Integrating Family Planning into HIV Care/ART Services in Uganda

Author(s):

Ibrahim Kirunda

Topics: FP-HIV integration, HIV/AIDS, HIV/AIDS basic care and support, Reproductive Health

Region and Country: Africa, Sub Saharan, Uganda

Organization: USAID Health Care Improvement Project/URC

The Report

Problem:

The Ministry of Health in Uganda identified prevention of HIV infection and improvement of linkages between family planning (FP) services and HIV care and support as a priority for its national Quality of Care Initiative in HIV Care. Integration of FP and antiretroviral therapy (ART) services in Uganda had not previously been given proper attention in the push to expand ART services in the country. The only commonly used FP method was a condom, but even then, condoms were given for prevention of re-infection but not for family planning, although they are an important method of dual protection.

As part of a national improvement collaborative to improve ART and other aspects of HIV care and treatment, 10 teams participating in the collaborative volunteered to give a specific focus to improving the integration of family planning and HIV/AIDS services. Sites participating in the collaborative had reported increasing numbers of pregnancies among HIV-positive clients on ART and lacked FP services in the same clinics. Thus, a new emphasis on improving FP-HIV integration was added for a new group of teams that joined the collaborative in January 2007. While 13 teams originally asked to participate, another 2 teams later began monitoring progress in FP-HIV integration, for a total of 15 sites focusing on this process out of the 84 teams participating in the collaborative at that time.

Intervention:

New improvement indicators were added to monitor the percentage of HIV-positive clients of reproductive age who were counseled on FP methods, who were using at least one FP method, and, of those not using a method, who were referred elsewhere for FP services.

During the collaborative’s learning sessions, when teams came together to share experiences and results, the FP-HIV teams received additional training in family planning counseling and provision of contraceptive methods (in accordance with national guidelines) for HIV-positive patients and in using the national HIV Care/ART Card to collect data on FP service provision. The MOH provided FP supplies at no cost to these HIV service delivery points and also provided each health unit with a copy of the National Policy Guidelines and Service Standards for Sexual and Reproductive Health. At the learning session, teams developed action plans that identified changes they would introduce in their sites to increase use of family planning services.

Changes made by the teams have included:

- Providing additional on-site training in FP to all staff in the HIV clinic

- Providing group counseling to all patients on FP so as not to add much to provider work load or increase patient waiting time

- Asking patients using FP to share their experiences with other patients

- Ordering FP/HIV job aids from the MOH and displaying these in the HIV clinic

- Placing FP counseling materials and contraceptives in the same rooms where HIV care was delivered so that they would be readily available for clients who desired them

- Increasing the use of the HIV Care/ART Card and reviewing cards to ensure that data were recorded correctly

- Conducting special training sessions for men to facilitate women being able to choose to use family planning methods

Results:

Results from the 15 sites show sustained improvement in counseling on FP methods and in FP use. The percentage of HIV-positive patients of reproductive age who were counseled on family planning at their last clinic visit increased from 42% in January 2007 to 98% by January 2008. The percentage of HIV-positive patients of reproductive age seen in the clinic who report they are currently using at least one family planning method rose from 51% to 81% in the same period.

Over the course of the year, providers at the pilot sites reported that they could see several advantages to integration, particularly making services more easily accessible for clients, who did not feel comfortable going to another clinic where they were not familiar with the health providers. Clients were happier that they were no longer inconvenienced to walk to separate FP clinics for the services.

Lessons:

The MOH provided supportive policy guidelines and service standards for sexual and reproductive health, including FP-HIV care integration, which was important. Because the national MOH reproductive health program provided user-friendly contraceptive request forms and lines of credit for facilities to ensure availability of method mix and mechanisms for promoting informed choices at sites, integration became possible, even in rural facilities. The collaborative organized providers at each participating ART site to make use of these resources, and to monitor, on a monthly basis, their performance on FP-HIV indicators and have a measure by which to gauge how they were improving. Seeing positive results helped to motivate providers in ART clinics to sustain their efforts to make family planning services available for HIV clients.