Pioneering research shows integrated services can enhance access to quality HIV, maternal, and reproductive health services.
In sub-Saharan Africa—home to nearly two-thirds of people living with HIV globally—most HIV infections are sexually transmitted or associated with pregnancy, childbirth, and breastfeeding. The region also has high rates of unintended pregnancy, particularly among HIV-positive women. To better meet the sexual and reproductive health (SRH) needs of those living with HIV and to provide HIV prevention services to women visiting health facilities, many have argued for the integration of sexual and reproductive health and HIV services. However, there is a lack of evidence on the benefits and costs of integration and which models could be most effective for integrating HIV and SRH services.
Together, three organizations—the International Planned Parenthood Federation (IPPF), the Population Council, and the London School of Hygiene & Tropical Medicine—designed and implemented the Integra Initiative. Conducted from 2008 to 2013, the initiative sought to generate rigorous evidence on the feasibility, effectiveness, cost, and impact of different models for delivering integrated HIV/SRH services in settings with high and medium HIV prevalence in sub-Saharan Africa. Specifically, the study aimed to:
- Assess the extent to which different models of integrated service provision increase the range, use, and quality of selected SRH and HIV services, and lead to a greater diversity in the profile of clients.
- Explore whether the provision of integrated HIV and SRH services leads to reductions in HIV risk-behavior, HIV-related stigma, and unintended pregnancies.
- Assess the efficiency of using different models for delivering integrated services in terms of cost, use of existing infrastructure and human resources services for HIV-positive mothers and infants, as well as referrals for clients requiring additional services.
The largest-ever evaluation of different models of HIV and SRH integration, the study used a number of quantitative and qualitative methods, including an economic analysis, to evaluate four models for delivering HIV services in existing SRH facilities. Conducted in 42 government and IPPF health facilities in Kenya and Swaziland, the study evaluated:
- Integration of HIV counseling and testing and antiretroviral therapy (ART) into family planning services (Kenya);
- Strengthening of HIV counseling and testing and ART services (including family planning) in postnatal consultations (Kenya and Swaziland);
- Integration of HIV counseling and testing and ART into family planning services for youth (Swaziland); and
- Comparison of facilities offering fully integrated SRH/HIV services with facilities offering stand-alone HIV services.
At the end of the five years, the study showed that while there are benefits to clients and providers associated with integrating HIV and SRH services, integration does not automatically lead to reductions in stigma, cost, or unintended pregnancies. Instead, various health system and community factors, as well as individual client choice, determine the extent to which a fully integrated model can and should be implemented.
Specifically, the study demonstrated that:
- Integrating HIV services into family planning and postnatal care services can improve the use of HIV counseling and testing.
- Integration does not reduce the overall quality of care as is often perceived, but can increase the quality of family planning and postnatal care.
- There is potential for integrated delivery of services to improve cost efficiencies but this is often unrealized at the facility level.
- Most clients prefer fully integrated services to save time and money. Yet many women living with HIV prefer sexual and reproductive health services, such as family planning, to be integrated into specialist HIV units as they trusted the providers at these facilities, enjoying continuity of care from them, had reduced fear of stigma within specialist sites, and benefited from the opportunity to meet other clients living with HIV.
The Integra Initiative has provided valuable evidence on when and how to improve integration of HIV prevention, family planning, and maternal health services to improve health outcomes and increase efficiency and cost savings in health systems.
The initiative also produced the Integra Index—an innovative tool that measures the degree of service integration at a health facility.
Evidence from Integra has contributed to a Kenyan policy outlining a minimum package of integration as well as an overall integration strategy for the country. The Kenyan government has also adopted the initiative’s mentorship approach and toolkit for training health workers in the skills needed to integrate health services.