Evaluation of a Family Planning and Antiretroviral Therapy Integration Pilot in Mbale, Uganda

This report presents the findings from a case study of an integrated family planning (FP)-antiretroviral therapy (ART) pilot project carried out in Mbale, Uganda, from March 2006 to April 2007. Observing an urgent need for high-quality, voluntary FP services to help people living with HIV (PLHIV) achieve their fertility intentions and to reduce HIV incidence, the Mbale branch of The AIDS Support Organization (hereafter, TASO/M) sought to create a comprehensive FP programme in collaboration with the Ugandan Ministry of Health (MOH) and the ACQUIRE Project - an initiative funded by the United States (US) Agency for International Development (USAID) and managed by EngenderHealth, in partnership with the Adventist Development and Relief Agency International (ADRA), CARE, IntraHealth International, Inc., Meridian Group International, Inc., and the Society for Women and AIDS in Africa (SWAA).

The pilot was designed using ACQUIRE's FP-ART integration framework, which is based on a systems approach to build site capacity in training, referral, supervision, and logistics. To improve the training system, ACQUIRE began by developing the FP-integrated training curriculum. Following a performance needs assessment (PNA), ACQUIRE conducted a 2-week training consisting of didactic and clinical practicum portions for 23 TASO trainers, and supported the newly trained trainers to train 15 service providers and counselors and field officers, as well as 12 community nurses and selected PLHIV volunteers. The training content included FP updates, counseling skills, FP method provision, and special considerations for women using ART. Organisers adapted provider job aids and a client brochure designed by ACQUIRE in Ghana to support PLHIV (materials available on request).

After the trainings, TASO/M staff fully integrated FP into existing ART services. This included giving FP health talks in the waiting area, providing FP methods on-site (oral contraceptives, emergency contraception, injectables, and condoms), and referring clients to the Mbale Regional Referral Hospital for long-acting and permanent methods, or LAPMs (implants, the intrauterine device (IUD), and sterilisation). ACQUIRE bolstered the supervision system by providing training in facilitative supervision and COPE® (which stands for client-oriented, provider-efficient services) to on-site supervisors and department heads and by orienting these individuals to the special needs of clients in FP-ART service delivery. In addition, ACQUIRE helped adapt monitoring and supervision checklists to include FP services and promoted their use among supervisors. In the area of logistics and referral, ACQUIRE worked with TASO/M to analyse and improve its data collection systems and mechanisms for FP referral to Mbale Regional Referral Hospital.

ACQUIRE worked with TASO to develop and support a communications strategy to increase public awareness of and knowledge about FP within the communities adjacent to TASO/M. ACQUIRE helped TASO integrate FP messages into health education activities, orient AIDS community workers to FP, and conduct awareness sessions on FP for community groups. The TASO staff appeared on local FM radio stations to talk about FP and respond to listeners' questions. To address myths, rumours, and fears about FP methods, community nurses were trained to counsel about and provide FP methods. Male involvement in RH/FP was promoted as a part of the overall communication effort. Advocacy work included integrating FP into TASO/M's ART protocol, encouraging TASO/M management to allow field officers to provide FP services during community outreach activities, and facilitating consultation with TASO/M headquarters for future FP-ART scale-up.

In November 2007, ACQUIRE conducted a retrospective evaluation using a case study methodology to assess the FP-ART integration pilot. Data collection included 105 client exit interviews, 30 provider-client observations, 37 self-administered provider questionnaires, 6 key informant interviews with program staff (from ACQUIRE, the MOH, and TASO/M), 3 group discussions with PLHIV, and 3 group discussions with providers. If "the hallmark of an accomplished project is scale-up or replication", ACQUIRE's partnership with TASO/M was successful: the model will be rolled out to all of TASO's 11 centres and 15 minicentres throughout Uganda over the next several years, as part of TASO's 5-year strategic plan (2008-2012). Those who would like to replicate the ACQUIRE model are instructed to start with a 5-step process (see Figure 1, page 9), the key feature of which is stakeholder participation to identify a realistic level of integration to aim for and to guide decisions about where, how, and when to integrate.

