Day 4 Digest (May 4, 2006)
Welcome to day #4 of the online forum on Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services. We now have over 400 participants in the forum.
Today’s digest contains comments/questions from Joseph Dvora, who works with Population Services International (PSI), Abebe Shirbru from Ethiopia, Margaret Butau from Zimbabwe and Arif Bashir from Pakistan. It also includes a response from Dr. Edward Bonku and links to resources mentioned in yesterday’s digest and a summary of some of the important questions that have been raised in the past three days.
Today's Comments and Questions
--- Joseph Dvora, PSI
Thank you for this information (day 2). I would like to share some of the work PSI is working on in the field of integrating FP into VCT services. Like Dr. Reynolds mentioned, we have added questions about pregnancy desire and use of contraception onto all VCT client intake forms (such as: do you or your partner want children in the next two years (yes/no)? If not, are you or your partner using a method of contraception (if yes, what method)? If the client replies NO and NO to these 2 questions, the the counselor is prompted to refer the client or provide FP information or services according to what is available on site during the post test. Questions are asked during pre-test). Systematic questions and checklists (as suggested before) work very well with VCT counselors, however we have found that these tools must be accompanied by TRAINING of counselors in FP and dual protection and not alone. In addition, we have developped brochures and IEC about FP in VCT sites which has facilitated discussion during the pre and post test counseling sessions. We have not yet formally evaluated the use of and success of such tools, but initial analysis shows that the tools increase referrals to and information about FP in VCT sessions- mostly with women though (men rarely get information about FP).
--- Abebe Shirbru, Community Mobilization Manager, Ethiopia
Thank u for this existing forum really which I am assuming that I will acquire better understanding about the Family planning HIV/AIDS integration. I want to address a question for Ms. Betty Farrell in today's her session. Of course, dual protection is very important matter from every angle in related to family planning and HIV/AIDS including that of PMTCT. But I want to know that apart from knowing about the important aspects of dual protection knowing about the power imbalance between couples in terms of accessing commodities and making decisions to use the commodities are crucial for health providers. From your experience would you please tell me how could health provider overcome the gender inequalities while they are catering the service to their clients. For example in Ethiopia women are in subordinate position to make decisions to use condom it is up to the men to make the decisions. So, what kind of skill do the provider should possess to challenge the prevailing gender inequalities. For me this is central matter while we are discussing about dual protection and Family planning and counseling integration.
---Dr. Edward Bonku, Engenderhealth/AQUIRE, Ghana
Thank you, Michelle.
I make a basic assumption that the questions you have put across relate specifically to the Ghana settings for the pilot integration of FP into ART services. If that is the case, let me begin with the first which looks at the event of having some women getting pregnant despite the use of integrated services. At the exploratory stages of introducing the concept of integration to stakeholders and interested parties, some of the interactions and dialogue between the program developers and health care providers at the target pilot sites confirmed that, indeed some of the HIV+ women who were on ART had reported pregnancies which were unintended. "There are unwanted pregnancies among the clients of the HIV program. At Korle Bu Hospital one physician remembers three unwanted pregnancies among a total of 4000 clients" (source: ACQUIRE/FHI Feb. Trip Report). This is a chance account but quite possibly highlights the fact that there may not be a very high incidence of pregnancies among HIV+ women on ART, although there may also be a number of unreported cases. It definitely is the goal of integration, to improve the access of such women to FP services and therefore increase their chances of not having unintended pregnancies. Integration should therefore help eliminate the incidence of unintended pregnancies if implemented successfully (i.e. if it responds well to clients' and providers' expectations). Certainly, some FP methods do not provide absolute contraception, and or with poor compliance could lead to method failure and result in an undesired pregnancy. Such cases would be dealt with, as existing with support mechanisms for existing family planning services i.e. referrals for appropriate counseling and other services as needed.
The second question about what we know of factors that influence reproductive health decisions or decision-making has a surfeit of literature about it from the global, international and national contexts. Whether we know enough, is another issue. Certainly, enough may not be enough since there is a variety and complexity of local contexts that exist or can be imagined. For example, in the year 2003 report of the Ghana Demographic Health Survey, on p.43 "Only about one-third of married and unmarried women make sole decisions about their own health care. A third of married women report that their husbands make sole decisions about their health care and three-fifths of unmarried women report that someone else makes sole decisions about their health care". Some of the factors underlying these trends are further demonstrated in the report and include apart from marital status, age, rural or urban residence, level of education, employment and wealth. Arguably, several other factors can be identified through other evaluation methods.
The third question about how the health care system can help address these factors can be considered along a variety of dimensions. I find a conceptual model from the ENABLE Project for addressing the issue of empowerment as one of such practical steps. It involves four progressive stages which are:
- Access * Having the knowledge and means to obtain health care, education, credit and other benefits;
- Conscientization * Being aware of women's reproductive rights and able to recognize gender inequities;
- Participation * Being involved in groups and civic activities that directly reinforce one's health and well-being; and
- Decision-making * Having the power to determine how to meet one's own needs in reproductive health and other areas.
