This third episode will cover the integration of family planning with HIV services, an approach that shows significant potential to improve access to family planning and better meet SRH needs overall. Our guests this episode will provide their perspective on why integration is important, what challenges still exist, and what evidence-based recommendations they have for strengthening services to better meet people’s comprehensive SRH needs.
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From Knowledge SUCCESS and FHI 360, this is Season 6 of Inside the FP Story—a podcast developed with the family planning workforce, for the family planning workforce.
Each season, we hear directly from implementers and decision makers from around the world on issues that matter to our programs and services. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I am Sarah Harlan, Partnerships Team Lead with the Knowledge SUCCESS project. I am pleased to introduce our narrator, Charlene Mangweni-Furusa.
Narrator: Welcome to Season 6 of Inside the FP Story. This season, we are discussing the larger context of sexual and reproductive health—or SRH. Our first two episodes provided an overview of SRH broadly, as well as adolescent and youth SRH. This third episode will cover the integration of family planning with HIV services, an approach that shows significant potential to improve access to family planning and better meet SRH needs overall. Our guests this episode will provide their perspective on why integration is important, what challenges still exist, and what evidence-based recommendations they have for strengthening services to better meet people’s comprehensive SRH needs.
Narrator: First we will start broadly, by discussing HIV in the context of overall sexually transmitted infections, or STIs. This term encompasses HIV as well as other infections like gonorrhea, chlamydia, herpes simplex virus, and human papillomavirus (or HPV). While STIs are spread predominantly through sexual contact, some can also be transmitted during pregnancy, childbirth and breastfeeding, and through blood.
STI rates are high in many countries around the world, and this has a direct impact on sexual and reproductive health: Some STIs can lead to infertility, pregnancy complications, and even cancers without early and adequate treatment. In addition, STIs disproportionately impact sexual and gender minorities—including those who identify as LGBTQI+, who also often have unmet SRH needs due to stigma, provider bias, or other challenges.
So it's clearly important to prevent and treat STIs. It is also crucial to integrate these activities with family planning and other SRH activities. Millions of individuals around the world—particularly young women—are at risk of both unintended pregnancies and HIV infection. And those living with HIV and other STIs need access to contraceptive services that support their fertility desires and choices.
A quick note: Programs should address all STIs. However, the remainder of this episode will focus specifically on the integration of HIV with family planning, since this is the area for which we have the strongest evidence base related to integration.
“FP-HIV” integration maximizes access to SRH services through combining FP and HIV systems, information, counseling, and/or service delivery. Integration can be achieved through systems approaches such as integrated supply chains, logistics management information systems, and health management information systems. It can also be achieved through integrated services at all levels of the health system.
You will hear two real-life examples of integrated programs in this episode. However, FP-HIV programs vary widely across different contexts. Each program’s structure and services depend on a number of factors—including infrastructure, the capacity of health providers, and the needs of clients.
Early research in this area identified FP-HIV integrated services as an approach for preventing mother-to-child transmission of HIV through reduction of unintended pregnancies. Over the last decade or so, we have gained a deeper understanding of the ability to meet holistic SRH needs through integration. Integrating services helps ensure equitable SRH access for millions of women affected by HIV (including adolescent girls and young women, female sex workers, those who live in areas with high HIV prevalence, and women whose partners are living with HIV).
Before hearing from our guests, we also want to define some terms related to HIV programs that we will use in this episode. The term “HIV services” is an umbrella term that includes both prevention and treatment. Prevention services include behavioral and clinical interventions to reduce transmission and acquisition of HIV, including promotion of condom use, HIV counseling and testing, and use of pre-exposure prophylaxis (or PrEP) or post-exposure prophylaxis (or PEP). PrEP is medicine that is taken to prevent HIV infection when needed, while PEP is medicine that is taken to prevent HIV after a possible exposure. HIV prevention services can also include “index testing,” which involves testing the contacts of a person living with HIV. Meanwhile, treatment services include the provision of antiretroviral therapy (or ART)—which involves taking a combination of HIV medicines everyday.
We will now hear from our guests with real-life examples of FP-HIV integration. First, here is Maria Mkandawire, the Technical Director for the Malawi EMPOWER Project, led by FHI 360. This work is part of the PEPFAR DREAMS Partnership. DREAMS stands for “Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe.” The partnership works to reduce HIV infections among adolescent girls and young women in 15 sub-Saharan African countries. DREAMS also includes a focus on ensuring that adolescent girls and young women have access to contraceptives and other SRH services.
Maria’s program works in three districts in Southern Malawi. We asked her to describe the services provided by her program.
Maria Mkandawire: We provide basically short-term family planning services, which include injectables like Depo Provera. We also provide oral contraceptives like the combined oral contraceptives, including emergency contraceptives. We also provide HIV testing services, which include the HIV self-test, as well as index testing. We provide pre-exposure prophylaxis information. We also provide gender-based violence services—where we do the screening, including provision of post-violence, clinical and non-clinical care and support services, excluding pre-exposure prophylaxis. We also provide condoms information and education.
Narrator: This particular program provides short-acting contraception, and when long-acting reversible contraceptive methods are requested, they provide referrals to other facilities.
