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Kenya: Integrating Services for FP and HIV Improves Quality and HIV Testing
OR Summary no. 78 (PDF)

Background

The Kenyan government’s reproductive health policy highlights service integration and quality of care. While integrating counseling and testing for HIV (CT) into family planning (FP) can potentially increase the range of services to clients at risk from sexually transmitted infections (STIs) including HIV, few studies have documented the feasibility, effects, or costs of such integration.

From 2005 to 2007, the Population Council worked with the Kenyan Ministry of Health (MOH) to test the feasibility of two models for integrating CT into existing FP services. Both models featured client education on HIV prevention, including CT, during FP visits. In the “testing” model, FP providers were trained to offer CT services and post-test counseling during the same visit, while in the “referral” model, FP clients wanting CT services were referred to a specialized CT facility. A total of 23 clinics took part. Nine clinics in Nyeri, which had limited CT services, implemented the testing model, and 14 clinics implemented the referral model in Thika, which offered CT at a number of sites.

A total of 75 providers in both intervention areas received five (for the referral model) to nine days (for the testing model) of training covering FP methods, screening and counseling on STIs including HIV, record-keeping, and (for the testing model) HIV testing and counseling. The project included development of training materials, support for supplies and HIV test kits, and modification of registers to monitor CT services. Providers were trained to routinely use the Balanced Counseling Strategy Plus (BCS+) toolkit, which is an adaptation for high HIV prevalence settings of the Council’s BCS tool for improving the quality of FP counseling.

The tool includes an algorithm to structure an integrated consultation; 15 memory-aid cards for choosing a family planning method, and four cards for assessing and preventing risks for STIs and HIV, including dual protection; and corresponding brochures for the method chosen by the client.

Pre- and post-intervention measurements of the intervention’s feasibility, impact on quality of care (based on 27 indicators), use and effect of the BCS+ tool, effect on CT uptake and on dual protection, and the incremental costs were obtained through focus group discussions, interviews, facility assessments, and observation of client–provider interactions and client exit interviews (about 550 at baseline and 530 at endline).

Findings

• Integrating STI/HIV counseling and offering CT within FP services was feasible and acceptable to clients and providers.

• Overall quality of care improved significantly in both models, especially in the referral-model clinics (see table below). The increased quality may have been due to greater use of the BCS+ tool by providers at the referral clinics (75%) versus those at the testing clinics (41%). Average quality scores were significantly higher during consultations where providers used the BCS+ tool (18.86) than where they did not (12.19). 

• Counseling on HIV CT increased significantly during FP consultations. The proportion of providers discussing CT increased significantly between baseline and endline (from 39% to 88%). A significantly greater proportion of providers offered an HIV test following the intervention (from 1% at baseline to 39% for repeat clients and 48% for new clients).

• Between half and three-fourths of the women who were offered an HIV test accepted—35 percent in the testing model and 20 percent in the referral model. This indicates that CT is a desired service that should be offered to FP clients.

• Integrating FP and CT services increased the average time spent with clients from about 10 minutes to 14 or 15 minutes. The staff cost for this addition—about three minutes for the testing model ($US0.41 per client) and four minutes for the referral model ($0.24 per client)—was reasonable. Estimated costs for onsite counseling and testing range from $5.60 per client at a hospital setting to $9.53 in a dispensary, compared to an estimated per-client cost of $27.00 at a stand-alone CT clinic (as calculated by Sweat et al. 2000).¹

    *p<0.05; **p<0.01

Utilization

• Based on these findings, the MOH adopted and recommended expanding both models of the integration strategy nationwide. Training of provincial-level trainers in all eight provinces began in September 2007 with support from FRONTIERS, the Centers for Disease Control, and USAID through its bilateral APHIA II partners. Over 150 providers have received training, which is ongoing.

Policy Implications

• Integration of STI/HIV screening and counseling and HIV CT into FP services is feasible, increases clients’ access to STI and HIV testing services without compromising the quality of existing FP services, and is affordable in time and cost. The BCS-plus is an effective tool for addressing STI and HIV risk among FP clients in this context but FP providers need to use it routinely to ensure its effectiveness.

July 2008

[1] Sweat, M. et al. 2000 “Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania,” Lancet 356:113–121.

Source: Liambila, Wilson, Charlotte Warren, Saiqa Mullick, Ian Askew, Rick Homan, Ibrahim Mohammed, Robert Ayisi, Margaret Gitau, Josephine Kibaru, Mary Gathitu, Judith Maua, Helton Jilo, Juma Mwangi, John Njoroge, Anthony K. Wanyoro, Peter Mohammed Njuguna, and Andrew Mboche. 2008. "Feasibility, acceptability, effect, and cost of integrating counseling and testing for HIV within family planning services in Kenya," FRONTIERS Final Report. Washington, DC: Population Council. (PDF)

This publication is made possible by the generous support of the American people through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Cooperative Agreement No. HRN-A-00-98-00012-00. The contents are the responsibility of the FRONTIERS program and do not necessarily reflect the views of USAID or the United States Government.
 

For more information contact:
Frontiers in Reproductive Health (FRONTIERS)
Population Council
4301 Connecticut Ave. N.W., Suite 280
Washington, DC 20008 USA
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: frontiers@popcouncil.org

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This page updated 20 August 2008

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