SUMMARY REPORT
INTEGRATING HIV AND SEXUAL AND REPRODUCTIVE HEALTH SERVICES: INTERSECTIONS IN EAST AFRICA This is a summary report of a conference call organized by the Africa Grantmakers’ Affinity Group and the Funders Network on Population, Reproductive Health & Rights held on September 12, 2007. This call was part of the Conversations With/Dialogue On series organized by AGAG as a service to its members to promote information sharing and learning.
Historically, family planning services have been offered separately from HIV programs. But the potential benefits of integrating these two closely related services are becoming increasingly evident.
WHY THIS TOPIC? The three main reasons for this topic: • the feminization of HIV/AIDS, which recognizes the need to address both sexual and reproductive health issues • prevention efforts are inadequate • people with HIV who have access to antiretroviral (ARV) medicines are living longer and their reproductive health needs must be addressed and their rights must protected. Moderator Bill Bacon, Program Officer of the David and Lucile Packard Foundation, opened the session by welcoming the two guest speakers and over thirty participants. He thanked the speakers participating on the call, Ms. Monica Oguttu and Dr. Ngudda Maggwa, who are both based in Kenya. Dr. Ngudda Maggwa, Director for Research, Africa Region, Family Health International/Kenya, opened the discussion. In its relatively long history, family planning programs demonstrably improved the health of women and couples. However, the data show that HIV-positive women in many African countries have high rates of unintended pregnancies because they are not able to meet their contraceptive needs. For example, a recent assessment in Uganda cited that over 90% of Ugandan women on ARV therapy who became pregnant had not planned or wanted to become pregnant. In South Africa, 84% of pregnancies among women who are getting HIV services are unintended. Contraceptive needs can be met in the context of HIV services and provide opportunities to assist these women in a more effective way than the traditional vertical programming approach.
Dr. Maggwa and his colleagues noticed that as people begin to feel better after receiving ARV therapies, they resume sexual activity, thus increasing the risk of unintended pregnancies. Another reason for the increase in unintended pregnancies was the practice of family members with HIV-positive parents resorting to selling or trading sex in order to support their ailing relatives. This group would benefit also from the integration of family planning and HIV programs. “It is the right thing to do and we need to be doing it,” Dr. Maggwa said. There is a growing body of data that supports this approach. Dr. Maggwa mentioned examples of pilot programs in Kenya, Nigeria, Ghana, South Africa, and Zimbabwe that integrate family planning into HIV voluntary counseling and testing (VCT) services and home-based HIV programs. Results from these tests will inform other programs and if positive, can be brought to scale. Dr. Maggwa closed his remarks by saying that integration in the reverse direction is also effective. The Population Council has been testing models of integrating HIV services into existing family planning programs in Kenya and South Africa. Ms. Monica Oguttu, Director of Kisumu Medical and Educational Trust (KMET) in Kenya, spoke from her experience as a midwife and educator in rural communities, home to 80 % of Kenya’s population and where skilled attendants are few in number. These communities are feeling the impact of the exodus of skilled health attendants to the United States and Europe. Ms. Oguttu opened her remarks noting that an integrated approach is necessary because most communities have only one health provider, so the services must be integrated or people do not get the services they need. “In rural communities, most women have to get permission from their husbands to go to get health services,” Ms. Oguttu said, “so they want a one-stop shopping experience.” They need to get all their health needs, immunizations, antenatal care, family planning, and HIV services in the same health facility. In linking services that are usually delivered separately, Oguttu stressed the importance of involving all the stakeholders in making the change. The community, the staff, and the providers all must be heard. Finally, Ms. Oguttu noted that integrating services helps preserve client anonymity and confidentiality. “When HIV programs were introduced in these regions,” she said, “we even had stand-alone centers for VCT.” Many people were reluctant to go to the clinics for fear of the stigma associated with the disease. “Now, with integrated services, it de-stigmatizes the HIV programs in this area.” Women come with their children for immunizations and at the same time get HIV counseling and family planning services.
KEY POINTS •
There is evidence of the benefits of the integration of HIV/AIDS and reproductive health programs.
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HIV programs serve people who may not normally visit a family planning clinic.
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Integration helps de-stigmatize services.
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Participation of all stakeholders is crucial to successful integration of services.
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Research to understand the interaction of HIV drugs and hormonal contraceptives is needed.
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Integrated services increase male involvement in sexual and reproductive health.
