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12 public HIV care and treatment centers (CTCs): 6 hospitals, 6 health centers purposively selected for having high CTC client load and a co‐located FP clinic within the same facility
Target group: Women of reproductive age living with HIV attending HIV care and treatment
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Enhanced referral: Piloting a facilitated referral model for integrating FP services into CTCs managed through the TUNAJALI program. The 7 steps of the referral model included: 1) Screen clients for unintended pregnancy risk, 2) Provide informed choice counseling on contraceptive options or safer pregnancy, 3) Refer for services, if desired, using the CTC referral form, 4) Document the referral, 5) Staff member accompanies the client to the FP clinic, 6) CTC client accesses FP services in a timely manner, and 7) CTC and FP staff follow up on referrals and services through monthly meetings and tracking of completed referrals. The screening process was supposed to be initiated at every clinical visit for women of reproductive age.
Training: For CTC and FP providers and supervisors, followed by supportive supervision for CTC and FP staff, and monthly meetings with FP and CTC staff to review progress
Additional components: FP group education sessions, monitoring using national forms and registers; job aids.
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Unmet need: 3% decline in unmet need post‐intervention among all women (p=0.10). 8% decline in unmet need among sexually active women (p=0.05).
Contraceptive use: 12% increase in contraceptive use among sexually active women (p=0.01). 16% increase in dual‐method use (p<0.01).
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Chabikuli et al. 2009
Location: Nigeria
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71 public health facilities providing HIV treatment, prevention of perinatal transmission, and/or HIV testing and counseling (64 with treatment and FP) involved in a facilitated referral model between HIV and FP units
Target group: Women living with HIV attending HIV care and treatment
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Enhanced referral: Piloting a facilitated referral model for integrating FP services into 71 public health facilities providing HIV treatment, prevention of perinatal transmission, and/or HIV testing and counseling (64 facilities with ART and FP)
Training: For providers, followed by supportive supervision, 4 job aids (at the FP clinics), 1 job aid at the ART clinic
Additional components: Adding HIV data elements to the FP register and improving data flow from the facility to the state and federal level
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Contraceptive use: Monthly mean couple years of protection delivered at the FP centers increased from 32.3 before integration to 38.2 after integration (p<0.001)(*data includes HIV‐ and HIV+) Service ratio of referrals from HIV treatment centers increased by 3.4% after integration, and 81.7% of these referrals were women living with HIV
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Chibwesha et al. 2011
Location: Lusaka, Zambia
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Design: Cohort, one year follow‐up post‐ integration, November 2009–November 2010)
Sample size: n=18,407 women
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Enhanced referral: Peer counselor–delivered standardized FP counseling, focused on promotion of dual‐method use. A printed counseling tool was used as an aid to provide information on barrier methods, short‐ and long‐acting reversible contraception, and sterilization. Clients were referred to FP clinics for all commodities.
Training: 109 peer counselors were trained to provide FP counseling, with a focus on dual‐method use. In addition, the study trained and certified 42 FP nurses at separate FP departments located within the same facilities where clients would be referred.
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Contraceptive use: Only 9.8% of the women not using modern contraception at baseline desired a referral for contraceptives at the FP clinic. Contraceptive uptake was demonstrated for 61.6% of the women desiring a referral to FP. At baseline, the prevalence of modern contraceptive use was 59.2%, with 75% reporting condom use, followed by DMPA (9.9%), oral contraceptives (6.7%), implants (5.4%); IUDs (3.4%); and prior sterilization (1.1%). Among those using modern contraception, only 17.7% reported dual‐method use and 26.5% reported more effective (noncondom) FP use.
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Design: Cross‐sectional, mixed methods comparative study of 4 clinics with different integration models
Sample size for quantitative questionnaire: n=602 women and men attending HIV care
Sample size for qualitative interview: n=16 providers; n=22 women and men on ART
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One‐Stop Shop: (Clinic A)—All reproductive health (RH) and HIV services are intended to be available from a single provider in a single location; clinic formerly provided RH care before HIV services were integrated. Clinic B (partially integrated)—HIV treatment services decentralized in a primary‐care clinic. RH and HIV services are intended to be offered by different providers in different locations, but within the same building Clinic C (partially standalone)—HIV unit in a separate building on the grounds of a facility that offers RH services in other buildings; operates through referrals Clinic D (fully standalone HIV clinic)—HIV clinic, FP counseling, and condoms are available onsite, but must get referral for contraceptives
Training: Providers at the HIV standalone clinic had been trained on RH counseling
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Unmet need: Unmet need was higher in the most integrated model, Clinic A, compared with the HIV standalone clinic, Clinic D, (45% versus 25%); the difference was not statistically significant after adjustment for confounders
Contraceptive use: Since diagnosis, clients in the HIV standalone clinic, Clinic D, reported less FP counseling but no difference in FP method provision. Condom provision was significantly higher in the standalone clinic, Clinic D.
