C-Change Picks - Integrating HIV/AIDS and Family Planning/Reproductive Health Services

C-Change Picks #8 - Integrating HIV/AIDS and Family Planning/Reproductive Health Services
Information about Social and Behaviour Change Communication, sponsored by C-Change
July 7 2009

From The Communication Initiative (The CI) and the United States Agency for International Development (USAID)'s C-Change programme.

C-Change Picks is an e-magazine supported by C-Change and implemented by The Communication Initiative that focuses on recent case studies, reports, analyses, and resources on social and behaviour change communication in the health sector - in particular HIV and AIDS, family planning and reproductive health, malaria, and maternal and antenatal health - as well as in the environmental sector. If you have received this newsletter from a friend or colleague and would like to subscribe, please contact cchange@comminit.com

C-Change Picks #8 focuses on integrating HIV prevention and care with family planning and sexual and reproductive health programming and services. This issue includes reports that address gaps in services for HIV prevention among women during their reproductive years, in particular; pregnancy and vertical transmission of HIV; the broad range of rights issues among people living with HIV including reproductive health rights; and programmatic examples of integration of services for HIV and family planning/reproductive health from several African countries. The issue closes with three recent training resources that may be of use in the field.

In Ethiopia, the C-Change programme is working with the President's Malaria Initiative (PMI), the President's Emergency Plan for AIDS Relief (PEPFAR), and the government of Ethiopia to assist pregnant women in accessing antenatal care including services for prevention of mother-to-child transmission of HIV (PMTCT) while at the same time presenting malaria prevention messages.

During a workshop run by C-Change in early 2009, local stakeholders developed a package of "Essential Malaria Actions" that is intended to help families focus on key protective behaviours (e.g., "Parents, to protect your children against malaria, insure that all your children sleep under a bed net every night."). A similar collection of essential actions is being compiled for antenatal care to help families deliver "healthy newborns." Communication efforts include community recognition of families who have carried out the essential malaria prevention and antenatal actions. Families are given Malaria Protection Stickers to post on their front door, and are then encouraged to mentor another family so that they too receive a Protection Sticker. One goal of the program is to gradually produce a shift in social norms. This will occur as the number of Malaria Protection Stickers visible on the front doors in the community increases. Recognition ceremonies of Champion Communities - those that have at least 100 families with protection stickers - will be designed to create even greater demand among community members to earn a sticker. These celebrations of success will in turn be amplified through mass media in order to engage other communities in the process. Click here for more information about the C Change programme.

C-Change Picks continues to seek new knowledge and experiences in social and behaviour change communication - your case studies, strategic thinking, support materials, and any other relevant documentation. Please contact cchange@comminit.com

In this Issue...

HIV and AIDS and Family Planning/Reproductive Health: INTEGRATING SERVICES

Strategic Thinking and Programming Approaches

1. Addressing Gaps in Provision and Use of Condoms and Contraceptives in HIV Prevention
2. PMTCT through Integrated Services
3. Protecting Sexual and Reproductive Health and Rights of Women and Girls Living with HIV
4. Evaluation of a Family Planning and Antiretroviral Therapy Integration Pilot in Uganda
5. Peer-to-Peer Support for PMTCT and Family Planning in Ethiopia
6. Radio Soap Integrating Reproductive Health and HIV Transmission Messages in Nigeria
7. Enhancing Life Skills Education for HIV Prevention in South African Schools

Training Resources

8. A Handbook for Measuring and Assessing the Integration of Family Planning and Other Reproductive Health Services
9. Toolkit for Increasing Access to Contraception for Clients with HIV
10. Training Guide for HIV Counseling and Testing for Youth

HIV/AIDS and Family Planning/Reproductive Health: INTEGRATING SERVICES

Strategic Thinking and Approaches

1. Addressing Gaps in Provision and Use of Condoms and Contraceptives in HIV Prevention

This Population Action International report, entitled "Comprehensive HIV Prevention: Condoms and Contraceptives Count", presents evidence that scaling up HIV prevention will require much broader access to and use of proven prevention technologies - "namely male and female condoms to prevent primary infection, and contraceptives to prevent mother-to-child transmission by preventing unintended pregnancies". The report details public health strategies and a programming framework that can be applied to address gaps in the provision and use of condoms and contraceptives.

