fp/hiv integration translating integration goals into practice in asia caroline francis, associate...

FP/HIV Integration

Translating Integration Goals into Practice in Asia

Caroline Francis, Associate DirectorFamily Health International/Cambodia

Reconvening Bangkok: 2007-2010 – Progress Made and Lessons Learned in Scaling Up FP-MNCH Best Practices in the Asia and Middle East Region, 6-11 March 2010

RECONVENING BANGKOK 6-11 March 2010

Presentation outline

1. What do we mean by “integration”?2. The need for FP/HIV messaging and

services in concentrated HIV epidemics in Asia

3. The challenges – vertical funding streams, policies, centers and programs; dismantling the message; capacity; and commodities

4. Pushing past the challenges – some practical examples of integration in practice and directions for future


What do we (broadly) mean by integration?

Integration =

combining different kinds of RH and HIV services/programs to: • Increase access to FP/RH/HIV, information, services and products• Improve health outcomes of clients (e.g. most at risk populations,

mothers and infants, PLHIV)• Contribute to HIV and FP goals (including United Nations

Millennium Development Goals)


Clients Seeking HIV-related Services

FP/HIV integration is important because -

Share common needs:

often both sexually active and fertile are at risk of HIV infection or might be infected need access to contraceptives need to know how HIV affects contraceptive options and vice versa

Clients Seeking FP Services

AND


FP/HIV integration is important because -

At the individual, community and societal levels

Protects right of women/people with HIV to determine #/spacing of children

Reduces unintended pregnancies and unsafe abortion

Improves maternal/infant health Prevents vertical transmission of

HIV

At a health services/systems level Makes better, more cost efficient use of resources

Systematizes commodities procurement processes

Reduces reporting/ records burden and makes more efficient use of client and provider time


While we know that integration is important, the problem is that . . .

Most of the practical examples are from

Africa, not from Asia

AND

The situation is different in Asia


Concentrated HIV epidemics are the norm in Asia

Source: UNAIDS


Asia has lower fertility rates and better overall contraceptive use than in Africa

FP use (%) TFR

Bangladesh 58 3

Cambodia 40 3

China 90 2

India 56 3

Indonesia 60 2

Lao PDR 32 3

Nepal 48 3

Pakistan 28 4

PNG 26 4

Viet Nam 79 2


Concentrated Asian HIV epidemics demand particular HIV prevention priorities

Maintain focus on condom/lubricant promotion and ensure access in all high risk contexts

Target new tools, messages and approaches to most at risk populations

Interrupt high-transmission networks reach people when they are newly affected and promote positive prevention

Scale up efforts among entertainment workers, male clients, MSM, IDU/DU and PLHIV to reach 60-80% of population


This means that our FP/HIV integration efforts in Asia can also be more targeted

Let’s take two target audiences from Cambodia with significant FP needs:

1. Female entertainment (sex) workers (EWs)

(n= 30,000+; HIV prevalence 14.7% among brothel-based workers)

2. People Living with HIV (PLHIV)

(n= c. 35,000 on ART)


In Cambodia, female entertainment workers use condoms as their primary FP method

PSI/Cambodia TRAC 2009


But it’s clear they have unmet FP needs ...

97%

63%

31%

0%

20%

40%

60%

80%

100%

Condom use at lastsex w/client

Condom use at lastsex w/SH

Had an abortion in last12 months

PSI/Cambodia TRAC 2009


In Cambodia, most of those with HIV are receiving treatment

45%

15%

40%OtherHIV+

(~23,500 adults)

ART(26,551 adults)

OI(8,987 adults)

In 2008, an estimated 59,000 out of 9.4 million adults* were living with HIV in Cambodia…

…this amounts to 0.6% HIV prevalence in the adult population…

…60% of these infected individuals are already receiving antiretroviral therapy (ART) or treatment for opportunistic infections…

Source: NCHADS*Persons aged ≥ 15 years (based on pre-2008 census estimates)


And sexual activity among those on ART increases over time (few report unprotected sex and multiple partners)

Sexually active in the past 6 months, by gender and duration of follow-up

43

52 55 57

79 82

91

23 25 26 2528

36

45

0

10

20

30

40

50

60

70

80

90

100

Enrollment 3 mth 6 mth 12 mth 18 mth 24 mth 30 mth

%MenWomen

Enhanced Patient-Based Longitudinal Assessment of PLHIV on ART (NCHADS and FHI 2008)


The first challenge we face: promoting dual methods for EWs and PLHIV

In HIV prevention, condoms have been promoted as THE FP method for prevention against STIs, HIV and unplanned pregnancy.

But it’s not enough. How can we support PLHIV and EWs to use condoms + an additional method without creating an onerous burden on users?


