Elements of Family Planning Success

Major opium trafficking routes traverse rural Iran, but patterns of drug use and HIV infection in these areas are unknown. In 2004, Iran's Ministry of Health integrated substance use treatment and HIV prevention into the rural primary health care system. Active opium or heroin users (N = 478) were enrolled in a rural clinic. Participants received counseling for abstinence from substances, or daily needle exchange and condoms. On enrollment, 108 (23%) reported injecting; of these, 79 (73%) reported sharing needles. Of 65 participants tested for HIV, 46 (72%) tested positive. Participants who received daily needle exchange/condoms stayed in the program longer than those who did not (AOR 2.08, 95% CI 1.1-3.88). This project demonstrates that HIV risks exist in rural Iran and suggests the innovative use of Iran's rural health care system to extend prevention and treatment services to these populations. (author's)

Integrating counseling and testing (CT) for HIV into family planning (FP) services potentially increases the range of services available for FP clients, many of whom are at risk of STIs including HIV in high prevalence settings. Systematic evidence about offering CT in FP settings has remained extremely limited, despite the widespread interest in this model of FP-HIV integration. FRONTIERS supported the Division of Reproductive Health (DRH) and the National AIDS and STI Control Program (NASCOP) of the Kenya Ministry of Health (MOH) to design, implement and compare two models of integrating CT for HIV within FP services in 23 health facilities in Nyeri and Thika Districts of Central Province, Kenya in terms of their feasibility, acceptability, cost and effect on the voluntary use of CT, as well as the quality of FP services. The study utilized a pre-post intervention design to obtain information from FP providers and their clients in 2006 to 2007. Data were collected through provider-client observations (554 at baseline and 530 at endline) and client exit interviews (552 at baseline and 530 at end line), pre and post intervention interviews and focus group discussions with health providers, and a health facility assessment of the readiness of facilities to offer HIV CT within FP services. Introduction and implementation involved: (a) holding sensitization meetings at national, provincial and district levels; (b) reviewing and developing training materials; (c) application of the Balanced Counseling Strategy (BCS) Plus approach; (d) modification of facility registers to record the required data; and (e) training of health providers. The MOH provided all required equipment and supplies, including HIV rapid test kits and FP commodities. Two models were pilot-tested. The "testing" model was implemented in Nyeri District, an area with relatively few VCT sites. In this model, FP clients were educated about HIV prevention generally, and CT in particular, and offered HIV CT during this consultation by the FP provider. The "referral" model was implemented in Thika district, an area with good accessibility to VCT services. In this model, FP clients were educated about HIV CT, and those interested were instead referred to a specialized CT service, either within the same facility or to another CT service (at another health facility or a stand-alone VCT center). The study demonstrated that both models were feasible and acceptable to providers and to clients as means of integrating and linking HIV prevention counseling, condom promotion and counseling and testing with FP services, and are effective in increasing quality of care and service utilization. (excerpt)

In Uganda, there is an urgent need for quality, voluntary family planning (FP) services to help people living with HIV (PLHIV) achieve their fertility intentions and to reduce HIV incidence. The AIDS Support Organization (TASO), one of the leading local nongovernmental organizations (NGOs) in Uganda providing HIV counseling, prevention, care, treatment, and support services to PLHIV, provides services in 11 centers and 15 minicenters. TASO clinicians and administrators struggle to meet the FP needs of PLHIV who arrive at their clinics with unplanned pregnancies and/or incomplete abortions. Although TASO/M has provided limited FP services to ART clients on an ad hoc basis since 2004, it lacked a comprehensive FP program. The ACQUIRE Project-in collaboration with TASO/M and the Ugandan Ministry of Health (MOH) implemented an FP-ART integration pilot from March 2006 to April 2007 with the launching of FP services in September 2006. This report details the results of a retrospective evaluation conducted by ACQUIRE in November 2007, using a case study methodology to assess its FP-ART integration pilot, including its effect on the program processes and FP method mix and uptake at TASO/M.

