Nairobi, Kenya - Safari Park HotelSeptember 12th - 14th, 2 012www.integration2012.org-
Executive Summary............................................................................................................................................. 3Introduction......................................................................................................................................................... 5Track 1: Systems and the Environment.............................................................................................................. 7 Information Systems and Monitoring and Evaluation.................................................................................... 7 Client Management Information Systems..................................................................................................... 8 Supply Chain Management........................................................................................................................... 8Track 2: Models of Sexual and Reproductive Health and HIV Integration........................................................ 9 Integration of Family Planning and HIV Services........................................................................................ 10 Integration of Maternal, Neonatal, and Child Health and HIV Services....................................................... 14 Integration of Cervical Cancer Screening and Prevention and HIV Services.............................................. 16 Interventions to Address Gender-Based Violence....................................................................................... 16 Interventions at the Community Level......................................................................................................... 17Track 3: Policy & Organizational Change to Respond to the RH/HIV Integration Agenda............................ 19 Policies and Guidelines to Scale-Up Services............................................................................................ 19 Public Private Partnerships......................................................................................................................... 20 Enhancing Integration through Training....................................................................................................... 21 Health Care Workers’ Perspectives............................................................................................................. 21 Patients’ Perspectives................................................................................................................................. 22Track 4: Reaching Target Populations.............................................................................................................. 23 Target Populations....................................................................................................................................... 23 Male Involvement........................................................................................................................................ 24Track 5: Integration Assessment...................................................................................................................... 26 Integration Assessment Tools..................................................................................................................... 26Future Research in SRH/HIV Integration in Sub-Saharan Africa.................................................................... 29Advancing Programming in SRH and HIV Integration..................................................................................... 31Committee Members......................................................................................................................................... 32Sponsors............................................................................................................................................................ 33Co-Hosting Institutions..................................................................................................................................... 33Acknowledgements and Additional Resources............................................................................................... 34TA B L E O F C O N T E N T S
E X E C U T I V E S U M M A R YI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 3The Integration for Impact conference, held inNairobi, Kenya in September 2012, explored thepotential public health impact of integrating HIV andsexual and reproductive health (SRH) services intoa single delivery setting. Specifically, the conferenceparticipants examined the aims of integration, differentdelivery models, recent evidence of impact, measurementmethods, the human rights dimension, and the next stepsfor scaling up integrated services in sub-Saharan Africa.Aims: During the opening session of the conference,the keynote scientific speaker, Dr. Mbizvo, and plenaryspeakers, Drs. Macharia and Okello, described thebenefits of integration. Dr. Mbizvo described howintegration of HIV and SRH services can meet clients’needs more efficiently, effectively, and comprehensivelythan separate services. Drs. Macharia and Okello usedexperiences from their respective countries as examplesof how integration of HIV and SRH services alsoprovides an opportunity to build on existing programs,structures, and institutions and to promote universalaccess to both HIV and SRH services. They describedhow service integration has the potential to reduce healthcare costs, promote coordination and efficiency, andenhance overall public health. A frequent refrain wasthat integration “just makes sense” given the manycommonalities between HIV and SRH service programs,such as a similar client group and overlapping healthservice delivery features.Models: Speakers presented a range of integrationmodels to address the needs of different targetpopulations and delivery settings. For example, in the“one stop shop” model, health care workers provideintegrated SRH and HIV services in one room. In the“supermarket model,” stronger linkages are madebetween health care workers and departments atthe same health facility. Presenters gave a variety ofexamples of uni- and bi-directional linkages betweenHIV services and one or more SRH services, includingfamily planning; maternal, neonatal, and child health;prevention and management of gender-based violence;and screening and prevention of sexually transmittedinfections and cervical cancer.PHOTO:BENSONONSONGODrs. Michael Mbizvo, Sheila Macharia, Velephi J Okello, and Issak Bashir at the opening session
EXECUTIVE SUMMARYEvidence of Impact: While most presenters sharedresearch and programmatic evidence that supportsthe integration of HIV and SRH services, othersacknowledged that integration is not a panacea. Somereported that both clients and providers prefer integratedservices, although the speakers acknowledged thatintegration can further strain limited human resources,space, equipment, and supplies at health facilities inresource-limited settings. Other speakers presentedevidence on the benefits of integration for a range ofprocess outcomes, including increased access toand uptake of key SRH and HIV services. However,few speakers reported positive health outcomes as aconsequence of integration (e.g. reducing unintendedpregnancy or reducing vertical transmission of HIV).Few studies examined the cost and cost-effectiveness ofintegrated services.Measurement: During the plenary session on thesecond day, Dr. Ian Askew identified ways to improvethe measurement of integration. Several presentersshared sets of integration measures used to quantifyintegration at the policy, health systems, and servicedelivery levels. During the third day of the conference,panelists recommended that as integrated servicesare scaled up, one or two measures of the impact ofintegration should be included in reports to governmentsand donors. Such measures can help to ensure thatintegration is broadly implemented, and thatevaluation of different models of integration can becompared across programs and regions.Human rights: Throughout the conference,presenters reiterated the need to focus on human rightsand to involve the target community when designingmodels of integration. During Dr. Kevin Osborne’splenary address, he advocated for the provision of highquality SRH and HIV services with a focus on client-centered care to all people. Key affected populationsshould help to plan the design and implementation ofresearch and programs these populations includewomen with unmet need for contraception, peopleliving with HIV, men who have sex with men, sex workers,injection drug users, and other marginalized populations.Several speakers discussed the need for organizationsto empower community members to demand highquality healthcare services that meet members’ needs.Others discussed the importance of addressingstigma and discrimination among those using HIV andFP services, since both stigma and discriminationmitigate the potential benefits of integration and areassociated with worse health outcomes.Scale-up and advocacy: During the final day of theconference, panelists summarized the key messagesfrom the conference and outlined the steps that arerequired to scale up integrated services. The panelistsargued that in order to successfully integrate services,community, regional and national stakeholders mustcontinue to advocate for integration. There was anemphasis on using research-based evidence to makeadvocacy statements and guide the scale up of services.Country leaders must take ownership to promote acoordinated and coherent response, and must includeintegrated services in national plans and budgets. Thepanelists also called upon the international communityand donors to support governments to provide high-quality SRH and HIV services for all.Opportunities for evaluation and implementation science:Panelists discussed the need for additional evidence tobetter understand the intervention components that aremost essential to making integration work in a range ofsettings and how best to scale up these components.They also discussed the need to understand the longer-term impacts of integrated service delivery through morerigorous evaluation and use of implementation scienceas integrated services are scaled-up.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 4
I N T R O D U C T I O NI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 5The Integration for Impact Conference took placeon Sept 12-14, 2012 in Nairobi, Kenya. Therewere 349 attendees from 30 countries, includingrepresentatives from ministries of health, non-governmental organizations, academic institutions,people living with HIV/AIDS (PLWHA), policy experts,donor organizations, and members of the media. Theconference brought together representatives fromcountries with high HIV prevalence and totalfertility rate (TFR); however, interest inattending the conference extendedbeyond the initial target countries.One hundred and fourteen peoplereceived scholarships to attend theconference. Scholarship recipientscame from Burundi, Cameroon, Ethiopia,Kenya, Nigeria, Malawi, Mozambique,Rwanda, Senegal, South Sudan, Swaziland,Tanzania, Uganda, Zambia, and Zimbabwe.Context:Although HIV/AIDS prevention and care programs areexpanding in sub-Saharan Africa, these services areoften offered in isolation from sexual and reproductivehealth (SRH) services, including maternal neonataland child health (MNCH) services and family planning(FP) services. Program managers and policymakersincreasingly recognize the missed opportunities andinefficiencies created by these vertical or “siloed”approaches. A growing body of evidence from somesub-Saharan African settings suggests that integratingreproductive health and HIV services may improveaccess to (1) HIV prevention information and servicesfor HIV-negative individuals, (2) contraception forHIV-positive individuals, (3) prevention of mother-to-child transmission services for pregnant women, and (4)cervical cancer screening. Integration may also leadto earlier initiation and sustained use of anti-retroviraltherapy (ART) among women attending for sexual,reproductive and maternal health services.Efforts to integrate MNCH, FP, and HIV services areexpanding with support from governments, internationalPHOTO:BENSONONSONGOThe map shows in blue the African countries that were representedby conference participants. Additional conference participants camefrom Canada, India, Nepal, Netherlands, the United States, and theUnited Kingdom.
