services.

Addressing the concerns of providers that an expansion of their counseling and clinical roles requires more work must be done. Providers feel most challenged when they are not involved in the decision making processes that impact the practical aspects of their work.

A paradigm shift is required. Working with providers to understand that successful HIV care and FP care requires knowledge about the other service is key to successful integration. Delivering clear messages about how HIV treatment can impact successful contraception and vice versa is one approach. As HIV care and FP becomes more complicated, the need for HIV specific providers grows. We cannot realistically expect FP providers to conduct all HIV services and vice versa. Addressing their gaps in knowledge and keeping the information about HIV or FP services limited to a few key messages also is important.

2. Dr. Shelton outlines a number of useful approaches that can support integration.

As a provider of both HIV and obstetrics and gynecology services since the beginning of the epidemic and as the complexity of HIV care grew, it was important to me and the clinic in which I worked to recognize our limitations early in the process. We worked as a team to outline the deficits in our ability to deliver integrated care and problem solved to address those deficits as a group. Addressing educational needs and logistics with all members of the staff was key to ensuring successful integration.

Training that includes technical information and practical exercises allows each clinical setting to determine what approach to skills building and service delivery will best work for them. The use of a wide range of providers to deliver information also is helpful. Education and counseling can come from health educators as well as clinicians.

As a community expects certain services, clinical settings will need to meet those needs. Our clinical site met the increasingly complex HIV needs of our clients, by bringing an HIV care provider into the setting to conduct clinical follow up. Other HIV specific clinical sites have brought in women’s health care providers or family planning providers to address the needs of their clients. In all cases, establishing formal relationships between HIV and family planning settings allows providers to jointly determine how best to work with a patient to meet her needs.


3. Dr. Jacobson of FHI raises the question of how to promote abstinence while offering family planning services.

This becomes a discussion about providing information to clients. Family planning is really about planning for a family by assisting clients as they make decisions about whether or not to become pregnant, how to maintain their health throughout, and how to ensure a successful and healthy pregnancy when they decide to start a family. Abstinence counseling and contraception counseling are not mutually exclusive. Abstinence counseling allows patients to feel comfortable about their current decision. Contraception counseling gives information that can be used in the future to adequately plan for when they decide to have sex, and appropriately spacing pregnancies.

Choosing to become pregnant and potentially exposing a partner of the child to HIV makes these discussions even more important. Optimizing maternal health with appropriate antiretroviral therapy will assist in a healthy pregnancy. The risks of partner exposure to HIV infection must be discussed so couples can make informed choices including avoiding those risks.

4. Response to Konjit Kifetew of Ethiopia

Konjit raised the issue that clients say they are abstaining from sex and actually do not and clients who previously may have felt unwell begin taking ARVs and resume sexual activity. The situation is further complicated by the difficulty in having open discussions about sex in the community.

Often when we discuss contraception with clients, we approach it without first determining whether or not the client wants to be pregnant or is the decision maker in the home enabling her to prevent pregnancy when she wants to. Providing contraception services assumes that the patient wants to prevent pregnancy.

We need to determine the patient’s needs in this discussion. Our best success may be helping a woman delay pregnancy until her health improves. Unfortunately, clients/patients may tell us what they think we want to hear. Opening a discussion about her plans for having children and providing information about how to do that safely may be one solution.

When patients begin ARVs, feel better, and resume usual life activities including sex, we can arm them with appropriate information about protecting themselves and others. Having the discussion in the context of HIV may assist with the difficult discussion about sex. It is also important to recognize that there need to be on-going discussions and patients will ultimately do what works in the context of their own lives. We can provide assistance, information, and skills to help them act in a way that best supports their health.

My overall comment is that we cannot stress enough the importance of keeping the information as simple as possible. In the international setting where treatment choices and contraception choices are limited and in the US where treatment choices are ever expanding, limiting the information to what providers need to know—such as hormonal contraception and ARV interactions and teratogenicity of some ARVs allows them to improve the quality of services they deliver in a realistic manner.