The second challenge we face: linking FP and HIV services for EWs and PLHIV

From funding streams, to policies, to institutions, to programs, to service delivery . . .

“It’s not my responsibility”


Cambodia’s HIV and FP Response in Action: The “Linked” Response for PMTCT

NMCHC NCHADS

Linked HCLinked HC

Satellite HC

OD RH

PHDNMCHC coordinator

Provincial AIDS officer (PAO)

STI Clinic

MaternityOI and ART

Service

VCCT

VCCT

ANC

ANC

FP/BS

FP/BS

FP/BS

PMTCT

PMTCT


FP referrals are almost nil, for both EWs and PLHIV

0

500

1000

1500

2000

2500

Month One Month Two Month Three

Total DSW andEW

Direct SexWorkers (DSW)

EntertainmentWorkers (EW)

Individualsreferred toVCCT

Individualsreferred toFamilyPlanning

Source: NCHADS 2008

Nu

mb

er o

f in

div

idu

als

Of 2000 EWs/DSWs in 2008 who sought gov’t STI consultations monthly, less than 50% referred to VCCT and almost none referred to FP


The third challenge we face: ensuring health provider capacity for FP/HIV messages, referrals or services

HIV health care providers and implementers in Cambodia have little training in FP, do not give consistent messages . . . and have little motivation to promote FP

(e.g. “I don’t know much about FP”; “condoms are all that’s needed”; “it’s not my job so what’s in it for me?”)


Pushing past the challenges for EWs: Promoting Dual Methods in HIV Prevention

FHI/Cambodia’s SMARTgirl program for EWs uses branding, targeted education and incentives to promote FP methods and service uptake


Promoting dual methods through SMARTgirl

1. Strengthening partnerships with FP service providers (e.g. MSIC, RHAC) and social marketing organizations (PSI) for referrals and products

2. Targeted communications stressing benefits of dual methods and responding to FP misconceptions/beliefs

3. Quarterly training to peer and outreach workers – using tools, making referrals, social marketing

4. Incentives for those who go and those who refer

THE RESULT – less than 10% service uptake after 6 months of intensive focus (we have much work still to do)


Pushing past the challenges for PLHIV – Adding FP to the “linked response”

NMCHC NCHADS

Linked HCLinked HC

Satellite HC

OD RH

PHDNMCHC coordinator

Provincial AIDS officer (PAO)

STI Clinic

MaternityOI and ART

Service

VCCT

VCCT

ANC

ANCFP/BS

FP/BS

PMTCT

PMTCTFP/BS

FP/BS

PPVCCT


Waiting room Doctors

Drug Dispensary

Drug Counselor

PatientsHome/ Community

Monthly visit

• Video spots• Posters/leafletson

PP and FP/RH

Prevention

PP messages • Pregnancy/FP RH/FP STI clinic

Systematic Referrals

NMCH NCHADS

• Key PP messages• Technical advice (pregnancy.)• STI screening • Refer to STI, FP

Psycho-Social and PP

Counseling

Key PP questions• Marriage/partner ?• FP/ baby ?• Last STI checking ?

Systematic Condom distribution

• Adherence• Drug interaction OC/ARV• Condom demonstration if needed

MMM

Triage

HBC

• PP messages• Referral to OI/ART, FP, STI

VCCTPost-test counseling

• Video spots• Posters• Education/information…

FP/RH

Pushing past the challenges for PLHIV – Adding FP to OI/ART sites

Referral or on site ?


Integration in concentrated epidemic settings: some final words1. Extensive “Point of care”/ “one stop” services may not be

needed, or even beneficial in concentrated epidemics. Instead find the openings!

2. There is unmet need for FP among most at risk populations, and condom use is not sufficient. Promotion of dual contraceptive use is key to FP/HIV integration efforts.

3. Capacity building on FP for PLHIV/MARPs is critical for both NMCH and HIV health care providers, and it may be useful to place FP service providers in HIV prevention, care and support services and vice versa (as per TB/HIV integration efforts in Cambodia)


Integration in concentrated epidemic settings: some final words

4. More M&E - We just don't have much in the way of evidence-based models of FP/HIV integration in concentrated epidemics. We need more data on the impact of FP/HIV integration efforts on key health outcomes, such as contraceptive uptake and continuation, prevention of unintended pregnancies, etc.

5. Countries/participants should take advantage of emerging opportunities under PEPFAR and the Global Health Initiative to do integration.


Acknowledgements

1. Rose Wilcher, Family Health International/NC2. Graham Neilsen, Family Health International/APRO3. Laurent Ferradini, Family Health International/Cambodia4. Gautam Bharat Raj, Family Health International/Cambodia5. Peter Cowley, Family Health International/Cambodia6. Somany Ngor, Family Health International/Cambodia7. Population Services International/Cambodia

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