Pioneering research shows integrated services can enhance global HIV and family planning efforts
A five year research project that looked into the cost, quality, health benefits and stigma reduction with integrated HIV and sexual and reproductive health service delivery in Africa shows that there are benefits to integration.
The flagship Integra Initiative supported by the Bill & Melinda Gates Foundation has built a solid evidence base to inform effective global approaches to some of the most pressing health priorities of today.
The Integra Initiative – managed by the International Planned Parenthood Federation (IPPF) in partnership with the London School of Hygiene & Tropical Medicine (LSHTM) and the Population Council – released its findings this week.
It is the largest ever evaluation of different models of HIV and Sexual and Reproductive Health (SRH) integration. The research was embedded within the day-to-day activities of 42 government and IPPF health facilities being studied in Kenya, Malawi and Swaziland.
The research findings demonstrate that there are benefits to using integrated models of service delivery. For example there is evidence to support integration of HIV counselling and testing into mainstream family planning and maternal health services.
Consumer choice remains important for clients. The research showed that women living with HIV often had a preference for integrated services provided within a specialist HIV unit or facility.
The research findings also show that integrating HIV and sexual and reproductive health services does not automatically lead to a reduction in stigma, cost or unintended pregnancies as there are wider systems and community factors that need to be taken into account.
Universal access targets for reproductive health and for HIV prevention, treatment, care and support are intimately linked. IPPF advocates for integrated services and health systems that can meet people where they are. Integra provides valuable insights that can improve the way HIV testing and prevention, family planning and maternal health services can be delivered together in the future.
Key findings include:
Integration is very complex and difficult to evaluate, requiring an independent measure of “integration”: The Integra research developed an innovative measurement tool, a multi-dimensional ‘Index’, to account for the actual degree of integration at each facility over time. This has not been done before for something as complex as integration of services. The Integra Index was able to show that structural integration does not necessarily lead to integrated delivery of care and future assessments must include measures of whether clients actually receive integrated care.
Integration can improve health outcomes: Integrating HIV services into family planning and post natal care services has improved uptake of HIV counselling and testing at these facilities. Over a two year period people with greater exposure to integrated facilities had better rates of using HIV counselling & testing services. Extensive analysis has shown however that service integration has no effect on reducing unintended pregnancies.
Integration can improve service delivery: The research countered arguments that integrating services could reduce quality of care due to overburdened and non-specialist service providers. Integrating HIV services into family planning and postnatal care services was not found to decrease service quality and actually increased the quality of family planning and postnatal care provided in some areas of service provision. Further research is needed, to ascertain whether the quality of HIV counselling and testing is compromised during integrated delivery of services.
Integration has the potential to lead to efficiencies: The economics research showed that there is potential for integrated delivery of services to improve efficiencies but this is often unrealised at facility level. There are some economies of scope when delivering provider initiated counselling and testing within family planning /postnatal care compared to stand-alone voluntary counselling testing (VCT).
Integration for individual choice and for women living with HIV: Choice is important. Clients preferred fully integrated services to save time and money. Many women living with HIV preferred 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 once within specialist sites and benefited from the opportunity to meet other clients living with HIV.
Integration needs investment to be scaled up: The Integra Initiative was the largest research project of its kind, but the integration intervention was small compared to size and complexity of the national health systems. The research recommends the need to scale-up integration throughout the health system whilst ensuring adequate support for staff delivering integrated care. Achieving integrated delivery of services needs substantial and sustained investment if the full benefits are to be realised. The Integra initiative offers new areas for future research and demonstrates that scaling up the different models is the only way to reap the full benefits of integrating SRH and HIV services.
IPPF’s Director General, Tewodros Melesse, said:
“We know that there is a clear and obvious link between sexual and reproductive health and HIV so providing SRH and HIV services in the same place and at the same time makes good sense.
“The reason we are excited by the Integra Initiative results is because it provides the evidence we need to help guide planners, managers and policymakers to champion human rights and save lives. This will help them to improve health outcomes and achieve great value for money through service delivery efficiency and cost savings.
“The findings help IPPF with its advocacy too as we work to ensure sexual and reproductive health and rights sit at the heart of the next generation of Millennium Development Goals – the so-called Post-2015 framework.
“As part of our Vision2020 initiative we are demanding governments provide comprehensive and integrated sexual and reproductive health and HIV services by the year 2020. Such work will help us argue the case for better sexual and reproductive health and rights for all.”
Dr Susannah Mayhew, the Principal Investigator from the London School of Hygiene & Tropical Medicine, said “One of our key findings of Integra is that you can have the infrastructure, the commodities, the supplies, and the trained staff in place, but while necessary these are not sufficient to actually deliver integrated care. To do that you need to have providers who are motivated and supported – by their managers and by the whole system. Where that has been achieved we do see that uptake of HIV counselling and testing improves and unmet need for HIV prevention declines and that’s a really important contribution.”
Meanwhile Charlotte Warren, Associate and Principal Investigator at the Population Council, said: “Through this project, we learned that integration is not a one-size-fits-all approach: it will look and feel differently at diverse facilities. And while this is not a simple process for health providers or systems, integration can provide significant benefits.
“These findings are encouraging and will help inform future efforts. Thanks to Integra, we now have a roadmap for health systems looking to improve the care they provide.”