Summarizes a study to: 1) evaluate two models of integration on feasibility, acceptability, cost and quality of family planning, and 2) develop and evaluate a "best" model for effectiveness, improving VCT uptake and enhancing the practice of dual protection. Client provider observations and exit interviews pre and post intervention were used. Conclusion reached that there is a rationale and need for integration of HIV into FP services in South Africa.

Provides an overview of integrated PMTCT/FP activities supported by IntraHealth under the Capacity Project in Rwanda.

HIV-positive women may be reluctant to attend gynaecology or family planning clinics for fear of divulging their condition. Therefore, a referral clinic was opened within the HIV clinic. Retrospective case-note reviews of 197 new patients revealed 109 with a variety of medical gynaecology conditions (menorrhagia being the commonest) and 88 sought contraception. The full range of contraceptives was used, including Mirena for the treatment of menorrhagia as well as contraception and the combined pill adjusted for interaction with liver enzyme-inducing antiretroviral drugs. The acceptance of contraceptive advice and gynaecological evaluation by the patients has resulted in improved reproductive health services for these HIV-positive women. In centres with large cohorts of HIV-positive women, this type of one-stop specialist clinic will be very effective in providing high-quality reproductive health care and hence, this type of clinic is recommended for such centres. (author's)

Globally, both the disjunction between sexual and reproductive health and HIV/AIDS, and the fact that HIV/AIDS has taken over the political and funding agenda, are well noted. A recent editorial in the journal, Reproductive Health Matters, summed up this trend, noting that although HIV/AIDS has been with us for more than two decades, "now, suddenly, following rapid shifts in political leadership, priority setting, power brokering, and funding policies in international health and development circles, it is widely considered an unassailable fact that in the global 'competition' for resources and attention, sexual and reproductive health has less priority and has lost out to AIDS, as if addressing the one had no connection with addressing the other". Has this trend been realized in Vietnam? If so, what are some of the factors that have shaped this trend and which of its characteristics should Vietnam take into account moving forward? (excerpt)

As DELIVER comes to an end, the liaison between commodity security and the supply chain has become more evident. There can be no security without a responsive supply chain managed by dedicated, well-trained professionals operating in a supportive management environment. DELIVER activity in Nigeria focused on development of improved logistics systems for reproductive health (RH) and HIV/AIDS program commodities. Consistent with DELIVER and Federal Ministry of Health (FMOH) objectives, DELIVER worked with the FMOH/Department of Community Development Population Activities (RH) and FMOH/National AIDS/STD Control Program (HIV/AIDS) to implement programs of national scale by collaborating with larger partners. Improving human capacity in logistics among key stakeholders was a DELIVER core activity. Since 2002, DELIVER, working with the FMOH and other partners, has trained approximately 2,000 government and nongovernmental organization logistics managers on the FMOH contraceptive logistics management system (CLMS) and 363 logistics managers and service providers on a streamlined CLMS in 2006. In addition, 142 FMOH personnel were trained in quantification, procurement planning, and the newly designed logistics system for antiretroviral drugs and HIV test kits. (author's)

The pilot phase 1999-2003 Women and Infants' Health (WIN) project and the scale-up phase 2003-2006 Maternal and Child Health Initiative (MCHI) integrated family planning into the spectrum of maternal and infant health care in 16 regions of the Russian Federation. WIN/MCHI's innovative design helped regional and municipal government-supported health facilities adopt internationally recognized, client-centered, evidence-based maternal and child health standards and practices in multiple areas: antenatal care; family-centered maternity care; essential newborn care; exclusive breastfeeding; and family planning counseling and services, especially for postpartum and post-abortion clients. Attention was also given to family planning for HIV-positive women and the prevention of mother-to-child transmission of HIV. The objectives were to provide a new evidence-based model for reproductive health care services and to increase access to, demand for, and quality of these services, as well as to increase the practice of preventive health behaviors among women in the community. WIN/MCHI chose strategies that not only stressed evidence-based medicine but that also offered a total paradigm shift from focus on the provider to focus on the client, a shift that transformed the way maternal and infant services were delivered. Implementation involved health care providers, administrators, and authorities in the planning, policymaking, hands-on training, and public education needed to achieve change. This case study looks specifically at the integration (horizontalization) of the family planning component into the other WIN/MCHI components. As a result, access to client-centered counseling has increased, unplanned pregnancies have decreased, and the abortion rate has declined. (author's)

