The integration of family planning and reproductive health (FP/RH) care with HIV service provision ensures FP information and care are made available to women and couples living with HIV without discrimination. Our partners at Amref Health Africa discuss the challenges of effectively addressing FP needs for vulnerable clients living in informal settlements and slum areas, and offer recommendations for reinforcing FP and HIV integration.
The integration of voluntary family planning and reproductive health (FP/RH) care with HIV service provision ensures FP information and care are made available to women and couples living with HIV without discrimination. In HIV programming, women with HIV or those at high risk of HIV are among the groups that require special consideration because their FP/RH needs are sometimes overlooked. This article provides insights to decision makers and program managers that, like all women, those living with and at risk of acquiring HIV have a right to make their own family planning choices. This is especially critical for the most vulnerable in informal settlements and slum areas like Kibera, where this article draws insights from. This piece discusses challenges to effectively address FP needs for this group and offers recommendations for reinforcing FP and HIV integration especially in slum areas where the workload at the health facility is always high.
Amref Health Africa, in collaboration with the Kenya Ministry of Health with funding from PEPFAR, has been implementing an integrated TB and HIV/AIDS care and treatment project within the informal settlements of Kibera, Nairobi. The project, dubbed Kibera Reach 90, is implemented in nine health facilities throughout the larger Kibera slums. Services provided include adult and pediatric HIV prevention, care, and treatment (including counseling and testing); prevention of mother-to-child transmission (PMTCT); integrated TB/HIV services; and voluntary FP/RH care.
Though the project predominantly focuses on HIV/AIDS and TB services, continuous quality improvement actions in the facilities revealed the need to include FP/RH care as well. It is proven that HIV/FP integration works, and Amref Health Africa supports these facilities to become more efficient in providing comprehensive high-quality care to their clients. This ensures no missed opportunity among couples and women seeking HIV services to access voluntary FP/RH care.
Kibera Reach 90 applies the Kenya Quality Model for Health (KQMH), which integrates evidence-based medicine through wide dissemination of public health and clinical standards and guidelines combined with total quality management and patient partnership. This model strengthens health worker capacity to ensure high-quality service delivery with available resources. Integrating care—including linking FP/RH counseling with HIV health education and counseling—can ensure there are no missed opportunities. Integration also includes the provision of HIV testing at antenatal care visits where FP/RH care is offered.
The project offers direct services to about 12,000 patients receiving antiretroviral therapy (ART), and the facilities monitor patients’ viral load. All couples/partners and women are given FP/RH information and care during their routine clinic checkups. Kibera Reach 90 leverages Community Health Volunteers (CHVs) for continued health education as well as peer-to-peer education and client support groups. The CHVs cover a total of 1,132 households, where they deliver door-to-door education about HIV/TB and FP/RH care. In 2019, 547 women and 27 adolescent girls received ART to reduce the risk of mother-to-child-transmission; 6,326 men, 13,905 women, 1,178 boys, and 2,077 girls were counseled, tested, and received their HIV test results. Additional components of care provided to mothers and girls include counseling on exclusive breastfeeding, PMTCT, and voluntary family planning care.
Furthermore, Kibera Reach 90 builds the capacity of government facilities by providing human resources support and technical assistance for achieving quality improvement goals. Project activities take place in the primary health facilities, where voluntary FP/RH care is part of the standard package for women accessing care at both outpatient and Maternal, Neonatal and Child Health (MNCH) clinics. Pregnancy intention and family planning screening tools are administered to people living with HIV to increase uptake of voluntary family planning and pre-conception care. This ensures that mothers access specialized services at the model project facilities without queuing with the rest of the facilities’ clients. Where the project is unable to offer FP/RH care as a one-stop shop, project staff makes referrals; upon presentation of the referral slips, the client is served without having to wait in line.
Since FP/RH integration with other care has proven to be efficient, all programs should adopt it wherever possible. Decision makers and program managers should leverage the established HIV infrastructure to deliver or improve access to comprehensive reproductive health care for those living with or at risk of HIV. Similarly, it is important to use data thoughtfully to avoid commodity stockouts, increase allocation of resources to voluntary FP/RH care, and ensure that the demand for care matches the supply.
One of the greatest lessons of Kibera Reach 90 is that thanks to integration, there has been improved access and utilization of FP/RH services. It has proved to be a sustainable approach that has also strengthened the capacity of health care workers.
While there are insufficient training opportunities for health care workers to keep abreast of the current knowledge and skills needed to implement FP/RH activities, those who have received additional training have shown great improvement. They make deliberate decisions to integrate services and when this is not possible, they are sure to make referrals.
Erratic stockouts of FP commodities has been a challenge. This is due to the fact that supplies are not funded within the current project. Therefore, full integration is dependent on county health services support, which is currently inadequate.
It is equally important to strengthen the capacity of peer educators and advocates to raise awareness about their clients’ rights and needs for FP/RH services.