Secondary
Client satisfaction: There was significant demand for more FP services: across sites, 48% would like STI services, 35.7% would like FP services, 31% would like counseling on sexual functioning, and 29.4% would like counseling on how and when to get pregnant. The demand for these additional services was no higher in the standalone HIV clinic than in the more integrated sites. Demand was greatest in the partially integrated sites.
Number of FP services received since diagnosis: The proportion of clients reporting FP services since HIV diagnosis varied by clinic, but was not consistently higher in the integrated sites. FP counseling was less common in the HIV standalone clinic, but FP method provision was not different and condom provision was significantly higher in the HIV standalone clinic.
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Coyne, Hawkins, and Desmond 2007
Location: Slough, United Kingdom
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One‐stop shop: The Garden Clinic started a specific clinic (FP Plus) to provide HIV‐positive women clients with screening for STIs, contraception, pre‐conception counseling, and cervical cytology. Commodities included LARC methods. The Garden Clinic already worked on a model of integrated sexual health care, and FP Plus was staffed by doctors and senior nurses trained in both STI management and FP.
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Contraceptive use: The proportion of women who relied on condoms alone for contraception declined from 30% to 7% before versus after integration (no statistical test performed). In the post‐integration period, 6 (20%) of the women initiated highly effective contraceptive methods at the FP Plus Clinic (n=3 IUD and n=3 DMPA or implant).
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Design: Repeated cross‐sectional, facility‐randomized trial
Sample size: n=12 intervention clinics with n=2,593 person‐visits (from 1,684 women) in the baseline period; n=6,972 person‐visits in the endline period n=6 control clinics with n=3,089 person‐visits (from 1,900 women) in the baseline period; n=5,559 person‐visits in the endline period
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One‐stop shop: Clinics were randomized to integrate FP services into the HIV clinic (n=12 sites) or to refer clients to FP clinics within the same facility (n=6). The integrated sites provided a method mix including LARC methods. All sites provided FP information and condoms.
Training: Peer educators were trained in leading group education. At all sites, staff were trained to provide reproductive health counseling through in‐class and practical components. Regular refresher trainings were held.
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Contraceptive use: Highly effective contraceptive prevalence increased from 16.7% to 36.6% in the intervention clinics compared with 21.1% to 29.8% in the control sites over the same period (odds ratio (OR)=1.81, 95% confidence interval (CI): 1.24, 2.63)
Pregnancy: Incident pregnancy within the first year after integration was 1.5 in the intervention group compared with 1.7 in the comparison group, but there was no statistically significant difference (IRR=0.90, 95% CI: 0.68, 1.20). NB: The study did not have data on pregnancy intention.
Secondary
Cost‐effectiveness: The marginal cost per additional woman using more effective contraception was $65. The marginal cost was $1,368 for each pregnancy averted. Economies of scale were identified in clinics serving larger populations (Shade et al. 2013).
Client knowledge and attitudes toward FP: Mean FP awareness scores increased between the pre‐ and post‐intervention periods among clients at both the intervention and control sites; there was no difference in awareness of methods between the integrated and non‐integrated clinics at endline (Onono et al. 2015).
Client attitudes toward male involvement in FP: In the intervention sites, the proportion of males that agreed with the statement that FP is “women's business” declined by 12% after the intervention, a more significant decline than seen at the control sites, aOR=0.43, (95% CI: 0.22, 0.85) (Onono et al. 2015).
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5 public maternal and child health services in low‐income, peri‐urban areas
Target group: Women living with HIV who are ≤ 6 months postpartum, attending child health services
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One‐stop shop: Providers were trained on reproductive health for women living with HIV, with a focus on IUD information, insertion and removal, and sterilization for women desiring no further children. The intervention included an improved referral system for tubal ligation.
