December 2003

Integrating STI and HIV services into family planning and antenatal care clinics is widely promoted as an effective way to reach sexually active women and their partners with information, counseling, and diagnostic and treatment services. Yet institutional attempts to integrate such services have not been particularly successful in sub-Saharan Africa, as researchers have found.

In South Africa’s KwaZulu Natal Province, where adult HIV prevalence is an estimated 33 percent, the government has adopted a policy to integrate key HIV/STI services—including counseling on condom use and dual protection, prevention education, HIV voluntary counseling and testing (VCT), and referral for STI treatment—into family planning and antenatal care. To examine how well the province’s services are integrated in response to the policy and to assess their quality and availability, the Horizons Program, the Population Council, and the provincial Department of Health conducted a Situation Analysis study at 98 randomly selected clinics and hospitals throughout the province, with funding from the U.S. Agency for International Development and the Italian government.

A Situation Analysis study typically involves a comprehensive, day-long, on-site examination of a facility by a team of interviewers and observers. In KwaZulu Natal, teams observed 418 client-provider interactions, conducted exit interviews with more than 400 clients, interviewed 229 service providers, and carried out a full inventory of supplies and equipment at 98 health facilities.

“These kinds of data, both quantitative and qualitative, enable us to understand if a health care system is actually able to provide integrated services and if the services delivered are of reasonable quality,” said Dr. Lewis Ndhlovu, Horizons/Population Council, one of the study’s principal investigators.

A counseling session at a clinic in KwaZulu Natal Province, South Africa. The Situation Analysis assessed the quality of counseling services offered by the facilities studied. Photo credit: Melissa May/Population Council

Results from the study show that family planning providers are promoting condom use. About 70 percent of the family planning clients observed were encouraged to use condoms for protection to prevent HIV and 55 percent to prevent pregnancy. (Additional prevention options, such as abstinence and being faithful to one partner, were discussed with far fewer clients.) Yet less than a third (28 percent) of clients received information on how to use condoms, and only 20 percent actually received condoms, even though they are available at health facilities throughout the province.

At antenatal care services, researchers also detected limitations in prevention education and counseling. For example, although 61 percent of facilities have educational materials on STIs and HIV/AIDS for clients to take home, providers discussed these topics and mother-to-child HIV transmission with only about a third of antenatal care clients. Many clients continue to have sex during pregnancy, yet only 4 percent received condoms to prevent infection.

Observers also noted important gender differences in counseling and provision of supplies to STI clients. While condom use was recommended to the vast majority of male (93 percent) and female (83 percent) STI clients, 71 percent of males received supplies of male condoms compared to only 34 percent of females.

The study also provided important insights into the strengths and weaknesses of VCT sessions. Both the nurse/observers and the clients in exit interviews reported that the mostly lay counselors were very attentive to establishing rapport, respecting confidentiality, listening to client concerns, responding to questions, and giving emotional support. In most cases, the counselors emphasized condom use in pre-test counseling over abstinence and monogamy and in post-test counseling, they discussed living positively and provided referrals to other medical services. But other key topics were discussed inconsistently during post-test counseling, including treatment options (with 46 percent of HIV-positive clients) and pregnancy and prevention of mother-to-child transmission (26 percent).

The study further shows that a significant percentage of clinic staff are providing health-related services without adequate training. For example, while almost all of the providers interviewed (93 percent) said they provided STI counseling, diagnosis, and treatment, only 64 percent of them had ever received in-service training in STI services. Similarly, while 59 percent of the providers said they were providing treatment for opportunistic infections, less than half of those interviewed (46 percent) had ever received relevant in-service training.

Inventories of medications and medical equipment reveal a generally positive picture. All of the facilities in the study where inventories had been completed had almost all of the Department of Health’s essential list of drugs, which include medications for STI treatment and many opportunistic infections, and 100 percent had such basic diagnostic and treatment equipment as stethoscopes, disposable syringes and gloves, and specula. This high level of preparedness is unusual in sub-Saharan Africa, based on results from similar studies conducted by the Population Council elsewhere on the continent.

This past summer, researchers presented results from the Situation Analysis at a data interpretation workshop in Durban, where participants discussed strengths and weaknesses of the province’s health services, established priorities for interventions, developed recommendations for program and policy changes, and discussed further operations research.

Horizons plans to provide additional support to the KwaZulu Natal Department of Health for operations research on how to strengthen the integration of HIV/AIDS prevention into reproductive health.

For more information on this study, contact Dr. Ndhlovu at lndhlovu@pcjoburg.org.za. The final report for this study is available at www.popcouncil.org/pdfs/horizons/kznsitanls.pdf.

Margaret Dadian

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This page updated
19 October 2007