Online Discussion Forum
March 5, 2007
Daily Digest #1
Welcome to the online forum on “Improving Client Provider Interaction: Responding to Clients’ FP Needs in HIV/AIDS Service Settings”. This forum will run for two weeks, beginning today (March 5) and ending on March 16. We have an exciting schedule planned for this forum with a panel of experts who will be available to answer questions and participate in the discussion.
We have included additional readings and resources on this topic at http://www.hivandsrh.org/videoconference/videoconference2007/index.php. (if clicking on this link doesn’t take you to the website, please cut and paste the entire link into the address section of your web browser).
We hope that this forum will provide you with up-to-date and state-of-the-art information on what is happening in the field and an opportunity for synergy between sharing global best practices and country-based experiences. This online forum will build upon existing partnerships and activities among three groups: the Implementing Best Practices in Reproductive Health Initiative (IBP) Initiative, the USAID Maximizing Access and Quality Subcommittee on Client Provider Interaction (CPI), and the USAID Family Planning and HIV/AIDS Integration Working Group.
We begin the discussion by summarizing the three presentations from the March 1 Videoconference on the same topic (please read below for summaries). We have also included questions for discussion below, some of which were sent as a follow-up to the videoconference event. The videoconference and corresponding PowerPoint presentations are archived at http://www.hivandsrh.org/videoconference/videoconference2007/
Throughout the week, feel free to send questions or comments, as well as submit your own experiences, findings or lessons learned on CPI as it relates to clients’ FP within HIV/AIDS service settings to fphivintegration@ibp.wa-research.ch. Or you can simply click "reply" to this e-mail and post your comment.
We look forward to rich and interesting discussions. Thanks for participating!
Best regards,
HCP and INFO Teams
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Contraceptive Needs and Preferences of PMTCT Clients in South Africa, Dr. Jennifer Moodley, Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town
Dr. Moodley presented the results of a collaborative study conducted by the Women’s Health Research Unit (WHRU) and Family Health International. The objectives of the study were to assess the contraceptive needs and preferences of clients in PMTCT clinics in South Africa and to evaluate the capacity of antenatal care, delivery services and child health services to meet the contraceptive needs of PMTCT clients. The study was also designed to assess the capacity of family planning services to meet the needs of HIV+ women and to identify ways to improve access to FP services by PMTCT clients. South Africa has a growing number of women who are pregnant and HIV positive. This study will also provide baseline information for designing future interventions aimed at facilitating the use of contraception by PMTCT clients. Dr. Moodley and her colleagues conducted structured observations in three types of clinics in both urban and rural areas of two provinces. They also plan to conduct focus group discussions with providers and a workshop with program managers. So far they have developed a demographic profile of clients and their partners. Most women involved in the study were between the ages of 16 and 40 and had 1 to 2 other children. They tended to be unemployed and married or in a stable monogamous relationship. Most had used family planning in the past and did not want to have another child. 90% said they would use contraception after delivery. Favored methods were the condom and the injectable. Dr. Moodley and her colleagues also asked questions about history of use of family planning, fears about safety of FP methods, interest in FP, exposure to counseling and service delivery preferences. They concluded that many of these women face a risk of repeat pregnancy. The women have misconceptions about the safety of some contraceptive methods. They have not received good counseling so far but expressed a desire to receive better counseling in the future.
***QUESTION: Jennifer Moodley mentioned in her presentation at the videoconference that the HIV+ women they observed in South Africa seemed to have misconceptions about the safety of some contraceptive methods. In your own experience, do women in your country have similar fears and misconceptions about the safety of some methods? If so, which methods? What are their fears? How have you or other providers tried to change their misconceptions?
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Integration Prevention, Counseling and Testing for HIV into Family Planning Services in South Africa, Dr. Saiqa Mullick, Population Council (Frontiers)
Dr. Saiga Mullick discussed the results of a study to integrate prevention, counseling, and testing for HIV into family planning services in South Africa. The objectives of this study were to evaluate two models of integration on feasibility, acceptability, cost and quality of family planning and develop and evaluate a “best’ model for effectiveness. In the “High level integration” model, FP providers were trained to routinely offer counseling and testing as well as to conduct testing if required. In the “Low level integration” model, FP providers trained to routinely offer counseling and testing but refer clients to vertical service for testing. This project was implemented in two phases at clinics which provide FP services, have a high volume of FP clients, have more than one professional nurse, conduct HIV testing, and provide STI treatment. In the first phase, feasibility, acceptability, quality of FP and cost were evaluated and client-provider interaction was observed and exit interviews were conducted pre and post intervention. In the second phase, the effectiveness of a “better” intervention model in increasing VCT and dual protection was compared to standard practice and evaluated. In both interventions, family planning services were standardized and strengthened through training providers in the “Balances Counseling Strategy” (BCS) approach to family planning. In this strategy, the client is given information and a choice on the narrowed down set of appropriate contraceptive methods. The information is also given to the client via pamphlets. Cards on STI/HIV risk and dual protection were also used during the session to ensure that STI risk information is provided during all consultations (“BCS plus”). In both the “high level” and “low level” models of integration, reproductive history taking increased, providers’ mention of condoms as well as instructions for how to use condoms increased, providers’ mention of dual protection and discussion of counseling and testing improved, clients’ reporting condom use at last sex, clients’ ever having had an HIV test and clients’ partner having had an HIV test improved. In the high level model, there was no significant change in discussion of contraceptive methods from pre to post intervention. More clients reported always use of condom after the implementation of the low level model; fewer clients reported always use of condom after the implementation of the high level model. Results indicate that integration of HIV prevention and the routine offer of testing in FP settings are feasible and do not negatively impact on quality of existing FP services. Dr. Mullick and colleagues are currently modifying the intervention to improve linkages with other services and to incorporate status specific care into FP services.
