Making the Case for Integration: Tides Foundation's Africa Family Planning and HIV Integration Fund

This report from the Tides Foundation is intended to contribute to a growing body of information about family planning (FP) /HIV integration in sub-Saharan Africa. It contains a summary of research, documentation on FP/HIV integration approaches, an evaluation of challenges and solutions, profiles of organisations working on the integration, and insights from experts representing government and philanthropy. It aims to contribute to a base on which to build a more robust model of care, treatment, and prevention.

"Large-scale HIV/AIDS programs can reach a broad range of individuals in need of family planning counseling and services for the dual purpose of planning for healthy pregnancies and avoiding unintended pregnancies. Benefits of an integrated approach include the provision of preconception counseling to optimize positive health outcomes for both mother and child; options for preventing unintended pregnancies for women and couples; and ensuring that the risk of HIV/AIDS is considered as part of informed family planning decisions....[A]stronger linkage between HIV/AIDS and family planning services has the potential to draw on the strengths and resources of both fields in order to help women and men in regions highly affected by HIV/AIDS to make better-informed reproductive and health decisions. Increasingly, program planners and health policymakers have begun to recognize the opportunities missed and efficiencies lost in the parallel approach."

The document describes and illustrates with photo images a Pathfinder International programme in Maputo, Mozambique, in which young women gather for a peer educator-led discussion about contraceptive and HIV prevention. It describes this programme run by Pathfinder-trained peer educators through Geração Biz, a programme which has earned the distinction from the World Bank of a “Best Practice Model”. The first year peer educator-led campaign of this on-going programme, which reached 55,000 community members in Maputo and 47,000 in Xai-Xai, used music, theatre, and dance to alert and engage community members at sites like clubs and schools and in homes through door-to-door campaigns and home-based care visits.

The document cites emerging models that utilise peer counsellors as service extenders, re-train health care workers, and partner with government and other existing distribution networks to deliver both knowledge and consumables (contraceptives, FP-focused materials - brochures and posters with information about contraceptive methods, and T-shirts and caps with dual protection messages) to a growing network of facilities. It calls for discussion on the following challenges:

• Explorations of the process of partnership building.
  
• The importance of attitude change among healthcare providers for institutional cultural change?
  
• The nuances of patient/client behaviour choices and worldviews.
  

Further challenges include: the scope of demands of integration strategies; capacity limitations for service provision; the challenges of United States (US)-African partnerships; the drains on human resources; doubts about the sustainability of funding; challenges of developing strong partnerships with local collaborators; changing attitudes of bias against HIV-positive individuals; gaps in the available best practice, operational research, and health outcomes literature; and the need to engage males as an underserved and underutilised population.

The report also reviews an Infectious Disease Institute (IDI) of Uganda programme aiming to provide sexual and reproductive services to 9,000-plus active clients. A part of its programme is called the Friends Council, which provides services such as peer education through morning health education talks in the clinic waiting rooms, games and arts and crafts for clients waiting for treatment or the pharmacy, peer counselling, and informal supports for clients who are HIV-positive, known by the institution as "friends". According to research done by the IDI among female friends, 30% had experienced pregnancy after their HIV diagnosis, of which 66% of those pregnancies were unintended. In addition, the rate at which women used FP services dropped from 78% before HIV diagnosis to 40% afterwards. In recognition of this indicator for integrated care, the IDI created a training programme prior to rolling out integrated services, using modified Family Health International (FHI) materials. In addition to integrating services, the IDI created two sub-clinics: a Transition Clinic, for those aged 16 to 24 transitioning into adulthood, and the Discordant Couples Clinic, established to minimise the risk of infection between HIV-positive and HIV-negative partners. "The ultimate goal of a FP/ HIV integration initiative is to offer more comprehensive, holistic service - a full SRH [sexual and reproductive health] package." Using a database of indicators, IDI continually adjusts its services. “Additionally, by pursuing a clear research and dissemination strategy, publishing articles in international AIDS journals and delivering presentations at major conferences, they contribute to the larger health community."

The document includes an interview with Roe Wilcher of FHI on, among other topics, best practice guidelines, evaluation, research challenges, and the role of private philanthropy. It recommends that funders:

• Participate in learning venues, working in collaboration with other funders.
  
• Engage in dialogue with the on-the-ground leadership of grantees.
  
• Actively pursue collegial relationships between government and institutional philanthropy.
  
• Support advocacy to further refine the structure and accountability mechanism of US programmes.