The authors state that "behavior change, including condom use, is critical to stemming the number of new infections... High rates of unintended pregnancies, including among women living with HIV or AIDS, is an urgent health and rights crisis. Preventing unintended pregnancies among women living with HIV and AIDS and those at risk of infection is essential for preventing mother-to-child transmission of HIV....Persistent variations in condom use across regions, countries and populations indicate that condom promotion should be targeted to address socio-cultural, political, economic and structural barriers faced by different groups (e.g. youth, married women and men, discordant couples, sex workers, men who have sex with men, and injecting drug users, among other groups)...."

Key social and behaviour change communication recommendations include:

1. Use the more than 20 years of epidemiological, psychological, programming, and marketing data to design a comprehensive prevention strategy that supports national and local ownership and generates local solutions to affecting the social and gender norms that influence sexual behaviour and use of condoms and contraceptives, among other prevention strategies.
2. Eliminate harmful government policies - the authors cite needs for "strong leadership and coordination - for advocacy and policy dialogue....Scale up also requires a supportive policy environment - one where policies are based on sound evidence that supports the efficacy of condoms and contraceptives in prevention the transmission of HIV. Likewise, the integration of contraceptives into HIV prevention programs must be supported at all policy levels."
3. Scale up and integrate condoms and contraceptives into other HIV prevention strategies, based on the social marketing concept of supply, demand, and support, and built on a foundation of leadership and coordination.
4. Put the contraceptives in comprehensive prevention to address high rates of unintended pregnancies, through expanding voluntary family planning services integrating family planning with other HIV services to increase contraceptive use.

See also: Comprehensive Condom Programming Framework.

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2. PMTCT through Integrated Services

According to "Missing the Target #7: Failing Women, Failing Children - HIV, Vertical Transmission and Women's Health", published in May 2009 by the International Treatment Preparedness Coalition (ITPC), HIV-positive women provided with testing, counselling, and comprehensive prevention and treatment, including the best drug therapies available, can prevent the vertical transmission of HIV to their newborn children. However, women in the economically poorest countries, particularly in the Global South, are not receiving what they need to prevent vertical transmission. This report focuses chiefly on the following countries: Argentina, Cambodia, Moldova, Morocco, Uganda, and Zimbabwe.

The document states and supports its position that "United Nations agencies and global funding initiatives (such as the Global Fund and PEPFAR [United States President's Emergency Plan for AIDS Relief]) have fundamental responsibility for realising the potential of comprehensive services to prevent vertical transmission of HIV." Coordination of agencies, research transparency, and increased programmes are part of what is advocated, as well as favouring "governments that show a clear interest in developing realistic policies and programmes to reduce vertical transmission by global funding partners."

ITPC has assembled 6 country reports on studies of services HIV-positive pregnant women receive for prevention of mother-to-child transmission (PMTCT). Each report has a set of recommendations specific to that country. Among the recommendations are the following communication-related strategies:

• Develop gender-based HIV/AIDS prevention programmes that focus on the specific risk factors and needs of women, and include peer education components.
• Incorporate people living with HIV/AIDS-provided peer counselling in all strategies and programmes related to prevention of vertical transmission.
• Integrate services and mobilise resources internationally, nationally, and locally - sexual and reproductive health care and family planning are essential interventions for HIV prevention, care, and treatment. Include women from at-risk groups in the design and planning of programme delivery.
• Reduce HIV-related stigma and discrimination.
• Train health workers for sensitivity to human rights and gender-specific issues and compliance with principles of informed consent and confidentiality.
• Enhance coordination between HIV/AIDS services and anti-violence referral services.
• Promote treatment literacy among women and children living with HIV.
• Improve civil society's capacity for and representation in policy advocacy and monitoring of HIV-related policies and programmes at national and local levels.
• Improve financial support for HIV-positive women and encourage male partners of pregnant women to be tested for HIV and engage more fully in prevention of vertical transmission services as part of a broader effort to involve the entire family in HIV treatment and care.
• Develop and distribute HIV and prevention of vertical transmission education materials for pupils and students, teachers, and parents.
• Create a series of advertisements for TV, radio, and newspapers that focus on reducing HIV-related stigma and discrimination against women.
• Initiate a wide-ranging campaign to raise the level of awareness about prevention of vertical transmission programmes and services.
• Mobilise and encourage HIV-positive mothers to form or join psychosocial support groups that can also help them engage in income-generating activities.
• Streamline reporting by initiating a web-based format to improve access to quality data for programme monitoring and evaluation. This step would also help facilitate efficient distribution of drugs, test kits, and other supplies.

Ensure that all health care workers receive adequate training in breast-feeding management and counselling, particularly as it pertains to HIV-positive mothers, in order to ensure that all expectant mothers understand the potential risks and benefits of all options and feel as though they can make realistic choices that will help keep their infant as well-fed and healthy as possible.

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3. Protecting Sexual and Reproductive Health and Rights of Women and Girls Living with HIV

"Sexual and Reproductive Health of Women and Girls Living with HIV: Guidance for Program Managers, Health Workers and Activists" published in November 2008 by EngenderHealth, offers guidance and recommendations for creating programmes that protect and promote the sexual and reproductive health and rights of women and girls living with HIV and AIDS. Based on experiences in Brazil, the resource offers recommendations in four key areas: creating a political and social environment for promotion of sexual and reproductive rights; strengthening health systems to improve the availability of comprehensive sexual and reproductive health; ensuring participation of adolescent girls and women living with HIV and AIDS in public policies and rights initiatives; and strengthening support available to them.

Three dimensions of vulnerability of this population of people living with HIV (PLHIV) were analysed: the individual dimension of vulnerability; social vulnerability; and the programmatic or institutional dimension of vulnerability.

Among the recommendations are the following communication-based aspects of providing for the right to sexual and reproductive health for women and girls living with HIV through strengthening health systems to improve the availability of comprehensive sexual and reproductive health:

1. Integrate into the curricula of graduate courses in human sciences and health sciences the themes of human rights, sexual rights, reproductive rights, ethnic/racial relations, gender relations, and diversity, in addition to questions related to overcoming stigma and discrimination associated with living with HIV and AIDS.
2. Foster the inclusion of the theme "social determinants of health conditions" in all permanent education activities for health workers, including correlating the process leading to poor health and socioeconomic, regional, ethnic, racial, gender, and age-related disparities and other factors (like gender violence against women, stigma and discrimination associated with living with HIV, and other human rights violations).
3. Guarantee that the themes of human rights and living with HIV and AIDS and rights are addressed in the programmes of permanent education and ongoing training for health workers and community health agents.
4. Broaden opportunities to update health workers' knowledge about and skills on the sexual and reproductive health of HIV-positive women and girls through training and certification.
5. Create opportunities for sharing and exchanging experiences and lessons learned in the promotion, defence, and enforcement of the rights of PLHIV.
6. Guarantee the development of strategies to broaden participation and engagement of the male partners of women and adolescent girls living with HIV and AIDS, particularly in counselling.
7. Develop communications and information strategies to promote the rights of PLHIV, especially their sexual rights and reproductive rights and the prevention of vertical transmission of HIV and syphilis, among others, by guaranteeing the broad dissemination of communications products directed at health workers, health managers, health service users, and society at large.
8. Widely disseminate the booklets Users' Rights and Health Service Users among women and adolescent girls living with HIV.