INTRODUCTIONorganizations, and donors. Integration for Impactprovided a platform for policymakers, programimplementers, donors, civil society and researchers tounderstand the current developments, practices, andlatest evidence on integrating MNCH, FP, and HIVservices in sub-Saharan Africa.Goals of the Conference:1. To present the latest research findings on the impact of integrating HIV and SRH services including: FP, MNCH, and screening and treatment for sexually transmitted infections (STI) and cervical cancer;2. To identify research priorities for expanding the evidence on integrated services; and3. To develop strategies for strengthening integration policies and translating research into practice.Conference Theme and Tracks:The theme of the conference was Bridging theGap, Delivering the Promise and Meeting HIVand Reproductive Health Needs. The programcombined a series of plenary, panel, and abstract-driven oral and poster presentations organized byfive sub-thematic tracks:• Systems and the Environment• Models of RH/HIV Integration• Reaching Target Populations• Policy and Organizational Change• Integration AssessmentConference Program, Abstracts,and Poster SessionThe first two days were devoted to presentations andpanel discussions on key findings from research about—and programmatic experiences with—integrating RHand HIV services throughout sub-Saharan Africa. Theprogram included one keynote scientific speaker, fourplenary speakers, 59 oral presentations (individualand panel), 44 oral posters (individual and panel), and28 posters.The third day consisted of a gathering of a smaller groupof researchers, implementers and policy makers that splitinto two groups. The first group discussed strategiesto advance programming in SRH and HIVintegration and a second group worked to develop afuture research agenda in SRH and HIV integrationin sub-Saharan Africa.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 6PHOTO:RACHELSTEINFELDPHOTO:RACHELSTEINFELD
T R AC K 1 : S Y S T E M S A N D T H E E N V I R O N M E N TI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 7As countries roll out integrated HIV and SRH services,a coordinated response is necessary to strengthenhealth systems. This response includes strengtheningof information systems including surveillance data,client management information systems, andmonitoring & evaluation. Laboratory networks andservices, supply chain management, and humanresources also need strengthening. Several presentersdiscussed their efforts to strengthen systems to supportintegrated service delivery.Information Systems andMonitoring and EvaluationFour presentations at the conference evaluatedroutine data to assess uptake and linkage to services, todevelop integration indicators and to improve datacollection and reporting.The non-profit organization FHI 360 evaluated sixFP and HIV service integration indicators in afeasibility study in Ethiopia, India, Rwanda, Tanzania,and Uganda to determine whether indicators couldbe calculated using existing data. They were able tocalculate three indicators using existing data: HIVclients receiving an FP method; FP clients tested forHIV; and service delivery points offering integratedservices. However, current data do not deliver a clearpicture of integration. Data could be improved by using:(1) unique client codes across all health services;(2) standardized formats to record client age; (3) servicecodes to identify the originating service in sharedregisters; and (4) limiting data from other sources infacility registers.The second speaker presented data on ARVuptake and linkage to HIV care among HIV-positivepregnant women in Ethiopia. Data from national surveysindicate that HIV testing among pregnant women is highbut only about 50% of HIV-positive pregnant motherstook ARV for prevention of mother to child transmission(PMTCT) or were linked to care. Management Sciencesfor Health conducted a chart review and traced unlinkedclients and invited them for an interview. There werehigher rates of reporting of ARV uptake and of linking HIVpositive women to HIV care and treatment documentedin the health center registries than what they reported tothe ministry of health. Among women not recorded aslinked, 27% were enrolled in HIV care and treatment atanother health facility and 62% had no or wrong contactinformation. These finding suggest that uptake of ARVsand linkage to care among HIV-positive pregnant womenare better than what is reported by the ministry of health.However, over a quarter of HIV-positive pregnant werenot being linked to HIV services, representing a missedopportunity. Improved data recording and reporting areneeded to capture the correct contact information forclient tracing.MEASURE Evaluation presented a systematicapproach to the Planning, Implementation, Monitoring,and Evaluation of Integrated Health Services. Theapproach used a stepwise method to ensure thatinformation informs decisions throughout the cycleof planning, monitoring, data collection, analysis,revision, and evaluation. Understanding the maincountry-specific health problems will help decisionmakers prioritize the points of care for integration. Logicmodels can facilitate national level planning,implementation, resource generation, and assigning ofroles and responsibilities. Linking client healthinformation and reporting systems also enables differentsystems to work together to facilitate decision making.PHOTO:RACHELSTEINFELD
TRACK 1: SYSTEMS AND THE ENVIRONMENTMEASURE Evaluation developed a toolkit for RapidMonitoring of AIDS Referral Systems (R-MARS) toassess the status of the referral system, establishindicators for monitoring referral systems, and evaluatereferral data. The presenter shared results from a pilotstudy that indicated that referral initiation is documentedas part of routine monitoring but referral completion ratesare not measured. Use of referral data to make decisionsabout health care delivery remained low. Referralassessments drew attention to referrals and their rolein strengthening the health care system. However,monitoring of referrals and their completion waschallenging, especially due to the high burden ofrequired reporting and lack of motivation to monitorreferral completion.Client Management Information SystemsIn order to improve data collection of integrated SRHand HIV Services, Family Health Options Kenya (FHOK)developed and piloted a clinic management informationsystem. The web-based system captures data on theprimary reason for a FHOK clinic visit and the totalnumber of services accessed during that visit. The mostcommon reason for a visit was FP (34%) and VCT (30%)and the average number of services accessed was four.The costs of software development, hardware, andtraining were significant. However, over time the systemis thought to be cost effective and increase the accuracyand completeness of data to inform decision making,such as prioritizing capacity building of service providersand infrastructural adjustments.FHI360 highlighted the limitations in adapting theDemographic and Health Survey (DHS) unmet needalgorithm for women accessing health services.Researchers at FHI360 calculated unmet need forcontraception according to the DHS algorithm andcompared to unmet need taking into account currentand anticipated sexual activity and timing of futurepregnancies. They found that estimates of unmet needamong women in HIV services may be inaccurate dueto assumptions about sexual activity among marriedand single women. A high percentage of women whowanted to become pregnant within two years were usingcontraception, indicating they did not want a pregnancyimmediately. Among the study population there wasa high reliance on condoms, despite its relatively lowcontraceptive effectiveness, and there were low ratesof dual method use. Screening for unmet need forcontraception within a population of HIV-positivewomenaccessingHIVcaremustconsider:(1)variationsinrecent and future sexual activity; (2) desire for children inthe near and distant future; (3) fecundity status; and (4)use of effective contraceptive methods.Supply Chain ManagementOne presenter focused on improving supply chainmanagement using lessons from the private sector. Shefocused on prioritizing supply chain management to meetthe growing needs of integrated health services. Thepresenter described the key attributes that are necessaryto improve the supply chain, including: clarity of rolesand responsibilities, streamlined processes, a visiblelogisticsinformationsystem,trustandcollaboration,anagilesupply chain, and aligned objectives. Improvementsin the supply chain can lead to more cost-effective,agile, and reliable distribution of contraceptivemethods and ARVs.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 8PHOTO:RACHELSTEINFELD
T R AC K 2 : M O D E L S O F S E X U A L A N DR E P R O D U C T I V E H E A LT H A N D H I V I N T E G R AT I O NI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 9Service integration may include a wide range of SRHservices including FP, maternal, neonatal and childhealth (MNCH), prevention and management ofgender-based violence (GBV), and screening andprevention of sexually transmitted infections (STI) andcervical cancer. SRH services may be integrated intoa wide array of HIV services, including HIV testing andcounseling (HTC), condom use, PMTCT, voluntarymedical male circumcision (VMMC), and HIV careand treatment. Service integration may take place atthe health facility level, in the community, or both. Inorder for service integration to reach the largest numberof people, integration should be bi-directional, providedthe evidence supports both “directions.” For example,if there is evidence of benefit, FP services should beprovided to people accessing HTC services, while HTCservices should be offered to people accessing FPservices.Dr. Velephi J Okello discussed the two key models ofintegration during the plenary session.1. ONE STOP SHOP MODEL In this model, the health care worker provides all integrated SRH and HIV services in one sitting. For example, a nurse at the antenatal care (ANC) clinic will provide ANC and PMTCT services to pregnant women. This same provider would also initiate ART for HIV-positive women eligible for ART. Similarly, a provider at the HIV clinic may provide HIV care and treatment services as well as FP, STI treatment, and cervical cancer screening. • The main advantage of this approach is that the number of referrals is reduced, which saves time for the client and increases the likelihood that the client receives all of the services that she requires. • The main disadvantage is that full integration of services will likely increase the waiting time for other clients unless sufficient number of health care providers are offering multiple services. Health care providers must also be cross-trained in all services.2. SUPERMARKET MODEL With this approach, services are provided by health care workers in different rooms but at the same health facility. For example, a pregnant woman may receive ANC services in one room, then go to the next room for HTC, and to another room for ART services. • The advantage of this approach is that health workers are able to specialize in one or two areas. This system is compatible with the current structure of the health system, where services are provided by different health workers trained in certain areas of health care. • The disadvantage with this approach is there may be insufficient communication between the health workers, resulting in lack of continuity in patient care. The approach also requires an ad equate number of consultation rooms and a strong referral system within the facility.Various presenters discussed the factors thatdetermine which service delivery approach should beimplemented at a health care facility. For example, inorder to provide the One Stop Shop model, thefacility must have a sufficient number of cross-trainedstaff and well-equipped consultation rooms with theappropriate space, equipment, supplies, anddocumentation materials. If the supermarket approachis chosen, the referral system will need to bestrengthened to ensure successful referrals. Health careworkers must be trained and supported to provide a widerange of services and be willing to take on additionalresponsibilities. Infrastructure, health care workercapacity to provide all services, patient volume, andpatient demand will have an impact on the selection ofthe service integration model at individual healthcarefacilities.