**QUESTION: Saiqa Mullick described a "Balanced Counseling Strategy” (BCS) approach to family planning in her presentation at the videoconference. In this strategy, the client is given information about a whole range of family planning methods available and the provider helps the client make a choice among appropriate contraceptive methods. The provider is trained to use an algorithm to help narrow down the choices and is equipped with job aids and communication materials to share with the client. At the same time, providers are trained to stress the importance of condom use for dual protection. In your own experience, how often do providers spend time helping clients decide on which family planning method is best for them? What is the best way to explain dual protection to clients who have selected other family planning methods?
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Integration of RH/FP and HIV/AIDS Activities: Experience of Pathfinder International from Implementing Best Practices (IBP) and Other Initiatives, Dr. Mengistu Asnake, Pathfinder International
Dr. Asnake discussed three experiences of integrating family planning (FP) and HIV/AIDS services in Ethiopia. The goals of these activities include:
1) increasing access to FP information and services in VCT/PMTCT settings
2) expanding FP services to HIV positive couples in order to prevent unintended pregnancies and mother to child transmission of HIV
3) reducing stigma and discrimination at VCT/PMTCT sites; and
4) identifying, selecting, and promoting best practices in integration.
All activities are supported by the Implementing Best Practices (IBP) Initiative. The first activity took place at 64 individual facilities (hospitals and health centers) in four regions of Ethiopia. The second took place at the community level; all CBRHAs took part in a refresher training in order to provide information on FP and HIV/AIDS to clients, provide condoms and pills, and refer clients to other FP methods as well as VCT and STI treatment. The third was designed to integrate FP into an existing HIV/AIDS care and support program. After these activities were implemented, a significant reduction in stigma and discrimination was observed. Dr. Asnake and colleagues note that challenges include high turnovers of trained providers at facility levels, seasonally high workloads and provider burnout, limited choices of FP methods at VCT sites, and little emphasis on FP counseling within HIV counseling trainings. Future plans include scaling up integration at more facilities, operational research on the process and outcomes of integration, and sharing experiences with other researchers.
**QUESTION: Dr. Asnake from Ethiopia talked about a strategy for reducing stigma and discrimination. He explained that, before training, many VCT counselors believed that HIV+ clients should abstain from sex completely. They did not even see a reason for discussing family planning with their HIV+ clients. After receiving training, counselors in VCT clinics were able to provide their clients with condoms and pills directly and refer them to other sites for other family planning methods. In your own experience, either as a provider or client, have you seen examples of provider discrimination and insensitivity to HIV+ clients? What has been done in programs in your country to address this problem?
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FOLLOW-UP QUESTIONS TO THE VIDEOCONFERENCE
1. Good Morning and Good Evening.
Two short questions from Jerusalem, Israel.
My name is Dr Inon Schenker. I am a Senior HIV/AIDS Prevention Specialist with the Jerusalem AIDS Project, which is an international NGO focusing on AIDS Prevention. We are also a national focal point in Israel on Male Circumcision and HIV/ AIDS.
This is a very informative video conference and congratulations to the organizers.
My Two questions:
1) To Peter of RHR in WHO/Geneva: What do you think could be the limitations of having FP services as the entry point to male circumcision services for HIV/AIDS prevention in Africa?
2) To Pamela at CDC/Atlanta: You mentioned a new initiative in training health care professionals. Could you comment on the issue of providers' gender: With the expected high flow of new male clients into FP\HIV services in Africa mostly to obtain male circumcision – is there a need to encourage more male providers in your trainings?
Thank you very much for addressing these questions
this morning.
Dr Inon Schenker, Isreal
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2. Warm greetings to all,
First, I wish to express my gratefulness for the very opportunity
After having attended the interactive video conference session of March 01, I feel that I have one major item of discussion of international perspective and that is: positions, application experiences, effectiveness (impacts), challenges, and solutions in relation to the opt out (provider initiated) counseling in the context of family planning/RH and HIV/AIDS integration and in the various settings, please. I had wanted to raise this point during the progress of the conferencing but time was quite a factor then. Many thanks.
With best regards,
MULUGETA Betre Gebremariam (MD, MPH)
Instructor, Assistant Prof., Behavioral and Reproductive Health Sciences
Department of Community Health, Faculty of Medicine, Addis Ababa University
Addis Ababa, Ethiopia