For individual women who want to postpone pregnancy, their options for family planning are: discuss dual protection using male or female condoms every time (learn correct use, negotiate with partner); present options for dual method use: pills, injectables, implants, IUCD, LAM if postpartum, natural FP, and Fertility Awareness-Based Methods (FABMs); inquire if ability to disclose HIV status is a factor in FP options/condom negotiation. For couples who want to postpone pregnancy, the options are: encourage fidelity in marriage and explain importance of protecting family by staying negative; encourage correct and consistent condom use for any risky sex (partners outside marriage); discuss dual protection using condoms every time (learn correct use, negotiate with partner); present options for dual method use: pills, injectables, implants, IUCD, natural FP/FABMs. (excerpt)

In as much as the conference theme referred to linking RH and FP with HIV/AIDS programs in Africa, many of the research presentations, and thus meeting discussions, centered on "integration" features, such as adding one service into the other, cross-training providers in counseling, provision of dual protection methods, behavioral change communication with youth, and policy coordination. Without an operating definition for integration the conferees were not able to arrive at a clear consensus on whether integrating services for reproductive health and family planning with those for HIV/AIDS would be effective in addressing prevention of adverse pregnancy and sexual behavioral outcomes. However, these sentiments belie what was a rapidly expanding body of knowledge generated through study findings shared at the two-day conference. Many researchers were pleasantly surprised at the extent of parallel and intertwined threads of investigations being pursued by other colleagues in African and non-Africancountries. Although the structural aspects of integration, such as how services are organized, administered and physically located, needed to be distinguished from their policy and financial underpinnings, conferees quickly recognized the complexity of linking two major health program areas. (author's)

Meeting the unmet health care needs of young people poses a continuing challenge for health systems worldwide, yet it is critical to containing the AIDS epidemic and reducing unintended pregnancies. An integrated approach to the delivery of reproductive health care expands youth access to health care by making multiple services available at the same facility, during the same hours, and often from the same provider. Integrated services for young people address the two major risks associated with unprotected sex-that is, unintended pregnancy and sexually transmitted infections (STIs), including HIV/AIDS. In addition, some integrated programs address other issues, such as sexual abuse or maternal and child health care. This report highlights tools that managers can use to integrate reproductive health, family planning, and HIV/AIDS services for young people. The tools described here, and the examples that illustrate their use, are drawn from USAID and other donor-funded programs. The tools are designed to help programs: make integrated services youth-friendly-that is, increase their ability to attract and retain young clients, train providers on how to offer integrated services to young people, develop job aids that help providers offer a wider range of services, and raise awareness of and gain community support for integrated services for young people. (excerpt) | Cubrir las necesidades insatisfechas de salud de los jovenes constituye un continuo desafio para los sistemas de salud en todo el mundo, no obstante, es algo esencial para contener la epidemia de SIDA y reducir los embarazos involuntarios. Un enfoque integral para la prestacion de servicios de salud reproductiva amplia el acceso de los jovenes a la atencion de salud, permitiendo que haya múltiples servicios en el mismo establecimiento, en el mismo horario y, con frecuencia, con el mismo proveedor. Los servicios integrales para jovenes atienden los dos riesgos principales asociados con el sexo sin proteccion, es decir, el embarazo involuntario y las infecciones de transmision sexual (ITS), incluyendo el VIH/SIDA. Ademas, algunos programas integrales se ocupan de otras cuestiones, tales como el abuso sexual o la atencion de salud materno-infantil. Este informe destaca las herramientas que los gerentes pueden utilizar para integrar los servicios de salud reproductiva, planifi cacion familiar y VIH/SIDA para jovenes. Las herramientas aqui descritas, y los ejemplos que ilustran su uso, son tomados de la Agencia de los Estados Unidos para el Desarrollo Internacional (USAID, por sus siglas en ingles) y de otros programas fi nanciados por agencias donantes. Las herramientas estan diseñadas para ayudar a los programas a: 1) hacer que los servicios integrales esten orientados a las necesidades de los jovenes-es decir, aumentar su capacidad de atraer y retener a los clientes jovenes; 2) capacitar a los proveedores sobre como ofrecer servicios integrales a los jovenes; 3) desarrollar materiales de trabajo que ayuden a los proveedores a ofrecer una gama de servicios mas amplia; y 4) crear conciencia en la comunidad y ganar su apoyo para los servicios integrales para jovenes.