5. Response to Dr. Rajat Kumar Das about improving the chances that HIV and family planning integration is successful by working with local government:

It is especially important to have a good working relationship with government bodies. They can assist health care organizations in the development, distribution, and quality management and evaluation processes that can make integration the norm for HIV and Family Planning health care. Building relationships between the government and health care organizations such as the local, regional, or national physicians and nursing groups as well as any organizations for mid-level and ancillary health care providers can ease the implementation of integration and hopefully improve its success

6. To Bernadette Kazibwe of the Clare Nsenga Foundation who discussed the problems of delivering health care in more rural areas:

The issue of circumcision has been discussed for a while. More recently, there have been studies to compare HIV infection and transmission rates in circumcised and uncircumcised men and clinical trials that provide circumcision as the intervention and compare rates of new HIV infection in circumcised and uncircumcised men. Those studies provide pretty good preliminary evidence that circumcision decreases the risk for men to get infected with HIV and decreases the chance that they will transmit HIV.

Along with encouraging abstinence and being faithful, considerable education is needed about safe behaviors for people who decide to have sex. There are so many worldwide misconceptions about how HIV can be transmitted and what safe behaviors are.

It is important that HIV and other health care information reach rural areas. In the US as in countries in Africa, the greatest access to health care and updated health information is also found in more urban areas. We also tend to focus our educational efforts on physicians when health care is delivered by many types of providers particularly in more rural areas. Health educators and mid level providers can be very helpful for the delivery health care and information. It may be even more useful to use local health educators and providers because they often have better information about local community beliefs.

Dr. Julitta Onabanjo - USA

Dear Friends,

Let me start by congratulating IBP/USAID, HCP and the INFO team for coordinating this most important online forum.

My contribution draws on the work that UNFPA with partners have been engaged with over the last few years on strengthening the links between HIV/AIDS and SRH.

There is no doubt that the HIV/AIDS epidemic has put an enormous additional burden on the health systems of most countries. Health service providers are at the heart of health systems, yet around the world, the health workforce is in crisis and this has subsequently affected the delivery of health care activities and particularly reproductive health programmes.

From the little research that has been conducted into how health service providers are dealing with the HIV epidemic (Bharat and Mahendra 2006) the following can be said: Service providers lack information on latest research findings; are rarely given training in sexuality and human rights and socio-cultural determinants that underpin reproductive ill health; lack counseling skills and are uncomfortable to talk about sex and sexuality; lack skills to conduct risk assessment; perceive, and are in fact facing a threat of HIV infection themselves; fear to find out their own status; and undergo tremendous stress and demands in providing HIV prevention and care let alone other reproductive health services such as family planning; are confronted with infrastructural inadequacy and poor working conditions; bear the brunt of serious shortages of staff; may face gender-based discrimination at work; may not have fundamental employment protection; and the list goes on.......

All of the above aspects point to an urgent need for health reforms including reform to the content and way in which pre- and in-service training takes place, as well as reform of health employment policies.

In 2005, UNFPA and EngenderHealth, in collaboration with the International Community of Women Living with HIV/AIDS (ICW), Ipas and Harvard University, hosted electronic discussion fora on the subject of sexual and reproductive health (SRH) policies, services and human rights
for HIV-positive women.

For participants in the interdisciplinary forum, the issue of health service provider attitudes appeared to strike a particular nerve, with many responses related to discriminatory practices and negative provider attitudes toward HIV-positive patients, and concerns about discrimination and stigma in the health care setting.

Other responses however were sympathetic to health service providers toiling in resource-challenged settings, with neither the training nor the equipment/supplies to care for patients safely. It was apparent from the discussions that providers' do fear that they may contract the
virus themselves while giving care. When protective supplies for universal precaution are unavailable, these fears are exacerbated. At times, there is even no soap or water to wash hands!!. Salaries are said to be poor, there are shortage of staff, and working under stress
increases the risk of accidents with few chances to obtain post-exposure prophylaxis if they are inadvertently exposed to a serious needle stick injury from an HIV positive client.