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONIntegration of Family Planningand HIV ServicesThe most widely reported model of integration presentedat the conference was the integration of FP and HIVservices at the facility level. Researchers and programimplementers discussed different models of FP andHIV integration, including (1) linkage of the two servicesthrough strengthening referral systems (the ‘supermarketapproach’), and (2) fully integrating services, with the twoservices provided in the same room or unit of a healthfacility (the ‘one stop shop’ approach). Several presentersdiscussed the importance of bi-directional models ofintegration, including (1) integrating HIV prevention intoFP, and (2) integrating the provisions of FP methodsand counseling into HTC, HIV care and treatment, andPMTCT.Several pre-formed panels and individuals presentedtheir research findings on the integration of FP andHIV services. Several studies showed an impact onincreased use of FP and HIV services while othersshowed no significant short-term impacts on healthoutcomes, e.g. reducing unintended pregnancy.The University of California, San Francisco (UCSF) andKenya Medical Research Institute (KEMRI) collaborationpresented a pre-formed panel and several relatedindividual presentations on a cluster randomized trial(CRT) involving HIV-positive women in Nyanza, Kenya.The trial compared integration of FP services into HIVcare and treatment services (the intervention group)with non-integrated services (the control group). Theoutcomes examined were (a) whether women who didnot wish to become pregnant used “more effective”contraceptive methods (“more effective” methodsrefer to hormonal, intrauterine, and permanent methods),and (b) rates of pregnancy. Women in the interventiongroup were more likely than women in the control groupto use more effective contraceptive methods (oddsratio 1.55, 95% confidence interval 1.13-2.11). This rise inthe proportion of women living with HIV using moreeffective contraception was not accompanied by adecrease in condom use. Rates of pregnancy were lowerin the intervention group though this difference was notstatistically significant. In a cost-effectiveness analysis,the researchers found that offering integrated servicesdid cost more than offering usual care (an extra $6.96per patient), with most of these additional costs due totraining, mentoring, and supervising personnel. However,integrated services were cost‐effective; such services cost$68 for each additional patient using more effective FP.During the CRT, the UCSF/KEMRI study team alsoevaluated patient satisfaction and familiarity with andattitudes toward FP after integrating services. FollowingFP service strengthening, satisfaction with FP serviceswas high and did not differ by integration status. HIV-positive women obtaining FP at the HIV clinic reportedhigher satisfaction with personnel and additionalavailable services compared to those obtaining FPelsewhere.The researchers found that familiarity withFP methods increased but did not differ by integrationstatus. Integration was associated with a decrease innegative attitudes toward FP among men, which couldimprove contraceptive uptake and continuation amongHIV-affected couples. The study team also found thatintegrating HIV and FP services was associated withmen at integrated FP/HIV clinics having highergender equity scores than those at non-integrated sites.However, among women, integrated services were notassociated with higher gender equity scores. Furtheranalysis is needed to examine whether improvementsin gender equitable attitudes among HIV-positive menserve to increase contraceptive use among their femalepartners.In a pre-formed panel, The Integra Initiative presenteddata and gave several other related presentations.Researchers from the initiative presented findings ontwo models of integration. The first model integratedHTC, STI screening and management, HIV care andtreatment (ART provision and/or referrals), and cervicalI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 10
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONcancer screening into FP services. The second modelintegrated HTC and HIV care and treatment (ARTprovision and/or referrals) into post-natal care and FP.There was a high demand for FP among postpartum HIV-positive women attending integrated HIV and postnatalservices in Swaziland and among all women two out ofthree women reported their most recent pregnancy wasunintended. Most women did not want any more children;however, postpartum women were using the same meth-odstheyhadusedpreviouslywhentheyhadanunintendedpregnancy. In order to meet a large unmet need forboth birth-spacing and reducing the likelihood of futureunintended pregnancies, the researchers found thathealth workers required additional training to providelong-acting methods of contraception.The Integra team also evaluated the effect of a postnatalcare (PNC) and HIV integration model on uptake ofprovider-initiated testing and counseling (PITC) andFP services among postpartum women in Kenya. Theproportion of women who were offered PITC andlong-term and permanent FP methods increased inthe intervention sites, although the difference betweenintervention and control sites was not statisticallysignificant. At 6 months, the team did not find asignificant difference between the Integra interventionand comparison arm for either unmet need for FP orunmet need for HIV/STI protection. The researchers willconduct the analysis again at 1 year to see if there is asignificant difference.Evidence from community surveys indicate that the needfor FP services is high in Swaziland and Kenya althoughthis was largely met. Need for HIV services is high amongmen in both countries but much lower among women.There were low levels of service utilization among thosewith a need for HIV services and high levels of missedopportunities for providers to address clients’ other SRHneeds when they use services. There was extremely lowlatent demand for (and receipt of) integrated servicesamong clients across all services. Most clients receivedthe number of services they desired, while a minorityreceived more services than desired. Strategies toimprove SRH service uptake at the population levelshould be explored.The final presentation assessed the links betweenfertility intentions, FP use and HIV status amongpostpartum women in Swaziland. HIV-positive womenknew earlier during the postpartum period that they didnot intend to have more children, and yet they were lesslikely to be using FP during the early postpartum periodthan HIV negative women. While FP use is prevalent,the early postpartum period should be targeted duringintegration programs to best serve the needs of women.Several individual presentations focused on integratingFP and HIV services.A comparative cross sectional study conducted inEthiopia by Pathfinder International and JohnSnow, Inc (JSI) compared clinics with FPservices integrated into ART clinics to similarfacilities where FP was not integrated. Unmet need forI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 11PHOTO:RACHELSTEINFELD
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONcontraception was low in both arms but waslower in the intervention arm. Contraceptive use wassignificantlyhigherintheinterventionarm.However,useoflong-acting and permanent methods was more commonin the control group.A pre- and post-intervention, cross-sectional study by theZambia Prevention, Care and Treatment Partnership andFHI360 examined the effect of integrating FP and HIVservices in selected sites in Zambia. The interventionincluded training, mentorship, and demand-creationactivities. After the intervention, there was a fourfoldincrease in HTC services among FP users. The numberof HTC and ART clients referred for FP services alsoincreased dramatically. The researchers found that itwas feasible to advance FP/HIV integration, althoughcapacity building and task shifting were necessary inlight of human resource constraints.Another study assessed integrating FP and HIV/STIservices through the Urban Reproductive HealthInitiative. Among a sample of female clients who soughtHIV/STI services, 82% did not receive FP informationat the time of visit and, of these women, 35% said theywould have accepted an FP method if it was offered.Of the HIV/STI clients who received information on FP,57% reported that it was provider initiated, 19%reported that it was client initiated, and 43% had heardabout FP through signs and videos on FP. In order toprevent missed opportunities for FP, more providersneed to initiate FP and HIV discussions and offer theseservices. Demand creation activities are also necessaryto encourage clients to actively ask for services.Researchers conducted a secondary analysis from anongoing trial in Tororo, Uganda that compared efavi-renz and lopinavir/ritonavir (LPV/r)-based ART amongHIV-positive pregnant/breastfeeding women. In thesecondary analysis, they estimated adherence to andeffectiveness of contraception among postpartumHIV-positive women. In this integrated FP/HIV caremodel, they found that pregnancy incidence was lowand contraception rate was high (78.6%). Most womenchose depot medroxyprogesterone acetate (DMPA);additional research should investigate barriers andfacilitators to long acting and permanent methodsamong post-partum HIV-positive women in research androutine care clinical settings.FHI360 presented a before and after cross-sectionalstudy that evaluated the impact of PMTCT-FPintegration on use of long acting contraceptive methodsamong post-partum PMTCT clients. The interventionincluded clinical training on IUD insertion, improvedaccesstosupplies,equipment,andinformation,educationandcommunication(IEC)materials,coaching,andreferralreinforcement. However, after the intervention therewere no changes in knowledge about IUD, there wereonly modest improvements in knowledge about femalesterilization, and there was no change in uptake of longacting methods. Process data and in-depth interviewsrevealed problems with implementation of the interventionrooted in human resource management. The potentialfor scale up and sustainability of interventions meantfor public sector implementation should be consideredwithin the design and rollout of programmatic researchon integrated service delivery.A sample of couples in Western Kenya completedinterviews on pregnancy intention and contraceptionand were tested for HIV. Concordant couples andHIV-negative women were more likely to be usingcontraception at baseline than discordant couples andHIV-positive women. Use of contraception increasedsignificantly from baseline to 6 month follow-up,especially use of IUDs. There was significant variationin the method of contraception over time, influenced bynumber of children, previous method of contraception,and pregnancy intention. However, the results suggestthat utilization of hormonal contraception and IUD wasnot influenced by the couples’ HIV status.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 12
