Article Text
Abstract
Introduction Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya.
Methods Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009–2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling.
Results Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care.
Conclusions These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time.
Trial registration number NCT01694862
- HIV
- child health
- health services research
- prevention strategies
- intervention study
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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Footnotes
Handling editor Stephanie M Topp
Contributors IJB and JF designed the analyses. JF prepared the data and executed the analyses and figures, and IJB wrote the first draft of the manuscript. CN, CW and SM designed the client flow tool. CN and JK organised the collection of client flow data. SM and CW designed and coordinated the Integra Initiative. All authors critically reviewed the manuscript and read and approved the final manuscript.
Funding The study was funded by Bill and Melinda Gates Foundation.
Competing interests None declared.
Patient consent Not required.
Ethics approval Approval was obtained from the ethics committees of the Kenya Medical Research Institute (approval numbers 113 and 114), the London School of Hygiene & Tropical Medicine (approval number 5426) and the Population Council (approval numbers 443 and 444).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data used in this analysis are available in online supplementary tables.
Collaborators The Integra Initiative team members at the London School of Hygiene & Tropical Medicine: Susannah Mayhew (PI), Anna Vassall (co-PI), Isolde Birdthistle, Kathryn Church, Manuela Colombini, Martine Collumbien, Natalie Friend-DuPreez, Natasha Howard, Joelle Mak, Richard Mutemwa, Dayo Obure, Sedona Sweeney, Charlotte Watts. At the Population Council: Charlotte Warren (PI), Timothy Abuya, Ian Askew, Joshua Kikuvi, James Kimani, Jackline Kivunaga, Brian Mdawida, Charity Ndwiga, Erick Oweya. At the International Planned Parenthood Federation: Jonathan Hopkins (PI), Lawrence Oteba, Lucy Stackpool-Moore, Ale Trossero. At FLAS: Zelda Nhlabatsi, Dudu Simelane. At FHOK: Esther Muketo. At FPAM: Mathias Chatuluka.