An additional dimension of gender was also highlighted by the discussion forum - most health care workers are women - have poorer conditions of work - and have a heightened awareness of HIV because they care for so many patients and children with HIV that they cannot save. Yet most carry on looking after their patients despite their fears. The importance of reforming the training curricular was also highlighted. One forum contributor stressed that until sexual and reproductive health issues are institutionalized -and humanized – in nursing and medical schools (i.e. "pre-service"), progress on this front will be minimal. Curricula are still very traditional and medical focused and subjects dealing with sexuality or adolescence, the rights of the clients, health as a human right, gender equity and its meaning, are hardly incorporated into pre-service training.

Finally, contributors felt strongly about the need for women to be able to speak frankly with health care providers about their sexuality concerns and needs, chastising those who blame women for their condition, and flagging the need for SRH-linked programs for those affected by gender-based violence: "/The environment at the healthcare service is not a good one to talk about what happens to you at the home. I think this must change. We should be able to talk about all our bedroom experiences in the health care service centre. Having an STI or an unwanted pregnancy should not be blamed to women as we do not choose to have these; we acquire these under severe violent situations in our homes, from our lovers. There should be programmatic linkages between sexual health and violence against women. I have heard researchers in different meetings reporting that the presence of an STI and or HIV and AIDS suggests that there has been violence. Why are then no programmes which address battered women in the sexual health service?

Any examples or case studies on how governments have reformed their health systems to ensure the better linkages between SRH including family planning service delivery and HIV/AIDS would be most appreciated.

Should you wish to know more about UNFPA's work on linking SRH and HIV/AIDS please visit our website www.unfpa.org and/or contact Dr. Lynn Collins, Senior Technical Adviser, HIV/AIDS Branch, UNFPA, NY at collins@unfpa.org

Kind regards

Contributor:

Dr. Julitta Onabanjo
UNFPA, New York.
E-mail: onabanjo@unfpa.org
Tel: +1-212-297-5262

Di Cooper - South Africa

I am Di Cooper, a senior researcher in the Women's Health Research Unit in the School of Public Health at the University of Cape Town in South Africa.

We have completed qualitative research among health care providers (as well as HIV+ women and men) around their reproductive intentions and dealing with these in service provision in Cape Town in South Africa. This was funded by the William and Flora Hewlett Foundation through
Population Council, who collaborated with us. Our policy briefing can be found on our website under units at the school of public health's website: http://www.publichealth.uct.ac.za

We are currently in the process of doing a quantitative survey, funded by the WHO that will include 235 HIV+ men, 235 HIV+ women and 70 health care providers.

A few insights from our qualitative research around integration of family planning and other reproductive health services that I would like to share with others include:

1. Providers felt there was no specific policy or service provision guidelines for providing or integrating reproductive health services for HIV+ individuals.
   
   
2. They felt ambivalent about being HIV+ and reproductive health and wished to have 'values clarification' type training in order to examine and come to terms with their own attitudes and those of their clients.
   
   
3. Those working in HIV care and treatment felt they needed more training on contraception for HIV+ individuals - especially interactions between medication for opportunistic infections and for those on ARV's and hormonal contraceptives.
   
   
4. Those working in HIV care felt that despite an increased load to some extent, integrated service reproductive health services (especially contraception) and HIV care would be worth exploring as clients often 'fall between the cracks' when being referred to repro health services
   outside of HIV care and treatment.

Regards
Di
--
University of Cape Town
Anzio Road 7925
Observatory
Cape Town
South Africa
Tel: 27-21-406 6528
Fax: 27-21-448 8151
email: dic@cormack.uct.ac.za
http://www.publichealth.uct.ac.za