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONIn addition to improving access to FP services forPLWHA, one researcher presented her research onIntegration of Safer Conception and RH Services forHIV serodiscordant couples desiring conception. Saferconception practices will help to curb HIV incidence,enable couples to fulfill their reproductive goals, andminimize the risk of HIV transmission amongserodiscordant couples. A qualitative study conductedin Kisumu, Kenya among HIV serodiscordant couplesfound that serodiscordant couples on average desired2-4 children and that HIV-positive women were unawareof safer methods of conception. Couples were interestedin safer methods of conception but they expressed someconcerns about discussing childbearing with health careproviders, including discouraging attitudes of healthcareproviders and time constraints during clinic visits.In order to provide comprehensive RH services, astandardized preconception counseling message forHIV-serodiscordant couples needs to be createdand health care staff need to be trained to conductpreconception counseling.Several presentations focused on unintendedpregnancy and abortion. The first presentation focusedon knowledge, attitudes and experience withabortion among HIV-positive individuals in Nyanza,Kenya. Among a sample of HIV-positive men andwomen accessing HIV care in Nyanza province, accurateknowledge of Kenyan abortion law was low andstigmatizing views of abortion were very prevalent.Unintended pregnancy was shown to be common andabout eight percent of women reported having hadan abortion. In addition to prevention of unintendedpregnancy, comprehensive services for HIV-positiveindividuals should include counseling on the risks ofunsafe abortion and referrals to safe, legal abortionservices when appropriate.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 13PHOTO:RACHELSTEINFELD
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONOne presenter discused recent research fromNigeria and Zambia showing that unintended pregnancyis higher among women who perceive themselves tobe at risk for HIV than among those who do not. Theresearcher believed that women who are at greater riskof being infected with HIV have more difficulty translatingtheir desire to prevent unintended pregnancy intogreater use of contraception. The investigators feel thatintegrating provision of HIV-related services and FPservices will better meet the needs of these women.In addition to presenting findings from research, otherpresenters focused on their efforts to promoteevidenced-based integration models. In Swaziland,International Planned Parenthood Federation (IPPF)conducted a case study to identify the best practicesto eliminate mother-to-child transmission of HIV bypreventing HIV and unintended pregnancies. The bestpractices included: (1) including PMTCT in community-based health education; (2) linking HTC to SRHservices; (3) encouraging male partner involvement;(4) giving information about dual protection and FPduring ANC consultations; (5) providing FP duringpost-partum visits; (6) identifying women who are at riskof, or experiencing, gender-based violence and referringthem for services to prevent and manage it; and (7)increasing awareness about the reproductive rights ofwomen living with HIV. IPPF developed an educationalvideo, the Love Letter, to promote promising practices toeliminate mother-to-child transmission of HIV.Integration of Maternal, Neonatal,and Child Health and HIV ServicesThe integration of Maternal, Neonatal, and ChildHealth (MNCH) services with HIV care was also widelydiscussed. The UCSF/KEMRI collaboration conducted aCRT of Integrated ANC and HIV Care and Treatment inNyanza Province, Kenya. In their study, fully integratedclinics provided HIV-positive women with ANC, PMTCTservices, and HIV care and treatment by the samehealth personnel in the MCH clinic. In the non-integratedsites, pregnant women received ANC and basic PMTCTservices in the MCH clinic, but were referred to aseparate HIV clinic to receive HIV care and treatment.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 14PHOTO:BENSONONSONGODr. Sierra Washington presenting the results of a cluster randomized trial of integration of ANC, PMTCT, and HIV care and treatment.
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONAt one year of follow-up, pregnant women receivedsimilar initial services at the ANC in both arms; however,results indicate strong positive effects of integrationon women’s timely enrollment in HIV care and use ofARVs during pregnancy. There were also trends towardspositive effects on other PMTCT uptake outcomes,but they were not statistically significant. Early infantdiagnosis remained a challenge in both arms. Duringthe one-year follow-up, integration of HIV services intothe ANC clinic was not associated with reduced verticaltransmission of HIV or a difference in maternal healthoutcomes. However, integration of HIV services into theANC clinic resulted in earlier initiation of highly activeART(HAART) in eligible patients. Members of the study teamregularly conducted integration assessments at the 12sites using a standardized integration assessment tool.The integration scores of the facilities matched their studyassignment (i.e. into intervention or control group), withsome variations based on the availability of resources.The researchers also examined the associationsbetween service integration, the woman’s experiencesof HIV stigma, and enrollment in HIV care and treatment.The reseacher found that HIV-related stigma was asignificant barrier to pregnant women’s engagementin HIV care and that integration of ANC and HIVservices may play a role in reducing experiences ofstigma. However, they also found that internalized HIVstigma continued to be an important barrier for somewomen at both integrated and non-integrated ANCclinics. Stigma-reduction interventions should be addedto ANC-HIV service integration to achieve maximumbenefits for women and infants.Surveys were conducted by researchers at FHI360before and after HIV and postnatal care (PNC) serviceswere integrated in SouthAfrica. Baseline findings showedthat provider knowledge of key components of PNCperiod was poor. As a result, providers were trained inhow to provide clients with a comprehensive packageof PNC services. Some improvements were made,although high staff turn-over affected the impact of theintervention.The Missed Opportunities in Maternal and Infant Health(MOMI) project presented a panel that discussedthe project’s efforts to reduce maternal and newbornmortality and morbidity through combined facility-and community-based interventions. In Kenya, theinvestigators found that postpartum care was notregularly integrated into child health clinics. Less thanone third of women received post-partum care, whereasover 70% of newborns received BCG vaccine,demonstrating missed opportunities for women. InMozambique, the MOMI project conducted a policyanalysis that found that the package of postpartumcare services for the first 28 days after delivery arewell-defined (i.e. FP, mother’s nutrition, etc) andintegrated into under-five services. However, the packageof interventions beyond 28 days (i.e. gynecologicalcancer and HIV screening, nutrition counseling, etc.) isnot well developed nor is it integrated with the under-fiveservices. Stakeholders were invited to attend local PolicyAdvisory Boards in Malawi to discuss and disseminatethe research outcomes. Involvement of stakeholdersI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 15PHOTO:RACHELSTEINFELD
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONfacilitated the translation of research findings intopractice and thus bridged the gap between re-search and policy. Participation of the stakeholders inthe research design and process promoted thedissemination of the results among health practitionersand authorities.And finally, the MOMI project presented a package ofpost-partum interventions in Burkina Faso. Theyconducted a review of MCH policies, a situationanalysis, and causal analysis of stakeholders todevelop a specific package of interventions. Theinterventions included strengthening of existingfacility-based postpartum care, integrating postpartumcare into the child-health clinics, and involvingcommunity health workers to mobilize mothers toattend post-partum care.In Nyanza Province, Kenya, the Elizabeth GlaserPediatric AIDS Foundation (EGPAF) integrated HIVcare and treatment into MCH clinics and empoweredmother mentors to provide follow-up on the mother-babypairs. After the intervention, they found improvements inmother-baby pairs’ access to HIV prevention, care, andtreatment services and the retention of mother-babypairs increased from 30% to 80%.Integration of Cervical Cancer Screeningand Prevention and HIV ServicesOne program in Nyanza Province, Kenya reportedfindings from the integration of cervical cancerscreening and prevention (CCSP) into HIV-care. In thisprogram,education,counseling,screening,andtreatmentare nested within routine clinic visits. Researchers whostudied the program found that community awarenessand patient education was essential for high uptakeof services. This same program evaluated the impactand cost-effectiveness of integrating CCSP intoHIV-care. The evaluation found that cervical cancerscreening within HIV clinics is extremely cost-effectiveregardless of the screening strategy. A single-lifetimevisual inspection with acetic acid (VIA) coupled withcryotherapy was the most cost-effective. Cost-effective-ness increased with increasing prevalence of cervicalintraepithelial neoplasia (CIN) 2/3 and increasingproportion of HIV-positive women enrolling into care.Interventions to AddressGender-Based ViolenceThere were two panels on interventions to mitigatethe impacts of gender-based violence (GBV). The firstpanelists presented their experiences with integratingsexual and gender-based violence (SGBV) servicesinto a public hospital in Kenya. The Gender-BasedViolence & Recovery Centre (GBVRC) in Mombasa,Kenya provides medical, psycho-social, legal, andspecialized referral services to SGBV survivors by amultidisciplinary team within a public hospital. The teamalso provides training, conducts research, carries outcommunity awareness and outreach activities, and mapsservice providers for GBV. It provides services to thecommunity 24 hours a day through the casualty ward andduring the week at the GBVRC. There is also a strongreferral network within the hospital. However, thelimitations include insufficient staffing and supplies andlong waiting times. Funding is donor-dependent and thereis an insufficient referral network and inadequatecollaboration with the police and legal services.Integration of services has led to ownership by thecommunity and improved access to information andreferrals to the justice system.One researcher presented five years of GBVRC data,which included data from more than 3000 survivors.The researchers found that most survivors were <18years and they did not observe changes over time in theproportion of survivors by age group. They also foundthat 83% percent of the survivors were female. Threequarters of the perpetrators are known to the victim.Selected findings from 5 years GBVRC research werepresented. They found that about 50% of the survivorsattending the GBVRC were children (<15 years). TheI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 16
