Addressing the Family Planning Needs of People Living with HIV and AIDS through Integration of Family Planning Services at an ART Center in Uganda

Developed for the International Conference on Family Planning: Research and Best Practices, November 15-18 2009, Kampala, Uganda, this presentation looked at a project to provide family planning (FP)-integrated HIV services for people living with HIV (PLHIV) in Mbale, Uganda. Included are the following: a discussion of an approach to integrating FP and HIV services, the range of levels of FP integration, and examples of interventions to strengthen service delivery systems in coordination with demand creation and advocacy activities.

ACQUIRE/Uganda, funded by the United States Agency for International Development (USAID), developed this 2006-07 pilot project with EngenderHealth, The AIDS Support Organization (TASO), and the Ministry of Health (MoH) to work with FP integration at the Mbale Antiretroviral (ART) Center because of low contraceptive use (24%) and a high unmet need for FP (40%) in a country of 1.2 million. Among PLHIV, with 130,000 new HIV infections yearly, there were found to be unintended pregnancies and a need for FP information and services.

The approach to integrating FP and HIV services included the following 5 steps:

1. Identify/refine the level of integration that can be adopted.
   
2. Assess the HIV programmes’ capacity to support FP.
   
3. Build or strengthen systems to support new services: supervision, logistics, referral, and training.
   
4. Identify resources to support integration, including partnerships and capacity.
   
5. Phase in FP methods to expand mix within HIV programme’s capacity. 

Levels of FP integration varied in that some included the following range of services: providing FP information to all ART clients; assessing risk of pregnancy; counselling on FP methods including their ability to prevent HIV/sexually transmitted infections (STIs), dual protection, potential drug interactions, and availability/access; providing condoms and instructing/demonstrating correct use; providing emergency contraceptive pills; and referring clients elsewhere for methods not offered on site. Some facilities added services such as providing oral contraceptives, injectables, intrauterine device (IUD) insertion, and/or surgical contraception, each with its appropriate counselling with follow-up referrals.

The TASO/Mbale Interventions fell into the following three categories: 1) strengthening service delivery, including assessing integration capacity, planning for action, training, adapting job aids and client materials, providing record-keeping and commodity logistic, and post-training follow-up; 2) generating demand including adding FP messages to health talks, orienting community workers to FP services, and providing radio spots and community message outreach on FP; and 3) advocating for integration by encouraging demand for provision of FP through outreach and facilitating consultation with the provider organisation to plan for FP integration.

The evaluation findings showed a level of integration appropriate for the site, a high percentage of clients counselled for FP resulting from strengthened delivery support, clients’ reproductive rights respected by ART providers, increased knowledge of FP among ART providers and clients, and clients satisfied with receiving FP from ART providers.

The challenges to integration included: the problem that record keeping forms may not accommodate FP; referral of clients for "Long-Acting and Permanent Contraception (LA/PMs)" can be problematic; contraceptive stock outs can occur; persistent rumours and myths on FP may exist within the community; stigma and discrimination may prevent PLHIV from receiving treatment and FP consultations; non-disclosure between sexual partners can interfere with the effects of testing, counselling, and FP method adoption; and the concept of FP dual protection needs reinforcement.

The lessons learned from this integration and its evaluation include the findings that: FP-integrated HIV services are acceptable, feasible, and effective in meeting HIV-positive clients’ needs. The participatory nature of programme design and implementation was critical to success. FP provision needs to be part of the comprehensive HIV prevention and treatment package. Finally, service delivery systems should be strengthened in coordination with demand and advocacy activities.