The DREAMS Partnership in southern Malawi is an example of successful community-level integration of FP and HIV services. One approach they have used is the formation of “DREAMS Clubs” for girls, where weekly sessions are held in community safe spaces and facilitated by members of the community. When girls come to these clubs, they talk to them about HIV services—both testing and treatment, if needed—and contraception.
Maria Mkandawire: So what we are seeing in terms of an integrated program, what we're doing is as we do the HIV screening, we also provide a number of interventions which are family planning services like condoms, which are provided for dual protection...We're also providing those, the actual contraceptives like condoms, which are also much as we provide them to avoid them contracting STIs, sexual transmitted infections, they're also preventing pregnancies.
Narrator: Maria used the term “dual protection,” which is an important concept in FP-HIV integration. This refers to using a method that prevents pregnancy as well as HIV and other STIs. At this time, condoms are the only method of dual protection, although research into other methods called multi-purpose prevention technologies is ongoing.
In addition, many women affected by HIV choose to use condoms in addition to another contraceptive method in order to achieve the highest level of protection against both pregnancy and STIs, including HIV. In cases where condom negotiation is challenging, this ensures that women have an alternative contraceptive method to prevent pregnancy—and where available, they can use PrEP and/or PEP to reduce risk for HIV.
Narrator: Joseph Matovu is a Senior Research Associate at Makerere School of Public Health in Uganda, who works on Research for Scalable Solutions—or R4S project—which is led by FHI 360. He is a behavioral scientist conducting research in HIV/AIDS, including a study on FP-HIV integration. We asked him to describe an example of a successful integrated program in Uganda.
Joseph Matovu: We have a service center called TASO. It's a non-governmental organization, an organization that specifically deals with HIV Care and Treatment. A person would come in for HIV counseling. They're tested and if they test HIV positive, they're given treatment, but also a holistic set of other services, psychosocial, nutritionally-related services, and family planning, among other things.
Narrator: TASO centers offer a “one-stop shop” model, where clients can receive FP counseling and methods from an HIV provider. While TASO centers are non-governmental, Joseph explained that most individuals in Uganda obtain services through government-run public health centers.
Joseph described his work on the R4S qualitative research study, which focuses on the extent to which FP has been integrated into facilities that provide ART—so that clients are able to receive family planning services at the same location as their HIV treatment. Of 18 facilities in their study, 14 were public and 4 were private non-governmental facilities.
Joseph Matovu: We included the private ones intentionally because the four included two TASO clinics, because we wanted to learn something about the TASO model and then be able to say, okay, is this the same thing that's happening in the public sector? Only one out of the 14 from the government side was integrating as per our definition. That is to say only one was providing services that were integrated where people would come get their ART refills and family planning at the same point.
Narrator: Only one of the public facilities was using the “one-stop shop” model, similar to the TASO approach he described previously. However, the governmental facilities did provide referrals to ART clients who also wanted to use family planning. While they may not all offer full counseling and access to contraception on site, they were still using some measures of integration.
Narrator: Although results vary by context, there is well-documented evidence that integrating FP and HIV can strengthen health systems, reduce unmet need for FP among HIV affected populations, and improve client satisfaction—which may lead to improved HIV outcomes, such as increased HIV testing, PrEP use, and adherence to ART.
Despite evidence about the impact of FP-HIV integration, in reality, there are still a range of challenges in fully implementing the approach. Due to siloed funding streams, supply issues, a lack of supportive policies, and more—family planning and HIV services are often kept separate.
Joseph talked to us about some of the challenges identified in the R4S integration study in Uganda.
Joseph Matovu: The HIV clinics are usually located in very small space, very small rooms. And they would say, if we have to add another service here, we would need another space. For example, if they need an injection or need a private place, where they would talk about the available family planning methods, and then if they choose injection, then we would give them their injection. But they said they didn't have that space to do that. But that wasn't really the main challenge.
The first main challenge was a shortage of staff. So these facilities are running with limited staff that provide services to patients in one facility. We found that they actually had one person running the HIV clinic.
And, related to staffing, is the issue of what we call territorial integrity, which is more to do with people and their jobs. These people who are doing family planning and the people who are providing HIV care are in two different worlds. They're all trained as providers, but in most cases they're like, “No, for us, we're trained to offer HIV services. We're not the family planning guys.” That doesn't mean they can't provide family planning, but they're like, “No, that's not within our docket. If you want family planning, kindly move over to the other place.”
Narrator: That “other place” was the maternal and child health clinic—where they could receive family planning. Some clients may be lost to follow-up if they have to schedule a separate appointment and wait in line again.
However, there can be challenges with “one-stop” services as well. For example, they often take longer to provide all services. And while the “one-stop shop” model is preferred by some clients, it sometimes is not feasible due to system or site limitations. Joseph also discussed the challenge of ensuring that there are enough family planning supplies at clinics where clients go for HIV services.
Joseph Matovu: There were loads and loads of shortages in terms of the family planning supplies. And so they were like, “You know what? We don't have the supplies here. Therefore you'd rather go to a place where we at least expect that some supplies will be there.” And that is the maternal child health clinic.