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONSexual Offense Act of 2006 makes sex with a minor apunishable crime (15 years to life in prison); however,in many communities early marriage and early sexualdebut are common. Therefore there is a differencebetween what is stated by the law and the reality facedamong youth. They also found that the local communityis often silent and condones some practices of SGBV.In order to address the root causes, a communityoutreach officer and local networks of SGBV paralegalsand community guides examined patterns of abuse,verified facts, and liaised with local police and thecommunity. Integrated approaches within the publicsector facilities have offered an opportunity to reach themost at-risk population and provide necessary referrals.The presenters from the second panel on GBVinterventionsfocusedonemergingevidenceforintegratingscreening for violence into HIV and primary health careservices in East Africa. The first presenter focused onscreening for intimate partner violence (IPV) at KenyattaNational Hospital. Providers and clients were comfortablewith the idea of routine IPV screening; however,clients were concerned about confidentiality. Providersrequired reinforcements to the health system to assureconfidentiaility and ensure that clients were properlyreferred. The second presentation was on integratingroutine IPV screening and supported referrals into ANCin a rural Kenyan clinic. This pilot study assessed thefeasibility and acceptability of an IPV intervention whereclinic staff and a new cadre of lay ‘Community ReferralPersons’ were trained to offer supported referrals fromthe ANC clinic to existing resources in the district. MostANC clients reporting violence were successfully linkedto local services directly or via a Community ReferralPerson. Health providers and community membersfound the intervention acceptable and felt empoweredto support IPV survivors. However, clinic staff requiredongoing support and mentorship for consistent screeningand referrals and local service providers (police, judicial,informal counselors) needed stronger links to encouragesuccessful referrals.Another researcher presented data from a pilot study ina district hospital in Dar es Salaam, Tanzania, based ona screening tool for GBV used by healthcare workers.Through focus group discussions and narratives,the providers revealed an overall appreciation of thetool. However, there were structural and attitudinalchallengesnecessaryfortheuseofscreeningtool.Thefinalpresentation focused on lessons learned by screeningand providing GBV care in selected health facilities inDar es Salaam. Health care providers were trained tointegrate GBV into HTC. A number of facilities werealready providing GBV services to survivors and theadditional training was viewed as instrumental for theprovision of standardized, quality care. The integratedapproach is promising in terms of strengtheningservices and targeting a large number of GBV survivors.However, the pilot also encountered challenges such asextra workload, gaps in human and material resources,limited space to provide privacy and confidentiality, lack ofreferral and support networks for providing a continuumof care, and a need for harmonized documentationsystem for GBV. Further training should focus onscreening and provision of GBV services and health careprovider’s beliefs and attitudes.Interventions at the Community LevelIn addition to facility-based interventions, many of thepresentationsfocusedoncommunity-basedinterventionsto create demand for services including referral to thehealth facility as well as services in the community.One presentation focused on creating demand forintegrated HIV and SRH services through community-based mobilization in Swaziland. Family Life Associationled National Community Health Days, broadcast radioseries, and hosted meetings of civil society organizations(CSOs). Community and CSO involvement were criticalin raising awareness, applying pressure on communityleaders and politicians to demand integrated services,and addressing socio-cultural dynamics.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 17
TRACK 2: MODELS OF SEXUAL AND REPRODUCTIVE HEALTH AND HIV INTEGRATIONAnother program used community health care workersto provide home-based FP counseling and HTC andto refer clients to nearby health facilities in NorthernMozambique. The number of clients who received theseservices increased dramatically. Counselors reportedproviding a more comprehensive package of servicesduring home visits, including individual and couplecounseling, though they found that providing morecomprehensive services increased the length of theirvisits which should be considered when implementingthis strategy to a larger population. Health care workersreported increased knowledge of clients, increased maleinvolvement, and an increase in referrals.Another presenter discussed strategies to reduceHIV-related maternal mortality and improve healthoutcomes through community systems strengtheningin Kenya, South Sudan, Uganda, and Zambia. TheInternational AIDS Alliance used community-basedinterventions to raise awareness, create demand forservices, and strengthen referral systems. The allianceconducted interviews and focus groups and found thatcommunities, governments, and health service providersunderstood the links between HIV and maternalmortality. The project resulted in strengthened pathwaysfor referral and follow up of HIV-positive pregnantwomen from community-based, non-governmental, andfaith-based organizations to the health system.In Malawi, the Ministry of Health piloted integrated FP,HTC, and PMTCT into nutrition and growth monitoringsessions with new mothers and mother father supportgroups. The ministry promoted exclusive breast feeding,immunization, child spacing, dual protection, malariaprevention with bed nets, and male involvement. Thisintervention led to increased FP access, immunization,under 5 attendance, home visits, and a decrease in thenumber of underweight children. However, an integrationpolicy with a monitoring framework for nutrition, HIV, andFP needs to be developed for this effort to be sustained.A community-based intervention in Burkina Fasofocused on the development of a village social map toolto capture household demographic and health data,such as immunization rates, rates of childhooddeworming and of vitamin A supplementation,contraception use, and cases of malaria, diarrhea, andacute respiratory infection. Regular meetings took placebetween community health workers and health workersat the health centre to review data and plan activities.ICRH and Population Council recruited PLWHA livingin the community who were not in HIV care andprovided one-on-one counseling by communityhealth workers. In a prospective cohort study, at theintervention sites there was an increase in HIV-relatedknowledge, disclosure, consistent condom use, anduptake of ART, and a reduction in risk behaviors. Therole of CHWs was strengthened through providingtraining, support, and incentives.A pilot project was conducted on the integration ofMCH within Community ART Groups (CAG) in ruralMozambique. Despite good adherence to HIV treatmentby group members, CAG members and their familieswere less successful in adherence to MCH care, suchas contraception, early infant diagnosis of HIV, paediatricHIV treatment, and infant nutrition. Poor adherence tosuch MCH care was due to socio-cultural barriers, lackof confidence in some MCH services, and structuralbarriers such as distance to health facilities, lack oftransport, unavailability of MCH personnel, andinconsisent supply of drugs and equipment. Interventionswere set up to strengthen knowledge and practiceof MCH personnel and to establish knowledgeableintermediaries from the CAG to promote MCH servicesand liaise with health services. As a result, follow-upof HIV exposed infants as well as identification andtreatment of malnourished or HIV-positive childrenimproved according to the district health services andactors within the community. Community participationdeveloped for HIV care offers a good opportunity to movetowards more comprehensive and family-oriented care.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 18
T R AC K 3 : P O L I C Y & O R G A N I Z AT I O N A L C H A N G E T OR E S P O N D T O T H E R H / H I V I N T E G R AT I O N A G E N D AI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 19One of the main barriers to integration is verticalplanning and programming, which is entrenched in thesystems of governments, donors, local and internationalorganizations, and health systems. During Dr. SheliaMacharia’s plenary session, she discussed the effortto advocate for (1) flexible, innovative funding; (2) areview of national policies and activities to supportntegration; and (3) the development of national taskforces comprised of representatives from the SRHand HIV divisions of the Ministry of Health to supportintegration throughout the health care system. During theclosing ceremony, Dr. Craig Cohen advocated for countriesto establish a minimum package of integrated services.Dr. Velephi Okello presented some of the opportunitiesthat various countries have used to improve integratedservices:1. Decentralization of HIV services to the primary health care level. This offers a great opportunity to provide integrated SRH-HIV services to the rural population.2. Task shifting to lower cadres of health care workers to enable clinicians to provide quality integrated SRH-HIV services.3. Simplification of diagnostic services, such as point of care CD4 machines and hemoglobin meters, to reduce patient waiting times for test results and minimize referrals to other facilities.4. Electronic medical records for HIV-positive patients, with SRH data incorporated into the system for ease of data aggregation and analysis.5. Global agencies have committed to funding integrated SRH-HIV services and expect countries to align SRH and HIV strategies according to this global commitment.6. System strengthening to improve the procurement and distribution of commodities.Dr. Shelia Macharia noted some important factors toconsider when implementing organizational change.These include effective coordination, planning, andpartnerships. Furthermore, it is critical to strengthenhuman resources, infrastructure, health informationsystems, and supply chains.Policies and Guidelines toScale-Up ServicesIn several presentations, presenters focused on thescale up of integrated services at a national level. Aftera needs assessment and a successful pilot, theTanzanian Ministry of Health initiated the scale-up ofFP/Care and Treatment Clinic (CTC) integration withan integration taskforce. The taskforce developeda training curriculum and job aids, trained mastertrainers, engaged regional managers, and modified datacollection forms. By 2012, the Ministry of Health andpartner organizations had scaled up integrated FP/CTC services at 116 facilities in 13 regions. Thechallengeshavebeenlackofconfirmedfunding,inadequatehuman resources and supplies, and inconsistentsupervision. The main lessons learned were:(1) pilots should not be overly expensive or complicated;(2) scale-up efforts need to be coordinated and addressall levels of the health care system; (3) services needto be rigorously monitored and evaluated; and(4) consistent funding sources need to be identified.Structured interviews with facility staff and keystakeholders and a desk review of policy andguidance documents were used to assess FP and HIVCare and Treatment integration in Kenya, including thegeographic coverage and degree of integration and thepotential challenges and enabling factors to scale-up.District hospitals and health centers were ratedhigher performing than provincial hospitals with regard tointegration. Researchers at FHI360 found that there areadequate strategies and guidance documents. However,there is a need for improved contraceptive availability,especially long term methods at the comprehensive carecenters, and additional dissemination and orientation ofservice providers to integrated service models, includinginto the pre-service curriculum.