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4. Evaluation of a Family Planning and Antiretroviral Therapy Integration Pilot in Uganda

This September 2008 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 by The AIDS Support Organization Mbale (TASO/M) in cooperation with the ACQUIRE Project at EngenderHealth and the Ugandan Ministry of Health (MOH).

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, 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 counsellors and field officers, as well as 12 community nurses and selected people living with HIV (PLHIV) volunteers. 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, and referring clients to the local hospital for long-acting and permanent methods (LAPMs).

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.

In November 2007, ACQUIRE conducted a retrospective evaluation using a case study methodology to assess the FP-ART integration pilot. Based on the evaluation, 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).

The evaluation provides an extensive list of recommendations for programmatic consideration.

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5. Peer-to-Peer Support for PMTCT and Family Planning in Ethiopia

Initiated in 2005 by IntraHealth International, Mother's Support Group (MSG) is a peer support model to address the needs of pregnant and postpartum women living with HIV and caring for babies in Ethiopia. According to the project's organisers, the programme is designed to empower mothers and mothers-to-be to access peer-based support and make linkages to services such as family planning, infant feeding counselling, nutritional guidance, antiretroviral therapy, prevention of mother-to-child transmission (PMTCT), and health institutional delivery. The MSG programme is based on the concept that peer support is an optimal model for effective education and social empowerment, and that mothers are particularly well-suited to provide support to other mothers.

The MSG programme seeks to:

• enhance access to and use of PMTCT services by building strong linkages between health care providers and peer support networks;
• ensure adherence to antiretroviral therapy among pregnant and postpartum women;
• lessen HIV-related stigma and discrimination;
• increase HIV-positive mothers' understanding of infant feeding options;
• reduce the incidence of new sexually transmitted infections and HIV among girls and women;
• increase acceptance and use of family planning among postpartum women; and
• build linkages with other programmes and services that strengthen women's health and decision making (i.e., nutritional support, income-generating activities, and skills training).

To achieve these objectives, the MSG programme fosters several mutually reinforcing strategies for peer-to-peer contact. The programme strategy includes the following components:

• Mentor Mothers: The mentor mothers are the linchpin of the MSG programme. The mentors are recruited by the site coordinators. There are 4 mentor mothers per site, and 2 mentor mothers work on any given day. Mentor mothers must be willing to spend at least 3 full days per week supporting HIV-positive mothers at the health center.
• Training of Mentor Mothers: The basic content of the 5-day training covers HIV transmission and infection, HIV and pregnancy, psychosocial issues, self-care, antiretroviral therapy, labour and delivery, and infant care. The trained site coordinators also attend the mentor training and present some topics.
• Support groups: Once trained, the mentor mothers facilitate separate support group meetings for mothers-to-be and mothers. On occasion, a postpartum mother may be invited to attend a group meeting of mothers-to-be to discuss topics such as partner disclosure. The mentor mothers also refer support group members for care such as PMTCT and family planning services.

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6. Radio Soap Integrating Reproductive Health and HIV Transmission Messages in Nigeria

Launched in July 2007, Ruwan Dare (Midnight Rain) is a two-year radio serial drama produced by Population Media Center (PMC) in Nigeria. Through character role-models, the drama aims to enhance knowledge and use of existing health services, provide information about reproductive and general health issues, encourage family planning, promote delaying marriage and childbearing until adulthood, promote small family norms, provide information about HIV transmission, and motivate people to take actions to improve their health and the health of their families.

PMC has established Ruwan Dare Listeners' Clubs, which include both male and female audience members, to provide ongoing feedback to the creative team. And, at the encouragement of listeners in the Kano State, PMC has also started a talk show call-in programme, where people can phone in and talk about the issues addressed in Ruwan Dare. Ruwan Dare will air through 2009 on four radio stations in northern Nigeria.

