The Integra initiative, which evaluated different types of sexual and reproductive health (SRH) and HIV services integration in Malawi, Swaziland and Kenya, has released key findings at the Integration for Impact conference being held in Nairobi this week (12 -14 September).
The Bill and Melinda Gates Foundation-supported initiative ran between 2008 and 2012 to gather evidence on the costs and benefits of using different models for delivering integrated HIV and sexual and reproductive health services (SRH) in high and medium prevalence settings.
Integration of HIV and SRH: the four models
The first model, evaluated in Kenya, integrates HIV services into family planning services. Within a family planning context, HIV counselling and testing, STI screening and management, HIV care and treatment through the provision of ART and referrals for HIV positive clients is also offered.
The second model, evaluated in Kenya and Swaziland, integrates HIV services into post natal care and family planning. Services offered include HIV counselling and testing, which includes repeat testing for mother and infants and HIV care and treatment, which includes ART provision, as well as referrals for HIV positive clients.
Integrated HIV and SRH services in International Planned Parenthood Federation (IPPF) clinics in Kenya, Malawi and Swaziland were also evaluated. Within this model, HIV counselling and testing, STI screening and management, HIV and treatment – including ART provision and referral of positive patients – and cervical cancer screening are embedded with maternal and child health, family planning and youth-friendly services.
A fourth prong of research compared a number of integrated and stand- alone HIV services in Swaziland. It evaluated a clinic offering fully integrated SRH/HIV services in one room, a clinic offering partial integration, with different providers offering SRH and HIV services in separate rooms, a hospital offering stand alone HIV services, and a stand-alone HIV clinic.
The data collected shows the benefits of integrating SRH and HIV services, something that is of great importance to Sub Saharan Africa in an era of limited resources and increasing health challenges.
Dr. Lawrence Oteba, SRH and HIV linkage advisor at IPPF African region office, said these innovations have “demonstrated that integrating SRH and HIV is an effective and efficient strategy. This is because it maximises space and human resource utilisation when a lot is being done in one space. This drastically cuts down on operational costs.
“There are also the immense benefits of task shifting, as we experienced in Malawi. When we started in Malawi in 2008, where there are few doctors, only doctors could initiate patients on ARVs, and there were just 30,000; the total number of clients for integrated SRH and HIV services provided by Family Planning Association of Malawi a member of IPPF. But in this model intervention, we trained clinical officers and by 2011 we had 359,000. This demonstrates the impact of integration on increasing access to services.”
Dr Oteba added: “The quality of care is also improved from the provider’s perspective, in that they become confident to deal with their clients and there is a resulting job satisfaction. But in addition, the clients are also able to reduce the costs (like travelling to the facility several times) when they can access all the care they need in one place and at one go. And we have been able to influence policy makers in Kenya, Swaziland and Malawi after them realising that, with integrated SRH and HIV services, costs are cut.”
Can integration benefit people living with HIV (PLHIV)?
According to Wesley Kumwenda from the Network of Journalists Living with HIV (Joneha) in Malawi: “As an individual, I would not mind even a stand- alone facility for getting HIV related services, because I am already beyond stigma. But for other members who are living positively with HIV, several milestones still have to be achieved in order to ensure they get all the services they need without fear…for encouraging such PLHIV to use the integrated SRH and HIV services these amenities must be provided without stigma.”
Views of a Kenyan youth on integration
Annrose Kibutha, a young girl working with Liverpool VCT, says: “As a young person, when I go to a service provider for services, my friends and I need to be told the advantages and disadvantages of using a particular method, for instance of family planning. When I enter a service place, I do not want people to know what I am getting from there – therefore if it is a youth clinic I do not want inscriptions written like ‘post – abortion clinic’, ‘STI clinic’, or ‘post abortion services provided here’. Everyone would know that I made an abortion.
“The greatest challenge my friends and I have encountered is the attitude of the service providers. These nurses in these facilities behave as if they are our mothers. They would ask you, why are you taking this and not that? They do not give us the good audience. We generally need youth friendly services, not a clinic where you enter and nurses look at you as if you have committed a crime.”
Fortunately, these fears were noted during the Integra based studies on integration for SRH and HIV in Kenya, Malawi and Swaziland. Key recommendations have been made that address issues of stigma among key populations at higher risks.