The health of women in the developing world is a growing priority for the global community. We are increasingly aware of women's vulnerability to AIDS and other diseases-and the cultural factors that can reduce their opportunities to live healthy lives. At the same time, there is ever-greater recognition of women's enormous influence on the health and well-being of their communities. PATH has been a front-runner in the race to offer women better health solutions since our first project, in the late 1970s-helping manufacturers in China set up facilities for producing high-quality condoms and other contraceptives. Today PATH's work extends across the spectrum of women's health. The projects highlighted in this issue of Directions range from better care for mothers and infants to new options for woman-initiated protection against HIV to programs that help give women an equal chance at a healthy life. We anticipate that over the next decade, the investment in women among PATH and organizations like us will only continue to deepen. When women are healthy, so are their families and communities-the starting point for a stronger, more stable world. (excerpt)

Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents' demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents' capacity to provide integrated services than demographic characteristics, while agents' gender and work-related characteristics are significantly associated with increased likelihood of serving more clients. (author's)

The project design included activities to support the HIV/AIDS program at the national level. It involved mobilizing private and parastatal businesses to initiate HIV interventions; supporting nongovernmental organizations (NGOs) and other networks to expand coverage; improving blood safety; strengthening sero-surveillance and behavioral surveillance; and supporting prevention and care initiatives. In 2000, with USAID's Leadership and Investing in Fighting an Epidemic (LIFE) Initiative, FHI expanded IMPACT/Kenya's geographic coverage from five to ten community sites in the three provinces and broadened its focus to include activities linking prevention, care, and psychosocial support. In 2003, IMPACT/Kenya adapted to address priorities put forth by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). As a result, IMPACT increased its focus on care and treatment and linked it to the prevention, care, and support program. Likewise, the communication response evolved from purely a preventionprogram to include treatment and support messages and prevention in the care setting. Nairobi was also added as a priority region. (excerpt)

FHI IMPACT/Bangladesh began activities in 2000 to support interventions for people most vulnerable to HIV. To date, FHI Bangladesh has received US$14,225,000 to lead the response to fight HIV in Bangladesh. FHI has supported USAID/Dhaka's strategy and the Bangladesh Ministry of Health's priorities by concentrating efforts on those groups most vulnerable to HIV/AIDS in this low prevalence setting. The FHI IMPACT Program, in collaboration with other key players, worked to reduce HIV/AIDS vulnerability among several high-risk groups including female, male, and transgender sex workers and their clients, men having sex with men (MSM), and intravenous drug users through targeted interventions. The IMPACT/Bangladesh program supported behavior change and care and support programs of a wide range of community-based organizations, including faith-based organizations, nongovernmental organizations (NGOs) and groups for people living with HIV and AIDS (PLHA). By 2005, IMPACT/Bangladesh was managing sub-agreements with 18 implementing agencies. Program priorities included national surveillance system strengthening, behavior change communication to reduce risk and vulnerability to HIV (including condom promotion among high-risk populations), improving management of sexually transmitted infections (STIs), and building capacity of government and NGO partners to plan, implement, and monitor HIV/AIDS interventions. (excerpt)