To monitor the effects of the programme on listeners, PMC has established 11 clinic research sites where exit interviews are being conducted to find out what is motivating clients to seek reproductive health and family planning services. Monitoring interviews conducted at reproductive health and family planning clinics with 220 clients in October-December 2007 showed that 55% of the clients reported that it was Ruwan Dare that had motivated their visit to the clinic. A second round of monitoring from the same group of clinics was conducted from January to March of 2008, and it showed that 66% of clients reported that the programme motivated them to seek family planning and reproductive health services. This increase of 11 percentage points provides additional evidence that midway through the course of its two year broadcast, Ruwan Dare has demonstrated a measurable impact on the lives of listeners in northern Nigeria.

According to PMC, Ruwan Dare was created as a result of the success of PMC's programme titled Gugar Goge ("Tell it to Me Straight"), which was a highly popular radio serial drama that addressed issues relating to maternal health and obstetric fistula. The evaluation of Gugar Goge pointed to widespread changes in behaviours and attitudes among audience members with regard to the issues addressed in the programme. It was this success that inspired the production of Ruwan Dare, which was created using the same methodology, but with new characters, storylines, and aims.

See also: Participatory Assessment of Gugar Goge, an Entertainment-Education Radio Soap Opera in Nigeria: A Qualitative Assessment Report.

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7. Enhancing Life Skills Education for HIV Prevention in South African Schools

According to this March 2008 research brief from the Horizons Program, reaching young South Africans with effective prevention programming has become key to slowing the rate of HIV infection. One of the main strategies the South African Government has used to build HIV prevention awareness and promote behaviour change among young people is through school-based life skills education, which is part of the Life Orientation Programme.

To improve HIV prevention programming for youth aged 10-14, Horizons, in collaboration with education specialists and representatives from South Africa's National Department of Education implemented a pilot project that consisted of three main activities: a consultative workshop, curriculum development, and pilot testing of the curriculum. The resulting Dare to be Different (D2BD) module includes messages that promote the advantages of abstinence and faithfulness/mutual monogamy and highlight the consequences of risky sexual engagement. D2BD also incorporates activities to build such critical skills as decision-making, critical thinking, problem solving, negotiation, resisting peer pressure, and communication.

A study of the pilot D2BD programme found that learners do indeed want more than just HIV prevention information. Teachers and learners generally agreed that D2BD does more than provide the basics of HIV prevention by building critical thinking and decision-making skills, fostering communication about HIV, and encouraging learners to identify risky behaviours and recognise the consequences of those behaviours. The study also revealed that D2BD improves parent-child communication through its Home Talk component.

According to study respondents, the Life Orientation Programme was easily able to incorporate D2BD into its existing curriculum. The report suggests that with a stronger focus on abstinence and partner reduction, the D2BD module helped fill serious gaps in the Life Orientation Curriculum. Horizons plans to revise the curriculum module based on the pilot's findings to further improve its acceptability and usefulness among teachers and learners.

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Training Resources

8. A Handbook for Measuring and Assessing the Integration of Family Planning and Other Reproductive Health Services

This Population Council manual, published in 2008, provides a roadmap for Assessing Integration Methodology (AIM), which is a tool for describing and measuring attempts to integrate the provision of family planning (FP) information and services with other relevant services. The focus of "Assessing Integration Methodology: A Handbook for Measuring and Assessing the Integration of Family Planning and Other Reproductive Health Services" is on the AIM and the instruments that can be used to collect data at health facilities offering, or considering offering, integrated services.

Benefits of integrating FP with other services include: (1) meeting multiple reproductive health needs of a client simultaneously, (2) reducing the stigma associated with providing a service independently, (3) combining several services needed for a multifaceted health condition, and (4) achieving cost efficiencies through sharing staff skills, infrastructure, and equipment. The Population Council's experience indicates, however, that creating service configurations for integrated services is usually not straightforward and can place a strain on the underlying logistics, training, supervisory, and management systems. This may be the case especially if the services are provided through different programmes, as is the case with sexual and reproductive health and HIV/AIDS services. In addition, these situations may overstretch service providers who have limited skills and support.