Training: Training on RH, IUD, and sterilization. Followed by job aids for reproductive health counseling, and twice‐monthly mentoring and coaching.
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Contraceptive use: Proportion using modern contraception did not improve between the pre‐ and post‐intervention periods (89.8% pre versus 83.5% post, p=0.03). Use did not increase for IUD (0% pre versus 0.5% post; p=0.48) or sterilization (7.1% pre versus 8.6% post; p=0.57). Majority (>70%) at both periods used an injectable hormonal contraceptive.
Secondary
Client knowledge and attitudes toward FP: The percent counseled on IUDs increased significantly from 7.8% to 23.7%; however, IUD knowledge was lower after the intervention. Post‐intervention, a greater proportion of postpartum women living with HIV reported correct knowledge of sterilization as a contraceptive option, although fewer women reported that they would consider it in the future (56.4% post versus 64.9% pre; p=0.22)
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Kosgei et al. 2011
Location: Eldoret, Kenya
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Design: Retrospective cohort study
Sample size: n=1,453 women under intervention care team, n=2,578 women under regular care team
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Contraceptive use: Incidence of modern method use was greater in the integrated site (58.1 per 100 person years (py) versus 44.7 per 100py; incidence rate difference (IRD)=16.4, 95% CI: 11.9, 21.0), as was reported new condom use (53.4 per 100 py versus 36.9 per 100 py; IRD=13.5, 95% CI: 8.7, 18.3). Incidence of noncondom FP use was low, and was lower in the intervention site, however (4.8 per 100 py versus 7.8 per 100 py; IRD=–3.0, 95% CI: –4.6, –1.4).
Pregnancy: There was no significant difference in the incidence of pregnancy between the integrated and regular sites (8.2 versus 7.0 per 100 py; IRD=1.2, 95% CI: –0.6, 3.0). NB: The study did not have data on pregnancy intention.
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Design: Quasi‐experimental, pre‐post with comparison group
Sample size: n=335 women pre‐intervention; n=274 with post‐intervention data
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Enhanced referral: Expanded a facilitated referral model for integrating FP services into HIV treatment services in 5 local government areas (see Chabikuli et al. 2009, for original model).
Training: For providers, supportive supervision, 4 job aids (at the FP clinics), 1 job aid at the ART clinic
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Contraceptive use: Modern method use increased in both the intervention (from 21.8% to 34.7%) and the control (5.3% to 17.6%) sites; there was no significant intervention effect (p=0.94). The use of highly effective contraceptives increased from 7% to 12% in the intervention sites and from 4% to 6% in the basic sites; the difference by integrated services was not assessed.
Pregnancy: Reported 31 pregnancies between baseline and follow‐up, 23 in the enhanced referral sites and 8 in the basic group. 5/31 of the pregnancies were among women who initially reported wanting no more children, while 22/31 were wanted pregnancies and 4/31 were among women who were unsure. There was no adjusted comparison of the outcome by integration status.
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One‐stop shop: Stepwise integration of FP services into Lighthouse Clinic for HIV treatment and care. Services included FP IEC (group‐level information in the waiting rooms delivered by peer educators), counseling, contraceptive commodities, and later, cervical screening. FP commodities expanded over time to include LARC methods.
Training: Providers received didactic and practical training and supportive supervision
Additional components: The integration involved renovation of the clinic to create private rooms for counseling and gynecologic exams and clinic supplies. Protocols were developed for providing the new services and the routine electronic data system was expanded to capture new services. The clinic became an official MOH point for FP service delivery.
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Contraceptive use: Contraceptive prevalence among nonpregnant women of reproductive age was 42% at the intervention site compared to 29% at the site with referrals. At the intervention clinic, 859 women started modern FP, made up of DMPA (55%), IUD (19%), combined oral contraceptives (14%), and implants (12%).
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One‐stop shop: During the intervention period, women participated in 3 peer‐led, 90‐minute group education sessions on sexual negotiation skills, empowerment, FP, and communications. Providers were trained in FP as described below. Contraceptives, including LARC, were provided on‐site.
Training: Nurses at the clinics participated in a 5‐day training in FP by national FP commission trainers, including the insertion and removal of LARC. Training included clinical/practical component.
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Contraceptive use: LARC prevalence was very high in both groups by 3 months postpartum (87.1% among women in the intervention group, compared with 81.8% in the control; p=0.34). Prior to most recent pregnancy, ever use of LARC was 2% among women in the intervention group, and 0% in the control group; therefore the uptake was significant (p=0.01), although it did not differ by exposure to the intervention.