In the Ghana FP/ART integration pilot for example, the Access and Conscientization stages are dealt with to an appreciable extent, by way of the training and orientation of service providers to respond to the needs of HIV+ women to the issues concerning their status with the infection and the services accessible. The lack of awareness of women's reproductive rights and of gender inequities, both among health care providers and clients is unquestionably, also a barrier to services. Through increased knowledge of the rights and of existing inequities health care providers are able to assist women to demand services and increase their ability to negotiate with their partners in health decision-making.
---Margaret Butau, Zimbabwe
1. Providers and clients in HIV care settings can arrive at informed decision that meet the clients' FP needs through use the Client Oriented Provider Efficiency (COPE) model. Service providers should always aim at
quality care that is shown by the degree of client satisfaction. Service providers must be knowledgeable, i.e. have the current information on condom efficacy and contraception in relation to PlWHA so that they can be able to share information with the clients and answer their questions. Use of evidence based practices will go a long way in achieving this objective.
2. What has worked so far? (Provision of information on and distribution of condoms at service delivery points, but some service providers are not aware or cannot define Dual Protection)
What will work? There is need to create awareness among service providers and the communities on "Dual Protection" and integrate the services into existing programmes like PMTCT and VCT
Question
What is your opinion on the "Triple Action" which is the addition of protecting fertility?
---Arif Bashir, counselor, National AIDS Contol Programme, NIH, Islamabad
1. If a couple cannot feel satisfaction when using the condom, then what should they use for HIV prevention. For FP they can use any other method but not for HIV.
2. I have met some clients who asked me that they do not release when they use condom, then what suggestion i should give them.
3. Some clients tell me that they do not feel satisfaction with the use of condom, some time allergy problems come with the use of condom. Then what they should they use for safer sex, moreover they have also other sex partners.
RESOUCRES MENTIONED THIS WEEK
Dual Protection from a Gender Perspective
http://www.rho.org/html/menrh_theme-dual.html
HIV Prevention in Maternal Health Services: Training Guide and Programming Guide, Engenderhealth, UNFPA, 2004.
http://www.engenderhealth.org/res/offc/hiv/prevention/index.html
Assessment of Voluntary Counseling and Testing Centers in Kenya
http://pdf.dec.org/pdf_docs/PNADA521.pdf
SHARE YOUR QUESTIONS / COMMENTS
If you haven’t posted a comment or question yet, we have included below many of the important questions that have already come up in the forum. Please take a moment to review the questions and share your comment with us at fphivintegration@ibp.wa-research.ch .
ASSESSMENTS, SITUATION ANALYSES
What other organizations have conducted integration assessments, situation analyses or community diagnoses? If you have done any of these, could you share some of your results or conclusions with the group?
What information do you think would be important to gather during a community diagnosis or situation analysis that is needed to inform integration activities?
WORKING WITH WOMEN VS MEN: IS THERE A DIFFERENCE?
Heidi Reynolds mentioned that in her research she found that providers were discussing fertility and family planning with women more than men. Would others agree with this? Why do you believe it’s more difficult or challenging to discuss fertility and family planning with men? How about with adolescents?
INDICATORS
What indicators do forum participants suggest should be prioritized to monitor FP into VCT integration?
TRAINING
Is whole-site or onsite training, especially for supervisors and managers, a factor with a big impact on whether or not providers discuss family planning? How can we expect big changes when we only train 1-2 people at each site?
SOCIAL, CULTURAL, ECONOMIC FACTORS
Michella Schaan, Botswana asked, “What happens when FP counselling and the provision of contraceptives is already integrated into the clinical setting which is treating HIV-positive women with HAART and many still become pregnant (often times unintentionally)? Do we known enough about the factors which influence reproductive decisions or lack of decision-making? How can the health care system help to address these factors (social, cultural, economic)??
GENDER ISSUES
Abebe Shibru in Ethiopia asked how health providers can overcome the gender inequalities when working with clients. He also asked what kind of skills do providers need to challenge prevailing gender inequalities?
PROVIDER STIGMA
What are some of the root causes of provider stigma? Can anyone suggest some practical ways that provider stigma can be reduced?
HEALTH EDUCATION
How can HIV positive clients be better equipped to articulate their own FP needs when they are receiving services?
VCT COUNSELING
Should there be routine unintended pregnancy risk screening in VCT?
How can providers introduce fertility and family planning discussions in VCT?
What information do VCT providers need from clients to know whether they should spend time counseling them about FP?
Documents mentioned in the forum can also be accessed at http://www.fpandhiv.org/videoconference/cpieventpage.php .