TRACK 3: POLICY & ORGANIZATIONAL CHANGE TO RESPOND TO THE RH/HIV INTEGRATION AGENDAThe Integration Partnership (TIP) presented apreformed panel highlighting its efforts to translateprogrammatic evidence into advocacy for RH/HIVintegration in Ethiopia, Kenya, and Nigeria and RH/HIVand MNCH/AIDS, TB, and Malaria (ATM) integration inTanzania and Zambia. TIP developed three synergisticapproaches to increase the prominence of RH/HIVintegration among international funders, acceleratedemand for services, and promote civil societyinvolvement in RH/HIV and MNCH/ATM integrationstrategies. These approaches include grants to civilsociety organizations, global advocacy (in the UnitedStates and Europe); and country-level advocacy by civilsociety partners. The first presentation was based onlessons learned in implementing a Reproductive Health/HIV Integrated Program in Nigeria. Friends Africa foundthat integration increased access to RH/HIV services,and resulted in higher numbers of clients requesting HIV,FP and STI services and stigma reduction among clientsseeking services. Planned Parenthood Federation ofNigeria (PPFN) leveraged Global Fund (GF) investmentsto increase coverage of RH/HIV integrated services.However, staff training and the availability ofinfrastructure remains a challenge. PPFN found thatintegration of SRH services needs to be included inthe HIV/AIDS policy and stakeholders must agree onentry points and appropriate models for integration.TIP partnered with Women and Law in Southern Africa(WLSA) to track and monitor the procurement ofcontraceptives with GF resources in Zambia. By linkingoversight of GF expenditures to current advocacyintegration efforts, TIP and WLSA were able todemonstrate Zambia’s successful procurement of RH/FP supplies to strengthen HIV services. In Ethiopia,Family Care International (FCI) examined Ethiopia’sGF grant portfolio, and collected information on relevantpolicies, programs, and approaches to promote MNCH/ATM integrated service delivery. These case studiesprovide lessons learned for other national governmentson how GF resources can be used to strengthen agovernment-led approach to integrate programs at allservice delivery levels. Through TIP, over 15 local CSOsin six countries received small grants for country-leveladvocacy on RH/HIV integration. Youth Vision Zambiapartnered with other RH and HIV CSOs to build advocacystrategies that promote integrated RH/HIV approaches.Civil society has created an enabling environmentamong international funders and the ministries of healthto pursue opportunities to leverage RH/HIV integration.By engaging with technical agencies and informingdecision-makers of the benefits of integration, the CSOpartners have linked supportive integration policies withdonor support and accelerated demand for FP, HIV, andother SRH services.One presenter demonstrated how her organizationempowered PLWHA to become advocates for integratedHIV & SRH services. Five PLWHA, all women, weretrained to analyze integration challenges through healthfacility exit interviews and home visits. These womenwere able articulate their real life experiences andengage with service providers, development partners,and government authorities at national and districtlevels. There is a need to engage and train more womenliving with HIV to lobby for integration based on personaltestimonies and real life experiences.Public Private PartnershipsIn Nairobi, Hope Worldwide Kenya mobilized funds fromprivate organizations to provide social and structural HIVprevention services to youth, people living with HIV, andorphans and vulnerable children and their caregivers.Services included health education, HTC, facilitateddisclosure, and vocational and entrepreneurial skillstraining. Contributions came from private entities suchas Wal-Mart and Coca-Cola.MEASURE Evaluation used the Organizational NetworkApproach in Ethiopia to understand how organizationsprovide HIV or FP services work together to meetclients’ needs, and reduce duplication or fill gaps. Thegroup found that few referrals were made betweenorganizations. Barriers to networking included too fewI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 0
TRACK 3: POLICY & ORGANIZATIONAL CHANGE TO RESPOND TO THE RH/HIV INTEGRATION AGENDAresources and not knowing with whom to cooperateor how best to cooperate. MEASURE Evaluation alsointerviewed female clients of a home based HIV careorganization. Housing and job training support were theclients’ largest unmet need. After the initial assessment,the group conducted network strengthening activities tobuild support for networks.Enhancing Integration through TrainingIn order to address the training needs of servicesproviders, Population Council designed and testedprotocols for a peer mentorship approach to improvehealth workers skills and knowledge to provide qualityintegrated HIV and SRH services. Using the nationaltraining materials on FP and HIV integration, mentoringtools were developed and pretested. A checklist wasused to assess the mentees’ level of knowledge andskills. The mentoring took an average of 100 contacthours over a period of four to six months. As a resultof mentoring, there was an increase in knowledge andskills among providers and an increase in use of longterm FP methods. Mentoring empowered first line healthcare providers with knowledge and skills and created aself sustaining system for learning, thus improving therange of integrated HIV/RH services.Another approach to improve capacity of health careworkers focused on a review of the pre-service curriculaeat medical training colleges (MTC) to ensure up to dateknowledge, adequate skills, and appropriate attitudesrelated to HIV/AIDS. In-service training manualsendorsed by the Ministry of Health were adopted forpre-service training. Competency based HIV/AIDStraining for MTC students should be incorporated andtaught comprehensively in pre-service institutions toincorporate appropriate knowledge, skills, and attitudeslaying a suitable foundation for in-service healthcareservices integration.Health Care Workers’ PerspectivesIn addition to addressing the training needs of healthcare providers, several presentations focused on thepersepctives of health care workers to provide integratedservices. For example, semi-structured interviews withhealth care providers from the VCT and HIV clinicswere conducted in Kumasi, Ghana on the integration ofFP and HIV services. Providers reported no formalcollaboration between their clinics and FP. All providersfelt that integration would be beneficial. Commonly citedbarriers were a lack of time, insufficient client education,client self-stigma and clinic space limitations. Mostproviders at the HIV clinic felt that a viable solution wouldbe for a FP provider to provide on-site services.Interviews were also conducted with service providersin Kenya and Swaziland about integrating HIV andreproductive health services. Researchers at the IntegraInitiative reported delivering integrated services in acombination of (1) provider-level integration, wherethe provider gives multiple services to a client in oneroom, and (2) unit-level integration, where clients movebetween rooms and providers, but in the same part ofthe facility e.g., the MCH unit. Many providers said thatintegration increased their workload, but they found waysto cope through better team-work. Providers valuedskill enhancement, more variety and challenge in theirwork, and better job satisfaction through increased clientsatisfaction. However, they expressed challenges suchas inadequate salaries, occupational stress due toincreased workload and client waiting times, and lessquality time with clients especially very sick clients. Moststaff were supportive of integration but mechanismsare needed to help providers cope with high stress andworkloads and improvements are needed in staffsalaries, staffing levels, and infrastructure.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 21
TRACK 3: POLICY & ORGANIZATIONAL CHANGE TO RESPOND TO THE RH/HIV INTEGRATION AGENDAA cross sectional study conducted among health careworkers in Nigeria found that lack of sufficient humanresources, training, and consumables were barriers toproviding quality integrated services. The training needsare compounded by frequent staff transfers of trainedpersonnel.The World Health Organization recently issued atechnical statement on Hormonal Contraceptivesand HIV Risk that stated that current data were notsufficiently conclusive to change the medical eligibilitycriteria (MEC) on contraceptive use. Due to potentialHIV risks, women using progesterone-only injectablecontraception are strongly advised to also use condomsor other prevention measures. Interviews were conductedto assess FP service provider perspectives of the WHOtechnical statement. All providers were aware of theWHO statement and none had modified their operations,since the guidance didn’t change current practice. Pro-viders expressed no intention to communicate the po-tential HIV risk of Depo-provera to women because theyfeared the information would cause many to abandon FP,potentially leading to an increase in maternal deaths.Providers should give accurate information to womenabout available contraception methods so they can makeinformed FP and HIV prevention choices.Patients’ PerspectivesPatients’ perspectives on integration of SRH and HIVservices in North Central Nigeria were presented. ANCclients preferred to receive SRH/FP and HIV-relatedservices in the same facility and by the same providerbecause they felt it would reduce the number of trips tothe facility, improve efficiency of services, reduce wait-ing time, and be a good opportunity to access additionalservices. But patients also expressed several disadvan-tages of integration, included fear of stigma and reducedconfidentiality, and an embarrassment to discuss HIV-related issues.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 2PHOTO:BETHNOVEYPHOTO:BETHNOVEY