Secondary
Client knowledge and attitudes toward LARC: Knowledge of IUD as a highly effective method was significantly higher in the group that had the peer intervention, 85.5% versus 56.3% (p<0.01).
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One‐stop shop: The Chhouk Sar (CS) clinic is a peer‐managed clinic that provides HIV care for key populations. The clinic began providing FP services and commodities on‐site. Method mix included LARC. Women received referrals for sterilization services. FP services were free of charge to the client and available 5 days per week. IEC and screening for unmet need was provided by the peer staff in the waiting room, and only clients with identified needs were referred to a private counseling room for individual counseling with a midwife or doctor (internal referral). Messages emphasized dual‐method use. IEC was supported by job aids including flip charts.
Training: Staff from Marie Stopes International Cambodia trained clinic staff during the first 6 months of the intervention, including theoretical and practical components. It appears that the trainers provided extended on‐site observation and supportive supervision for 6 months. The 2 fully trained health providers then began providing FP services without supervision.
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Contraceptive use: There was no significant change in the use of an effective FP method (12.6% before versus 16.4% after, p=0.86) or the proportion of women reporting dual‐method use (11% before versus 14.8% after, p=0.28); 76.2% of women continued to rely solely on condom use for contraception after the intervention.
Secondary
Client knowledge and attitudes toward contraception: Client awareness of modern contraceptives was higher after integration for IUD (96.8% versus 92%, p<0.05), injections (77.5% versus 67.2%, p<0.05), implants (85.5% versus 71.6%, p<0.01), and male sterilization (14.8% versus 3.6%, p<0.01) and female sterilization (49.4% versus 22.4%, <0.01), although not for emergency contraceptives or female condoms. Client knowledge of FP improved significantly regarding safety of FP use and specifically IUD use by women with HIV. After integration, 79.5% of the women using condoms only reported that they believe that the condoms afford them sufficient protection from pregnancy, a significantly higher proportion than baseline.
Attitudes: 26.5% after versus 12% before integration disagreed with the statement, “PLHIV should not have children.” The proportion of women who planned to use FP in the future was 94.3% after integration compared with 60.9% before integration (p<0.001).
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Design: Cross‐sectional comparing one‐stop shop integrated facility and site with information but no contraceptive provision
Sample size: n=797: n=389, intervention; n=408, regular care
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2 HIV care clinics, one within the national teaching hospital, one within a private faith‐based hospital
Target group: Women of reproductive age living with HIV who are sexually active and engaged in HIV care
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One‐stop shop: The Mulago HIV clinic, based in the national teaching hospital, provides FP education to groups and individualized counseling. Condoms, pills, and injectables are available on‐site. Clients are referred to the FP clinic within the same larger hospital campus to access LARC and tubal ligation.
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Unmet need: 30.9% in the integrated site compared with 45.1% in the regular care site (p<0.01)
Contraceptive use: Use of an effective FP method (includes reported consistent condom use) was higher at the intervention site (57.9% versus 50.0%; p=0.04); no difference in the use of any FP method (or any modern method (includes any condom use).
Pregnancy: 16% of the incident pregnancies were among women who reported at baseline that they did not want more children.
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One‐stop shop: A purpose‐built integrated center that combined previously standalone GUM and SRH clinic services into a single one‐stop location. In addition to the usual GUM services, which included HIV treatment and routine care, the integrated services included FP counseling and provision, and cervical cancer screening.
Training: Prior to integration, medical staff were trained in contraceptive counseling, provision, and cervical screening. Clinicians earned certification for contraceptive implant fitting through the Faculty of Sexual and Reproductive Healthcare's letter of compliance. All physicians were certified in fitting IUDs. Supportive supervision was provided by senior physician cover for GUM and SRH, and, when needed, the clinicians could refer clients to other specialist SRH services that were provided on‐site.
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Contraceptive use: Use of an effective contraceptive method by fertile, sexually active women was 24.9% pre‐integration and 39.3% post‐integration (p=0.07). The prevalence of LARC increased from 16.1% to 29.8% (p=0.07).
Unintended pregnancy: The unplanned pregnancy rate was 5.9 per 100 py in the pre‐intervention period and 4.1 per 100 py in the post‐intervention period. Statistical significance of the change was not reported.
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