What is the Integra project?

A 5 year research project to gather evidence for delivering integrated HIV and sexual and reproductive health (SRH) services in high and medium HIV prevalence settings.

The International Planned Parenthood Federation
(IPPF) in collaboration with the London School of
Hygiene and Tropical Medicine (LSHTM) and Population Council is implementing a Special initiative Project with support from the Bill and Melinda Gates Foundation.

This 5 year research project is gathering evidence
to determine the costs and benefits of using different models for delivering integrated HIV and sexual and reproductive health (SRH) services in high and medium HIV prevalence settings, to reduce HIV infection (and associated stigma) and unintended pregnancy.

Results

This project started in January 2008 and will run until December 2012. The first round of data collection has now been finalized and preliminary information was presented at the International AIDS Conference in Vienna, in July 2010.

Integrating SRH and HIV involves amalgamating a wide range of services

Three different models for delivering HIV services in
existing SRH facilities are currently been evaluated
in Kenya, Swaziland and Malawi in both IPPF and
government facilities. Using a combination of routine service statistics and process analysis, clinic- and cohort-based quantitative and qualitative behavioural research, community surveys and economic analysis, this project is assessing the benefits and costs of these different models for delivering HIV and SRH services.

The integration of HIV prevention counselling, including counseling and testing for HIV, into existing family planning services and the linkages with antiretroviral therapy (ART) services either on site or through referral will be evaluated in Kenya. In Kenya and Swaziland the project will also explore the benefits associated with strengthening HIV and family planning services among women attending ante-natal and postnatal care services. The provision of integrated HIV and SRH services with a focus on young people will be evaluated in youth friendly-clinics in IPPF Member Associations in Swaziland and Malawi.

Research objectives

• Determine the benefits of different integrated
models to increase range, uptake and quality of
selected SRH and HIV services.
• Determine the impact of different integrated
services on changes in HIV risk behaviour, HIV
related stigma and unintended pregnancies.
• Establish the efficiency of using different
operational models for delivering integrated
services in terms of: cost, utilisation of existing
infrastructure and human resources.
• Increase utilisation of research findings by
policy and programme decision makers through
involvement of – and dissemination to – key
stakeholders.

Our research questions

This study is built around 3 sets of research questions:

1. What are the relative benefits of different models of integrated SRH and HIV services over separately provided services? Does integration lead to:

• increases in the numbers of clients using service

• changes in the profile of clients

• increases in the range of services accessed

• improvements in the quality of services?

2. In the target populations, what is the impact of integrated services on:

• HIV related risk behaviour

• HIV related stigma

• unintended pregnancy?

3. What is the cost, feasibility and cost-effectiveness of providing selected integrated services, including:

• costs of integrating HIV and/or SRH services with existing services

• variations in costs by model of integration

• utilization of existing infrastructure and human resources? 

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Our methods

The study comprises 4 elements to evaluate each model of integration:

1. A time series of health facility assessments (using client-provider observations, client and provider interviews and facility inventories) to measure changes in quality of – and stigma associated with SRH – and HIV care.

2. A cohort study of clients attending clinics offering integrated and non-integrated services to compare their use of services, SRH/HIV-related behaviours and health status over a 30 month period.

3. Before and after surveys and qualitative research to measure perceptions and use of SRH and HIV services among community members served by clinics offering integrated and non-integrated services.

4. A full economic evaluation to determine the unit costs of service delivery and the economic costs for service users; enabling a cost-effectiveness comparison between integrated and non-integrated models.

Challenges we faced

• Despite assumptions being made about the potential cost-effectiveness of integration, high quality, scientifically rigorous, assessments are rare. A framework for cost-effectiveness analysis is being developed.

• Triangulation through a wide range of methods is imperative for highly complex ‘natural experiments’, including clinic-based, community-based, qualitative, quantitative and cost analyses.

• Integration in ‘real situations’ is highly complex and in constant flux posing interesting challenges. A number of steps have been taken to aid analysis, including the development of a ‘continuum of integration’ that will enable us to understand the nuances of integration on the ground.

Our partners

• International Planned Parenthood Federation
• London School of Hygiene and Tropical Medicine
• Population Council
• Family Health Options Kenya
• Ministries of Health Kenya
• Family Life Association of Swaziland
• Ministry of Health of Swaziland
• Family Planning Association of Malawi

For more information please contact

Alejandra Trossero, IPPF
atrossero@ippf.org

Anna Vassall, LSHTM
anna.vassall@lshtm.ac.uk

Charlotte Warren, Population Council
cwarren@populationcouncil.org

Charlotte Watts, LSHTM
charlotte.watts@lshtm.ac.uk

Susannah Mayhew, LSHTM
susannah.mayhew@lshtm.ac.uk