Operations research by Family Health International (FHI) and partners to evaluate the integration of family planning into voluntary counseling and testing (VCT) in Kenya suggests that it is feasible and acceptable. The intervention in 14 VCT centers improved several aspects of family planning provision without compromising VCT services. However, although a large proportion of VCT clients were considered at risk of unintended pregnancy, the intervention had little effect on contraceptive method choice or distribution. Advocacy and training activities should stress the importance of screening VCT clients for risk of unintended pregnancy with the goal of reducing unmet contraceptive need. VCT quality of care and contraceptive method choice, distribution, and uptake should continue to be monitored. (author's)

The international community and U.S. government are increasingly concerned about the prevalence of child marriage and its toll on girls in developing countries. One in seven girls in the developing world marries before 15. Nearly half of the 331 million girls in developing countries are expected to marry by their 20th birthday. At this rate, 100 million more girls-or 25,000 more girls every day-will become child brides in the next decade. Current literature on child marriage has primarily examined the prevalence, consequences and reported reasons for early marriage. Much less has been analyzed about the risk and protective factors that may be associated with child marriage. Also, little is known about the range of existing programs addressing child marriage, and what does and does not work in preventing early marriage. The work presented here investigates two key questions: What factors are associated with risk of or protection against child marriage, and ultimately could be the focus of prevention efforts? What are the current programmatic approaches to prevent child marriage in developing countries, and are these programs effective? (excerpt)

In Sub-Saharan Africa, HIV affects women disproportionately, particularly young women. In many of the worst-hit countries of the region, 10% to 30% of pregnant women are HIV-positive (UNAIDS). Family planning (FP) can help ease the burden of HIV and limit new occurrences of HIV infection by decreasing unintended and unwanted pregnancies in HIV-positive women, thereby preventing the transmission of HIV from mother to child. Not only is FP the most effective measure in the prevention of mother-to-child transmission of HIV (PMTCT), but it also improves the health and well-being of families by facilitating the spacing or limiting of births. Additionally, condoms-an FP method-prevent transmission of HIV to a partner. FP is an integral component of safe and comprehensive HIV treatment and care services. However, it is often overlooked as a preventive measure, as the health care system's focus is primarily on offering curative care or responding to the medical and social needs of HIV-positive women and couples. In addition, society has often presumed that people living with HIV (PLHIV) should not have sex or bear children. However, now that HIV is becoming more controllable due to the increased access to antiretroviral therapy (ART), an increasing number of PLHIV are living longer and fuller lives and planning families. They have the same right to and need for comprehensive, safe, and effective FP as their uninfected peers. Meeting the FP and reproductive health rights and needs of PLHIV should be a high priority. The World Health Organization (WHO) has taken an important step by updating its international guidelines and including contraceptive methods that can be used by HIV-positive women. (excerpt)

Integrating voluntary HIV counseling and testing (VCT) with family planning (FP) and other reproductive health (RH) services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit reproductive health clinics, we constructed multi-level logistic regression models to examine associations between family planning (FP) and HIV service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility FP-HIV integration level and the likelihood of VCT clients being atypical FP client-types, versus older (25+ years), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering FP and HIV services in the same rooms were 2-13 times more likely to serve atypical FP client-types than older, ever-married women. Facilities where counselors jointly offered FP-HIV services, and served many repeat FP clients, were significantly less likely to serve single clients relative to older, married women. Facilities offering many youth services were even more likely to provide older, married women with VCT services than youth, which may be explained by these facilities' use of highly integrated service delivery. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 percent and 80.6 percent, respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 percent and 34.2 percent, respectively). Compared with facilities offering co-located services, those integrating services at room and counselor-levels were 1.9 - 7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard MCH clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics. (author's)