QUESTIONS Q: Family planning introduction was helped and continues to be helped by on-the-ground demonstration projects. Despite the good data available, might the best approach still be country by country through demonstration projects? A: Dr. Maggwa explained that when he and his colleagues started talking about integration, they partnered with the Ministry of Health and other partners and examined assessments and research to develop prototype strategies that other people can use. “In other countries they have taken what we started in Kenya and adopted for use in their own scenarios. They start small and scale up. They don’t want to start from zero if they know something going on somewhere else.” Ms. Oguttu said that the same approach was used at the community level and the integration of services is beneficial in other ways. For example, when family planning was introduced in the area, women were the target group. Male involvement was not taken into consideration, creating a critical gap. But with the integrated services, she said, the male is included. Q: In looking at commodities availability, is there more of a focus on HIV rather than family planning solutions? A: “There is an overwhelming bias of resources toward HIV programs,” Dr. Maggwa said. For example, within the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) program, money is earmarked to buy ARVs and other HIV-related commodities. But US aid agencies are not allowed to provide family planning commodities with PEPFAR funding. These generally must be procured through local governments. Furthermore, distribution systems are neglected. Some countries have plenty of family planning stock at the central level, but they are not getting out to where they are needed. There is insufficient investment to make ensure these family planning products are available and getting to where they are needed. Q: What about the stigmatization of services? A: One of the ways to de-stigmatize services is to go to the people, Ms. Oguttu said, through home-based care programs. At KMET, the providers are clients who have been trained as community health workers. They do their work as witnesses and counsel. The people they serve often eventually will go the clinics for services.
ADVICE FOR FUNDERS Ms. Oguttu said donors must consider the involvement of the community – the consumers of services – in programming. The community of service providers must be involved so they can work as a team. If there is no teamwork, the results will not be good. Dr. Maggwa noted the changing face of HIV. “I would like to draw donors’ attention to the changing face of HIV in the region. We need to refocus our energies in terms of looking at young people.” People who were born with HIV, he said, are getting ARV therapies, they are feeling fine, and they are starting to be sexually active. “Nobody is paying attention,” he said. The focus has been on orphans and vulnerable children. “People think of them needing blankets and food, but they are beginning to reach sexual maturity. They are beginning to experience sexual and reproductive health issues that are not being addressed with existing programs.” Dr. Maggwa highlighted another neglected issue – the relationship between ARV therapies and hormonal contraceptives. “We don’t know enough,” he said, about the potential interactions between the drugs. “We don’t have studies that have been done. We don’t know enough to be confident about what we tell women.” Another challenge has been integrating commodities, logistics and supplies. Some programs that used to ensuring contraceptives are available have seen a shift in emphasis, and have been turned into HIV/AIDS interventions. The issue of contraceptive commodities is still critical, Dr. Maggwa said, and sometimes they are not available.
SPEAKERS Ms. Monica Oguttu is Director of K-MET, an NGO in Kenya that promotes innovative health programs. KMET addresses various health issues, especially reproductive health, through activities such as peer education programs to help increase young people’s knowledge in sexuality, family planning and communication. Trained as a midwife, she has worked as a Reproductive Health consultant in many organizations locally and internationally. In 2004, under her leadership, K-MET was presented the Margaret Sanger Award. Dr. Ngudda Maggwa is Director for Research, Africa Region, of Family Health International/Kenya, an international NGO with a mission to improve lives worldwide through research, education, and services in family health. Dr. Maggwa holds a Masters Degree in Obstetric and Gynecologic Care from the University of Nairobi, Kenya, and a Masters Degree in Epidemiology from the Harvard School of Public Health. He has worked in the Reproductive and Public Health Fields for more than twenty years.
RESOURCES HIV AND AIDS REPORTER www.eldis.org/go/topics/resource-guides/hiv-and-aids/hiv-and-aids-reporter The HIV and AIDS Reporter is produced monthly and lists dozens of documents on this subject that are available free on the Internet. The September 2007 Reporter focused on strengthening linkages for sexual and reproductive health, HIV and AIDS. Reporters are in PDF format. RESOURCES FOR HIV/AIDS AND SEXUAL AND REPRODUCTIVE HEALTH INTEGRATION www.hivandsrh.org This resource is designed to help efforts to integrate provision of sexual and reproductive health services with activities for preventing and treating HIV/AIDS. A selected collection of documents and other materials reflect field experience and the latest thinking of the health community on integration of HIV and sexual and reproductive health services. Topics include the key technical approaches to integration. TIDES AFRICA FUND www.hewlett.org/Programs/Population/Publications/Tides_Africa_Fund.htm A new partnership between the William and Flora Hewlett Foundation and the Tides Foundation, this Fund will make grants to support the integration of family planning and reproductive health information and services into HIV/AIDS prevention, care, and treatment programs in nine countries in sub-Saharan Africa. The goal of this initiative is to identify, enhance, and document integrated HIV/AIDS and family planning program models and promising efforts in the region, as well as to share these efforts so others may learn from them. Inquiries about the partnership and the grantmaking process may be directed to TidesAfricaFund@Tides.org.
Africa Grantmakers’ Affinity Group 437 Madison Avenue, 37th Floor New York, NY 10022 Tel: 212-812-4212 Fax: 212-812-4299 Email: agag@africagrantmakers.org Website: www.africagrantmakers.org A project of the Tides Center
Funders Network on Population, Reproductive Health & Rights Tel: 301.294.4157 Fax: 301.294.4158 Email: info@fundersnet.org Website: www.fundersnet.org