I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 3Dr. Kevin Osborne emphasized during the plenarysession that integration of SRH and HIV/AIDS is ahuman rights issue. Health as a human right focuseson: (1) ensuring universal access to quality health care,(2) client confidentiality, (3) informed decision-making,(4) informed consent, and (5) sufficient training forproviders to uphold the rights of clients. It is important torecognize that human rights violations still occur in thecontext of FP, such as forced sterilization and implantsnot being removed.Many of the linkages that have been supported to datedo not adequately address the needs of key populations.Key populations are populations for which HIV risk andvulnerability converge. They include sex workers (male,female, and transgender), men who have sex with men(MSM), injection drug users (IDUs), and those livingwith HIV who may be unable to access mainstreamservices. Such populations are usually stigmatized andcriminalized groups. Key populations, by definition,predominate in concentrated epidemics, but they alsocontribute to generalized epidemics, and account for asubstantial portion of the epidemic in many countries.Efforts for linked SRH and HIV responses are notadequately meeting the needs of these key populationsat higher risk of HIV infection.Meeting the HIV and SRH priorities of key populationsremains an area that is largely elusive and underexplored.Programs that aim to address the specific nuancesof these issues are sporadic and lack the ability toaddress some of the synergistic opportunities that wouldsupportbi-directionallinkages.Fuelledpartlybyahistorical,reactive, and superficial response, and a lack of a linkedresponse supported at the policy, program, and personallevels, the key issues facing key populations remainunaddressed.One strategy to improve access to integrated services forall people is to empower communities to demand qualityintegrated services including PLWHA, MSM, sex workers,and IDUs. Dr. Osbourne highlighted some successstories to provide integrated services to key populations. • Cameroon - stigma-free services for lesbian, gay, bisexual, transgender, and intersex people • Uganda - integrated SRH and HIV services for sex workers • Kenya - harm reduction services to people who inject drugs • Swaziland - the correctional services department provides integrated SRH and HIV services • Various countries - teen clubs and adolescent clinicsprovideintegratedSRHandHIVservices.Target PopulationsThere were several presentations at the conferencehighlighting efforts to reach key target populations.For example, there were two presentations on usingdrop-in services centers (DISCs) to provide integratedSRH services to female sex workers (FSW), male sexworkers (MSWs), and men who have sex with men(MSM) in Coast Province, Kenya. DISCs for FSW, theirclients, and other most-at-risk-populations (MARPs)were able to provide user friendly, integrated servicesincluding HTC, screening and treatment for STIs,screening for cervical cancer, provision of FP methodsincluding condoms, counseling for alcohol and drugreduction, counseling and referral for GBV, and otherservices. MSM/MSW peer educators facilitated healtheducation days aimed at educating their peers on HIV/AIDS/STIs and referring them for services at the DISCs.DISCs provide HTC, STI screening and treatment,FP services, condom and lubricant promotion, anddistribution and referrals for other SRH services.The International Center for Reproductive Health inKenya initiated a project to expand access tointegrated SRH services for FSWs in Kilifi. The projectinvolved behavioral communication; advocacy with gatekeepers; rescue, rehabilitation and reintegration of youngsex workers; capacity building and mentorship; linkageswith income-generating activities; alcohol and drugreduction counseling; sexual and gender based vio-T R AC K 4 : R E A C H I N G TA R G E T P O P U L AT I O N S
TRACK 4: REACHING TARGET POPULATIONSlence; service delivery; 100% condom promotion anddistribution; and monitoring and evaluation. Integratedservices have led to increased uptake of these servicesby FSWs and their clients by offering them at convenienttimes and at their usual hotspots.Another presentation focused on integrating HIVand SRH for FSW and Injecting Drug Users (IDU) inZanzibar. The resesarchers conducted interviews withFSW and IDUs to understand barriers to using SRH andHIV services. There were many socio-cultural factors thatprevented uptake of servies, including religious practicesand cultural norms that prevent people from accessingservices such as familiy planning. The reseachers foundthat there was a preferance for clients to receive ser-vices in a setting with clients and providers that are simi-lar in age to themselves. Distance from the service areaand availabiltiy of FP supplies were other barriers. Theresearchers highlighted the rationale of integrating SRHand HIV services for FSW and IDUs and the ZanzibarGovernment approved the integration of these servicesfor this population.Access to health services in North Eastern Province,Kenya is limited by distance, tradition, education, andlack of providers. The AIDS, Population, and HealthIntegrated Assistance (APHIA II) project linked HIV,RH/FP, TB, and MNCH services to increase accessto services, address local priorities, and engagestakeholders. Intervention approaches includedintegrated outreach, engagement of religious leaders,prevention messages, service delivery supervision,support for infrastructure and laboraties, M&E systemsstrengthening, and local leadership capacity building.As a result, HTC and ANC uptake increased, outreachcosts decreased, and facility revenue increased.An information centre was built at Seme border betweenRepublic of Benin and Nigeria to improve access to HIVrelated information and services to migrants and MARPs.Health providers along the corridor were trained toprovide information on prevention and syndromicmanagement of STIs and FP counseling and referral.Outreach programs were carried out in garages, carparks, and communities near the border. Greateraccess to SRH services was available to this underservedpopulation by integrating services.High HIV risks among fishermen are well documented,however the HIV risks, mobility and HIV VCT needsamong women in fishing communities are less well-documented. Qualitative research among migrants foundthat female fish traders are highly mobile and are at highrisk of HIV transmission and infection via exchange ofsex-for-fish with fishermen. Women who had neverreceived HTC, or who had tested long ago, were older,widowed, or currently married fish traders. These wom-en are at high risk of HIV and interventions to expandtesting, treatment, and prevention in fishing communitiesare urgently needed, particularly among highly mobilewomen and their partners.Male InvolvementMale involvement was also commonly discussed atthe conference. The first presentation focused on thefactors influencing partners’ clinic attendance amongHIV positive patients attending an ART clinic in Benuestate, Nigeria. Fear of stigma remains an important factorinfluencing disclosure of HIV and couple attendance forcare and treatment. Couple-level prevention programswith emphasis on reducing stigma should be incorporatedinto HIV prevention and treatment strategies.Researchers from the University of Ibadan, Nigeriapresented perceptions and barriers to participationin PMTCT among married men in Osogbo, Nigeria.Societal norms and inadequate knowledge of PMTCTwere identified as barriers to men’s participation inPMTCT. Community sensitization programs should beinstituted, such as health education aimed at breakingcultural barriers.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 4
TRACK 4: REACHING TARGET POPULATIONSSemi-structured questionnaires were administered to150 couples in Coast Province, Kenya on integration ofFP and HIV services. Most men (72%) reported that theyapproved of women’s contraceptive use, although only63% would allow their spouses to use contraceptives.Religious beliefs and fear of side effects were the mainreasons for poor uptake of contraceptives. Over half ofmen in the study (62%) stated they would allow theirspounces to use contraceptives. Programs promotingintegration of FP and HIV services need to encourageuse of condoms for dual protection, even as other effortsare made to increase contraceptive uptake.One study in Kenya, used in-depth interviews, to exploremen’s involvement in, and experiences of, their partners’health in the context of integrating SRH/HIV services.Most men were supportive of their partner’s use of SRHservices and offered support to their partners in the formof finances or by escorting them to the facility. However,men did not attend the services due to long waiting timesand cultural issues around men’s involvement in childrearing activities. Most men agreed in principle that bothmen and women should attend SRH services together.Due to the social and economic role that men play in thehousehold, their involvement is critical to the success ofSRH interventions.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 5PHOTO:RACHELSTEINFELD
I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 6Dr. Ian Askew’s plenary session focused on theimportance of integration assessments to documentexperiences of integration that were successful andimplement them on a larger scale. There are manyinstruments available to measure integration basedon data gathered from policy analyses, interviews withmanagers, health facility assessments, and exitinterviews with clients. Some of the integrationassessment tools include: • Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: a generic guide prepared and published by IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives, 2009. • Assessing Integration Methodology (AIM): a handbook for measuring and assessing the integration of FP and other reproductive health services(FRONTIERSManual.Washington,DC: Population Council, 2008).Evaluation of the design of a specific intervention is criti-cal to evaluate the impact of the intervention and to inter-pret the outcome. The factors considered are the popu-lation, outcome of interest, level of integration, servicesthat were integrated, the comparison group (i.e. random-ization/matching), and the theory of change, i.e. attribu-tion or dual outcome pathways.The key questions to consider include: • Is more evidence needed to justify introduction and/or expansion of an intervention? • What type of evidence is sufficient to inform whether or not to proceed with an intervention? And who decides on whether or not to proceed? • Costs and ethics of delaying introduction of an effective intervention • Costs and ethics of implementing an ineffective intervention.Integration Assessment ToolsThe Rapid Assessment Tool assesses services,systems, and policies and to date has been implementedin 39 countries. Several presentations focused on thechanges in policies, strategic plans, and integrationstrategies that have resulted from the use of this tool.An impact assessment of the tool has shown that its usehas led to system strengthening in the form of increasedpartnerships, coordination, and capacity building. Theimpact assessment also showed that the tool may haveled to increased service integration. Although it is notclear if the Rapid Assessment Tool caused all of thechanges listed above, conducting the Rapid AssessmentTool increased knowledge and progress towardbi-directional linkages at all levels. The impactassessment also showed that service integration hasbeen strengthened in the last three years.The Integra Initiative gave two presentations about howthe Rapid Assessment Tool was able to identify gaps inlinkages and integration. Researchers from the initiativefound that there are national policies that supportSRH & HIV integration but planning, implementation,funding, and monitoring and evaluation of SRH & HIVprogrammes are largely vertical. Shortage of serviceproviders and commodity stock outs limit the ability toprovide integrated services.The researchers foundthe policy environment to be supportive of SRH & HIVlinkages but in order to improve integration, logisticsmanagement systems, human resources, and M&Esystems must be strenghtened. Conducting theassesment brought together several bodies of theministry of health, and partner and civil societyorganizations, to support joint planning, capacity building,integrated supportive supervision, and systemstrengthening, including commodity management. Thecollaboration was aimed at making real changes at thepolicy and service delivery level.T R AC K 5 : I N T E G R AT I O N A S S E S S M E N T