In this context, AIM has been designed to fill the information gaps embedded in questions such as the following: Which service combinations are feasible? Which services are acceptable to clients and providers? Which services can effectively increase access to one or both services without compromising the quality or safety of their delivery? Does their joint provision lead to a synergistic impact on both the individual client's health status and that of the population served? In short, the rationale behind AIM is that offering services in a combined fashion requires appropriate methodologies for determining the feasibility of various combinations, assessing and monitoring the quality of service received, and evaluating their effect on utilisation.

To that end, the handbook:

• explains the basic principles of conducting studies using AIM,
• provides tips for the data collection, and
• makes available data collection instruments that have been validated in projects throughout the developing world for the integration of various types of services.

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9. Toolkit for Increasing Access to Contraception for Clients with HIV

This resource, published in January 2009, has been developed by Family Health International for trainers, presenters, providers, programme managers, and policy-makers to update and expand upon the information provided in an earlier module, Contraception for Women and Couples with HIV.

The toolkit includes:

1. A performance-based training curriculum that includes the resources required to conduct the suggested learning activities.
2. Counselling tools, checklists, guides, and other job aids for providers and programme managers.
3. An updated version of the orientation presentation contained in the original 2005 module.
4. Full-text resources of current guidance and technical information about integrating family planning and HIV services.

The toolkit, which offers access to multiple resources in pictorial and print formats, is also available on CD for users in developing countries with limited internet access.

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10. Training Guide for HIV Counseling and Testing for Youth

This 2008 training guide, a companion to HIV Counseling and Testing for Youth: A Manual for Providers, produced in 2005 by Family Health International, trains providers on how to use that original resource. This guide is intended to be used to train experienced HIV counsellors how to offer counselling and testing to youth and how to integrate HIV counselling and testing and other sexual and reproductive health services. It contains varies interactive sessions including those focused on interviewing, role-play, case study and discussion, referral mapping, and creating working groups for building community support.

The intention is that, by the end of the workshop described session-by-session in the guide, participants will be able to:

• Use HIV Counseling and Testing for Youth: A Manual for Providers as both a guide to services and programmes and as a reference tool.
• Describe and understand the concept of integrated services for HIV counselling and testing and other sexual and reproductive health needs and plan how to implement integrated counselling and services within their organisations.
• Identify and implement the key elements of HIV counselling and testing for youth.
• Explain the importance of quality referrals in providing HIV counselling and testing to youth and identify the referral systems in place and the gaps in existing referral systems in their communities.
• Demonstrate improved youth-focused counselling skills, drawing on resources in the manual.
• Understand how to gain community support for integrated youth services and how to develop promotional and social marketing campaigns for those services.

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Communication for Change (C-Change), implemented by AED, is USAID's flagship programme to improve the effectiveness and sustainability of social and behaviour change communication programmes, activities, and tools. C-Change works with global, regional, and local partners to incorporate knowledge about the social determinants and underlying causes of individual behaviours and takes into account research and lessons learned from implementing and evaluating activities. Employing innovative and tested methods, C-Change works to meet the continuing challenges posed by evolving health issues that require a behaviour change communication approach. C-Change also works to strengthen the capacity of local organisations to plan, implement, and manage programmes, thus ensuring sustained local knowledge and skills. Please visit the C-Change website. To contact C-Change, please email cchange@aed.org

The Communication Initiative (The CI) network is an online space for sharing the experiences of, and building bridges between, the people and organisations engaged in or supporting communication as a fundamental strategy for economic and social development and change. It does this through a process of initiating dialogue and debate and giving the network a stronger, more representative and informed voice with which to advance the use and improve the impact of communication for development. This process is supported by web-based resources of summarised information and several electronic publications, as well as online research, review, and discussion platforms providing insight into communication for development experiences. Please see The CI website.

This publication is made possible by the support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A-00-07-00004-00. The contents are the responsibility of the Communicative Initiative and the C-Change project, managed by AED, and do not necessarily reflect the views of USAID or the United States Government.