Narrator: While Joseph discussed the need to improve provider training and capacity, he mentioned that the study also showed that providers he spoke with were generally supportive of integration.
Joseph Matovu: The providers were equally excited about integration. If you ask about their perception, they were like, “That would be helpful, because it would help clients to spend little time here and then go back without really having to line up for a long waiting time.” The providers were positive about integration, but they actually highlighted those challenges that I mentioned. They said, you know what, we are few and, in some facilities that we call high volume facilities, serving 500 or a higher number of HIV patients. There are so many patients around, each one taking their medication, so it becomes a bit tricky for them to say, I will reserve time to, to now start providing injection.
Narrator: Based on his research and experience, we asked Joseph what recommendations he has for others looking to integrate FP and HIV services.
Joseph Matovu: We can cross-train, for example, the HIV providers so that they're able to provide not only set up refills, but also be able to provide other services, including family planning.
The issue of space could actually also be addressed. In one of the facilities we visited, they had constructed a separate family planning room next or adjacent to the HIV clinic. It wasn't already in use, but at least they had created a space so that if women have to get family planning, they just cross from one room to the other, and that will help to improve efficiency.
The other thing, we realized that integration of family planning into HIV was not very much highlighted and emphasized in the existing policy guidelines. And the providers were like, “No, we follow the guidelines, the guidelines don't tell us exactly how to integrate and at what point we should provide family planning if we are to provide it to people living with HIV.” So one recommendation we made was a revision of the existing guidelines and revision and development of family planning, HIV integration implementation guidelines.
And of course, the other thing is to continuously conduct surveys. We agree that we would need to go back at least one year after these findings have been shared to check and see if integration is really picking up.
Narrator: While Uganda has guidance on integration, some providers may not be familiar with the tools or be comfortable using them. This points to the need for further training among providers.
We asked Maria what advice she would give to someone who is just starting to integrate FP and HIV services. She provided some helpful and practical guidance.
Maria Mkandawire: For FP-HIV integration, the first thing to do is to have the necessary tools, but also to have adequate space to be able to provide those services. Space where we're looking at confidentiality, which is quite important, including privacy. Having a safe space where we can be able to talk about family planning, including HIV integration, for the client who is coming in.
Narrator: When Maria mentioned “tools,” she expanded to say that service providers must have access to documentation tools to use during clinic visits. Many tools do exist—for example, provider checklists that can help rule out pregnancy before starting a family planning method—but they need to be widely disseminated and providers must be trained on how to use them.
In addition to these practical training tools, Maria also mentioned the need to ensure that service delivery staff have knowledge about the benefits of integration. This also includes sensitization of providers, particularly for those who may not be used to talking to adolescents and youth about contraception.
Additionally, since the program is working with adolescent girls and young women between the ages of 10 and 24, there can be resistance among community members. However, she encouraged providers to keep an open mind.
Maria Mkandawire: So I think one thing that you should be mindful of as a service provider is not to judge. And then I think the screening process should be able to lead you to the fact whether this girl requires family planning services or not.
Narrator: She mentioned that community engagement can also support providers in ensuring integrated services are provided to girls and young women.
Maria Mkandawire: One other thing is to raise awareness, whether you're targeting gatekeepers, including community leaders and the families talking about the integrated services that you are providing, whether it is at a facility level or at community level. I think the community out there, including the traditional religious leaders, are very instrumental in terms of if you want to really advance an effective program. So providing that information at the community level is very important before you even start providing the integrated services.
Narrator: Finally, Maria recommended expanding integration within non-traditional delivery outlets like community-based distribution.
Maria Mkandawire: One of the challenges that we are experiencing is limited access to family planning methods, especially in hard to reach areas. So my recommendation, and which is something that we have also adapted on the project, is to also try to look at how we can expand the traditional outlets in terms of, for example, condom distribution and information. Under our project, we have community cadres like DREAMS Ambassadors, and the youth community based distribution agents who are actually there in the community, and are able to actually share such information and provide those primary services where they're providing information and also distributing condoms and contraceptives at the community level.
Narrator: Integrating FP and HIV services makes sense both conceptually and practically. Whether individuals are accessing health services from community health workers, public facilities, or private clinics, our guests this episode have made it clear that integrating FP and HIV services requires planning for both human resources and logistics, but is worth it because it ensures that SRH services are being provided in a more holistic manner.
One theme that has come up in each episode so far of this season is the need for holistic SRH care to address the range of individual needs. Integrating FP-HIV is one very practical strategy to address this need. Join us in our next episode this season, where we will explore another key strategy—menstrual health and FP integration.
Season 6 of Inside the FP Story is produced by Knowledge SUCCESS and FHI 360. This episode was written by Sarah Harlan and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Emily Hoppes, Catherine Packer, Brittany Goetsch, Joy Cunningham, and Trinity Zan.
Special thanks to our guests Maria Mkandawire and Joseph Matovu.
To download episodes, please subscribe to Inside the FP Story on Apple Podcasts or Spotify; and visit knowledgesuccess.org for additional links and materials.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
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