ACQUIRE reminds programmers that the foundation for successful integration is a holistic approach that addresses the interconnected elements of supply, demand, and advocacy. Supply activities are at the core of the model, but it is also critical to include demand activities in communities adjacent to sites, particularly those that address stigma against PLHIV. On the advocacy side, ACQUIRE found that it was important to garner management support for training and for deploying lower-level trained field officers to provide FP services in the community and to refer clients to the integration site; to lobby for funds to train new staff to compensate for staff turnover; and to incorporate FP service delivery guidelines into the HIV management protocols.

Selected findings:

Experience in integrating FP into ART:

• The level of integration was appropriate to the site, but it was important to prepare the site for potential increases in workload (and adding FP services required space accommodations).
• The PNA was an effective programme planning tool.
• Stakeholders took ownership of the decision to integrate services.
• Partner collaboration is essential.

Successes:

• Stigma against PLHIV lessened among providers and clients at TASO/M, but persists in adjacent communities.
• Clients reported hearing FP messages, were well informed about FP methods, and reported satisfaction with TASO/M FP services.
• Directly following sustained FP introduction in September 2006, the number of ART clients accessing FP showed a three-fold increase.
• Two-thirds of clients interviewed in exit surveys reported that they used condoms every time they had intercourse in the past 6 months. Of those receiving FP methods on the day of the survey, the majority reported getting injectables, condoms, and oral contraceptives.

Challenges:

• Although some providers demonstrated correct knowledge of FP and of dual protection, more training is needed to reinforce new content.
• FP referral protocols were implemented, though referrals remain somewhat problematic.
• Although TASO/M shifted away from the open market to the MOH system to procure FP commodities and supplies, stock-outs continued.
• FP record-keeping was challenging due to lack of systematic protocols.
• FP myths and misconceptions persist in the community.
• FP services to men were limited.

Recommendations:

Process

• Prior to integration, prepare on-site staff at all levels through orientation and discussion.
• Use participatory methods to engage stakeholders in identifying service gaps, defining what a successful programme will look like, and selecting an appropriate level of integration.
• Carry out site preparations before initiation of service delivery training. Ensure that there is adequate, private space for FP services and counseling.
• Develop partnerships with referral sites; explore how partners can jointly share resources, develop staff capacity, and develop and implement referral protocols and systems.
• Garner technical support from the MOH; discuss and identify opportunities to strengthen supplies of FP commodities and equipment.
• Strengthen relationships between the public and private sectors to better coordinate district-wide FP-HIV integration efforts.
• Identify a variety of ways that international NGOs can check in with field progress.

Supply

• Train staff in FP service provision. Develop and maintain a continuing education/refresher mechanism.
• Train staff to provide effective FP counseling using FP-ART curricula, national guidelines, and World Health Organization (WHO) medical eligibility criteria.
• Train PLHIV volunteers to assist providers in client counseling and referrals; consider stationing volunteers at an on-site FP desk to interact with clients.
• Develop a unified system to record FP clients and commodities and institutionalise and train staff on use.
• Ensure steady supply of FP and HIV/ART commodities to meet rising demand for integrated services.
• Use facilitative supervision to improve supervisors' capacity to oversee the implementation of quality FP-integrated services.

Demand

• Develop creative ways to provide services to men beyond providing them condoms.
• Address stigmatisation of PLHIV, as well as myths about FP at the community level, through targeted interventions. Consider partnering with existing groups already engaged in communications activities.
• Develop FP client materials in the local languages; disseminate them widely to clients and potential clients during client visits to sites and community outreach.
• Ensure that counselors cover the entire available range of FP methods, including those available at referral sites, so that clients are as informed as possible.

Advocacy

• Present study results to the MOH to discuss how this pilot might be applied to public-sector sites.
• Advocate for support to lower-level trained field officers to provide FP services in the community and for funds to train new staff, to compensate for staff turnover.