Lesson 1: Provide certified FP training to HIV clinic staff

Adequate training for staff, including refresher training with any new service, plays a key role in integration success. Programmes must decide who will be trained in FP, based on the existing clinic structure and personnel. Important considerations are: ensure that integration does not overburden existing services and compromise quality care; employ task-shifting to better distribute workload; and provide enough education and support for staff. In many settings, it may be more efficient to have a few key staff members perform more complicated tasks such as IUD and implant fitting or sterilisations while other, lesser-skilled, staff concentrate on patient screening or counselling. When possible, use existing MoH training opportunities. Finally, prior to initiating any services at a clinic, it is important to openly discuss and dispel myths about FP with all staff, even if they may not be directly involved with FP service provision.

At Lighthouse, prior to integration, all clinicians and nurses attended MoH training followed by in-house sessions to ensure accurate and current knowledge of FP methods, provide refresher training on STI diagnostics and treatment, and help providers translate clinical information into client-appropriate language. This combination training helped ensure a consistent, correct message from all providers. Lighthouse staff also received follow-up staff refresher training including: appropriate messaging for condoms as dual protection, management of irregular bleeding after IUD insertion, appropriate FP in HIV-positive populations, and LARC-specific training. Prior to the introduction of each new service (contraceptive implants, cervical cancer screening and cryotherapy), all staff members were trained.

Lesson 2: Incorporate FP services into the HIV care patient flow

The strategy for integration must maximise the impact of new FP services while not impeding routine clinic operations, slowing the patient flow, or affecting the quality of other services offered. Prior to beginning services, clinic operations must be reviewed by a team of staff and various strategies explored. For example, all women may be triaged to the FP clinic area for some basic FP education prior to their HIV clinic visit as part of an opt-out strategy. This strategy may increase client participation but also disturb flow. Alternatively, a clinic may introduce the FP services during the ART clinic visit and direct individuals who are interested to an additional service area within the clinic, an opt-in strategy that is likely to reduce the burden on clinic operation but likely reduce FP uptake.

At Lighthouse, although all women are exposed to FP messages and made aware of all services during routine visits, only clients who express interest during their ART review are referred to the FP room. For all follow-up visits, women enrolled for FP go directly to the FP area where they also receive their standard HIV care, including ART, therefore reducing visit time. Follow-up FP/ART visits are coordinated to ease client scheduling. VIA services are received only in the FP clinic area as standard ART review rooms are not equipped to perform pelvic examinations. Lastly, in 2013 the national electronic data system (EDS) for HIV services, employed at Lighthouse and MPC, included a new module for provider-initiated screening for risk of unintended pregnancy and active promotion of FP within routine HIV care. The FP module ensures that all HIV-positive women and men of reproductive age are screened for interest in and awareness of FP. This module reinforces our integration efforts and should positively influence FP interest and uptake in the near future.

Lesson 3: Use multiple modalities and messages for patient education

Educational messages should be carefully crafted to support pregnancy prevention and simultaneously emphasise available pregnancy care for HIV-positive women for prevention of mother-to-child-transmission (PMTCT). Also, dual-method promotion (male/female condoms together with another highly effective FP method) should be emphasised to prevent unintended pregnancy, decrease STI/HIV transmission, and reduce cervical cancer risk. Educational efforts and messaging should discuss group norms, gender and power issues, and be personalised to meet clients’ needs. It is critical to avoid messages that actively dissuade HIV-positive women from choosing to become pregnant as some HIV-positive women still desire children23 and may be fearful of discussing this intention with their health care providers for fear of negative reactions.24 Specifically targeting those in stable, long-term relationships and employing different uptake strategies for men and women may be useful in increasing dual-protection acceptance.25

At Lighthouse, we provide an open environment for discussion of FP issues and cancer screening through sensitisations, flipcharts and posters for both male and female patients in waiting areas. More in-depth education is available from any provider, and a specific FP counsellor is available during all clinic hours for one-to-one counselling. The multi-modality approach aims to increase understanding of the importance of FP, give an overview of the available contraceptive methods, emphasise dual-method use, stress the importance of cancer screening, provide support for those who desire children, and promote the importance of FP to improve wellness for men, women and families. Sufficient staff training also ensures that staff are actively engaged in consistent encouragement of FP services uptake and adherence, including message creation and delivery. Lastly, for women expressing a desire to have children or who are pregnant, staff members provide counselling to aid a healthy pregnancy and implement comprehensive PMTCT services according to MoH guidelines.

Lesson 4: Ensure adequate management of other gynaecological problems

In low-resource settings where routine health checkups and screenings are largely absent, many individuals with HIV never receive a complete gynaecological examination outside of antenatal care. Considering that PLHIV comprise a high-risk population, it is important that gynaecological issues including maternal and newborn health, STIs and reproductive tract infections, gynaecological malignancies, gender-based violence, prevention of unsafe abortion and management of post-abortion care are addressed in-house or through referral. Although FP services may be aimed primarily at increasing access to and uptake of contraceptives, it is imperative to include as many comprehensive reproductive health services as human and financial resources make feasible. All providers at Lighthouse are trained on other common reproductive health problems among HIV-positive women which can be diagnosed during VIA or FP reviews and referred, if necessary.

At Lighthouse, the package of reproductive health services increased in a step-wise fashion to incorporate services as finance and personnel resources allowed. The services available at the start of the integration included management of STIs as well as encouragement of treatment-seeking behaviours by partners. In addition to the FP services, in early 2012 cervical cancer screening using VIA and cryotherapy treatment were added. All clinical staff were trained using MoH standard modules on VIA and cryotherapy via a week-long training course. Information and referral are available for services such as tubal ligation and complex gynaecological care such as fibroid management, not available at Lighthouse.

Lesson 5: Implement a monitoring and evaluation strategy

Any new service must incorporate M&E from the programme planning stage to ensure quality care. For integration of services it is important to determine how services are implemented, how well clients and providers accept these activities, and identify areas where improvements can be made. Baseline statistics on contraceptive use and pregnancy rates among women at the clinic are important indicators of programme success when monitored over time. Quality assurance efforts such as direct observation, periodic facility assessments on FP uptake, and conducting exit satisfaction surveys with patients can help identify additional needs and guide efforts for improvement. Dissemination of results to staff is crucial.

At Lighthouse, M&E efforts emphasise high-quality data collection, data use and information dissemination. Routine data collection at Lighthouse combines standardised national tools (i.e. FP registers, STI registers) paired with the real-time patient-level EDS. For evaluation of Lighthouse quality of care, initial patient encounters were observed and each chart was reviewed by an FP-trained physician; concerns were then addressed through one-to-one staff meetings and staff group sessions. Informal FP client discussions were conducted after clinic visits to gauge patient perception and satisfaction. Patient and provider feedback was shared through weekly staff meetings to help identify and create solutions to obstacles encountered, delays in care, and staffing issues.

Lastly, as noted previously, in 2013 the EDS incorporated three questions about FP into routine patient management: (1) any current contraceptive use; (2) if yes, type of method(s); and (3) administration of DMPA as promoted in national guidelines. We use the EDS responses to monitor fluctuations in uptake, identify patient groups who may benefit from focused FP education, and better understand the preferred method mix of our clients. This routine information also provides insight into patient access, uptake, and method maintenance over time, allowing for evaluation of service quality.