TRACK 5: INTEGRATION ASSESSMENTThe Rapid Assessment Tool was also used to assesslinkages between SRH and HIV policies in SouthernAfrica. At the policy level, the United Nations PopulationFund (UNFPA) found that integration is mentioned inseveral relevant policies and strategies, although itis not systematically articulated. At the system level,there was progress made towards joint planning andbudgeting. However, there are significant gaps,including shortages of health workers, laboratories,referral systems, logistics, and infrastructure, and weakM&E systems including linkages indicators. At theservice level, there was stronger integration at lowerlevel health facilities “by default” and good coverageof most SRH and HIV services. However, weak healthsystems have a negative impact on service integrationand some SRH services were often not available e.g.GBV, safe abortion or post-abortion care, and PMTCTprongs 1 and 2. A high proportion of patients in the RapidAssessment reported that they experienced stigma anddiscrimination, in particular key populations includingpersons living with HIV (PLHIV). The rapid assessmentshave helped countries recognize the need to link SRHand HIV and to map and review their national policies,strategies, protocols, and guidelines.Other integration assessment tools were presented.The ACQUIRE Tanzania Project (ATP) used theAssessing Integration Methodology (AIM) at 12 facilities inTanzania. EngenderHealth conducted facility inventories,record reviews, client-provider observations, interviewswith services providers, and exit interviews to assessintegrated FP and PMTCT services. Facilities were ratedon FP integration ranging from FP referrals only (ratingof A) to fully integrated services (rating of E). Two thirdsof facilities ranked offered all short-term and long-acting FP methods, with referral for permanent methods.However, only condoms were readily available innon-FP units (with one exception). Most providersreceived some cross-training. However, most providers(67%) interviewed from VCT and HIV care andtreatment units had not received training on FP. Moreeffortsareneededtoaddressidentifiedgapsinprovisionofintegrated services.An integration assessment tool was developed by theInternational HIV/AIDS Alliance based on exiting toolsand literature to assess readiness, type and level ofintegration, and quality of services. The tool containedchecklists and questionnaires to describe programmesand services. The assessments found that programmeswere enthusiastic and willing to offer HIV services withFP/SRH services but that knowledge, policy, and clinicalpractice were highly variable in integration and quality.Additional funding, monitoring, training, and clinicalstandards are needed to further support HIV/SRHintegration.Baseline data collected from the Kenya UrbanReproductive Health Initiative using facility andpopulation surveys indicated that about 80% of healthfacilities reported having high levels of integration ofFP with other services, and 70% of providers statedthat they routinely offer FP with other services. In con-trast, only 17.2% of non-FP seeking clients reported thatthey were offered FP information. There is a large gapbetween what the facilities and providers report and whatwomen say they are experiencing.In a pre-formed panel, the Integra Initiative presented thebenefits and cost of integrated HIV/SRH services. TheI N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 7PHOTO:BENSONONSONGODrs. Michael Mbizvo and Ian Askew
TRACK 5: INTEGRATION ASSESSMENTresearchers developed an ‘integration index’ to measurethe degree of integration at facility level using datafrom client flow, health facility assessment, and costingtools. The index measures four dimensions of HIV/SRHservice integration: (1) physical integration (servicelocation based on the physical space of a building orclinic); (2) temporal integration (proportion of integrat-ed services available per day); (3) provider integration(proportion of integrated services provided per provider);and (4) functional integration (proportion of clients whoreceived integrated services with one provider). Theindex improves our understanding of integration andallows us to control for the degree of integration in ourevaluations. It also enables us to better understandfactors influencing efficiency and effectiveness and is animportant tool for policy makers and programme decisionmakers.The Integra Initiative also measured the costs andefficiency of integrated services, specifically PITCverses stand-alone HTC in Kenya and Swaziland. Costand output data were collected from routine monitoringdata from health facilities in Kenya and Swaziland. Thestudy found variation in use of resources and unit costsacross facility types. In most cases, the costs of PITCwere lower than stand-alone HCT. Most cost variationboth between and within integrated services wasaccounted for by differences in personnel costs. Theseresults show that there may be substantial gains inefficiency through the integration of SRH/HIV servicesthrough better utilisation of existing human resources.However, care should be taken to not expand integratedservices where services are already overstretched,unless additional staffing can be made available.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 8PHOTO:BENSONONSONGO
I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 2 9During the third day of the conference, participantsdiscussed research gaps and opportunities related tointegrationofRH/HIVservices.Themajorareasofinterestidentified by the group included the following topics:1. Stigma and discrimination2. Human rights, with a focus on key populations3. Male involvement and service integration4. Operations and systems.Costs and cost-effectiveness of interventions wasidentified as a cross-cutting research gap for all topics.Stigma and DiscriminationThe working group on stigma and discrimination feltthat there is need to better understand the layered andmultiple forms of stigma related to HIV and the impact onHIV, unintended pregnancy, use of SRH services amongPLHIV, key populations, and youth. The group felt that itis also critical to measure stigma and discrimination andunderstand how various interventions to address stigmaand discrimination impact policy, health care providers,clients, and the general community. It is also importantto understand how integration of SRH and HIV servicesaffects clients’ experiences of stigma and discrimination.Similarly, it will be important to understand the effect ofincorporating specific stigma-reduction strategies intointegrated services at both the facility and communitylevel.Human Rights with a Focus onKey PopulationsKey populations such as youth, migrants, traders,CSWs, and MSMs are disproportionately burdenedby the HIV epidemic. Although integration of SRHand HIV services is thought to improve access to services,additional research is needed to evaluate if integrationis the best model for these key populations or if thereare other innovative, flexible models that better meetthe needs of key populations. There is a need to studyF U T U R E R E S E A R C H I N S R H / H I VI N T E G R AT I O N I N S U B - S A H A R A N A F R I C A
FUTURE RESEARCH IN SRH/HIV INTEGRATION IN SUB-SAHARAN AFRICAwhether key populations are better served by specialservices designed to meet their needs, or by servicesintegrated into health services for the general population.Finally, key terms—such as coercion and violation—need definitions.Male Involvement and Service IntegrationSome of the research gaps that were discussed focusedon improving male involvement in SRH and HIV services.One key research priority identified by this workinggroup is to understand how integration of HIV and SRHservices impacts men’s engagement in and knowledgeabout HIV and SRH services. Research on methods andinterventions to make men more comfortable in SRHsettings was also discussed. Similarly, the groupidentified the need to explore other settings outsideof SRH clinics for men to learn about SRH and createdemand for services for themselves and their partners.Suggestions for other settings included workplaceprograms, the outpatient department, the HIV clinic,and the community. Priority should also be placed onunderstanding how transformative interventions aimedat changing gender norms impact behavior change,couple communication, and uptake of services. Someadditional research questions posed includedunderstanding how interventions such as provider trainingon couple counseling, training for couples on couplecommunication, and use of community forums andchampions for information sharing can impact maleinvolvement.Operations and SystemsThe final area of emphasis was on research andevaluation to improve operations and health systemsin the context of integration. One ongoing opportunityis to quantify how integration policies are financed andimplemented at national and local levels. Anotherresearch opportunity is to better understand howcomponents of the health systems impact the successof integration. These components include commodityavailability, infrastructure, community outreach, HealthManagement Information Systems, the capacity of healthworkers, and the health facility size. Other operationsresearch questions included how best to create de-mand for services, hold health providers accountable,and enable the health system to respond to commu-nity needs. The group proposed the development of aconceptual framework for a process evaluation for serviceintegration, with defined metrics and health outcomes,including quality of care. This framework would mea-sure scale-up of integration at national or sub-nationallevel and empower lower level health care workers tounderstand the meaning of ongoing evaluation andreporting.After identifying research gaps and opportunities relatedto integration of RH/HIV services, the group developeda research proposal to address the gaps and priorities.I N T E G R AT I O N F O R I M PA C T R E P R O D U C T I V E H E A LT H & H I V S E R V I C E S I N S U B - S A H A R A N A F R I C A 3 0PHOTO:BENSONONSONGOAngelina Namiba at the Integration for Impact Conference