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The Integra Initiative: Strengthening Evidence Based and Good Practises for linking HIV Services and Sexual and Reproductive Health Rights

The Integra Initiative Project was on Wednesday 27th June 2013 disseminated to health organizations, development partners and the media on its its evidence based and best practices approaches. The projected conducted by the Ministry of Health through the Division of Reproductive Health and NASCOP in collaboration with the Population Council, Family Health Options-Kenya and the London School of Hygiene and Tropical Medicine (LSHTM) had been working together in Kenya to determine the costs and benefits of using different models for delivering integrated HIV and sexual and reproductive health services in high and medium HIV prevalence settings, in order to reduce HIV infection (and associated stigma) and unintended pregnancy.

Four different models of integrated SRH and HIV services were evaluated in the ‘real world’ settings in Kenya, Malawi and Swaziland and the research was mainly embedded within the day-to-day activities of the health facilities being studied. Integrating HIV services into Family Planning model was evaluated in Kenya , Integrating HIV and SRH services (IPPF clinics: FHOK in Kenya, FPAM in Malawi and FLAS in Swaziland), while the following two models were done in Swaziland,that is, Integrating HIV services into post-natal care and Family Planning, and Comparison of Integrated and stand-alone HIV services models .

Findings from the Integra costing indicate that integration has the potential to facilitate efficiency gains in some contexts, for example by optimizing provider workload in the provision of HIV counselling and testing.According to Mathias Ghatsha Chatuluka, Executive Director of Programs for Family Planning Association of Malawi, ‘The integra initiative motivated me to think of increasing access  to sexual and reproductive health and HIV services in rural and hard  to reach communities through the ‘mobile van’ increasing the community-based coverage in rural communities.

Political commitment to SRH and HIV integration is highly needed to facilitate the uptake of integrated services by providing an enabling environment. The Kenyan government has developed supportive policies in regard to this project. For instance, the ministry of health initiated the process of integrating Reproductive Health  (RH) and HIV services more than a decade ago, where initial efforts were made to integrate  HIV counselling and testing during pregnant women’s antenatal visits. An Integration Technical  Working Group (TWG) was formed in 2002, and co-chaired by the department of Reproductive Health (DRH) and the National AIDS and STIs control Programme (NASCOP). It coordinates all the efforts between partners working  on RH and HIV integration in an attempt to leverage resources and advance the research agenda for evidence-informed programming. ‘We have made a lot of progress through the RH and HIV TWG and other countries are learning from us’ says the Programme Officer, NASCOP.

The TWG has witnessed the inclusion of RH and HIV integration and different capacity development interventions like mentoring in various policy documents such as: National Health Strategic Plan (2005-2010); Kenya National AIDS Strategic Plan 111 (2009/10-2012/13); National Reproductive Health Policy (2007) and Strategy (2010/2015); and National RH and HIV Integration Strategy (2009).

However, despite the progress and achievements of this integration, there were witnessed missed opportunities for meeting reproductive and HIV needs in Kenya which accounted for 31% women and 21% men. In as much as there is  expected improvement in quality,uptake and efficiency of services, little is known about service needs at the population level and whether such needs are being met. The result of a community survey conducted in Kenya showed that Family planning need was high  with 71% women and 67% men. The unmet need was a result of non-service use for men and missed opportunities for women who accessed a health facility but did not receive Family Planning services. The HIV service need was lower (21-22% among women and 54-63% among men). The unmet need was again due to non-service use while missed opportunities accounted for 31% women and 21% men.In brief, findings from the survey suggested high levels of unmet HIV service need at the population level because of poor service use for both sexes and missed opportunities for integrating HIV services within Family Planning and other services women already receive.

In addition to the above, there are some barriers that hinder women and their partners from accessing  integrated SRH and HIV services.This incorporate lack of well-trained providers who provide these services professionally and also cultural barriers to men seeing themselves as needing SRH and HIV services. Lack of funding is also another obstacle for women living with HIV themselves to organize and support one another’s needs, visions and rights through peer-led community services.

This form of integration  gives clients an opportunity to utilize a wide range of services in one visit. ‘Integration is a critical driver for provision of quality health services’,remarks Jackline Kivunaga,a research coordinator at the population council in, Nairobi, Kenya.It is also notable that one of the many things that collective responses to HIV have shown the world , over the last 30 years, is that communities can stand up, demand access to better quality services , defend their sexual and reproductive rights, and ultimately make a difference to policies and programmes. The increasing movement for women, girls and their partners to demand sexual and reproductive  health and rights, including family planning can learn from these successes.

In conclusion, one of the key findings from the Integra iniative is that greater attention is needed to understand and generate demand for accessing, and reduce missed opportunities for offering, integrated SRH and HIV services services. This message, adding momentum generated from the Family Planning Summit in 2012, is a call to action to policy makers and providers alike, to listen to and continue to more effectively meet our client’s need in a holistic and integrated way.

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