The Tides Africa Fund

In 2008, with the support of The William and Flora Hewlett Foundation, The Tides Foundation developed the Africa HIV and Family Planning Integration Fund (Tides Africa), which administered HIV/Family Planning integration grants to non-governmental organizations (NGOs) based and/or operating in sub-Saharan Africa. All of the grantees selected are operating model-integrated service delivery programs in the area of family planning and HIV/AIDS care and treatment.

The Tides Africa Fund embodies the commitment Tides has historically made both in the domestic and international sectors for supporting reproductive health programs as well as broad-based HIV service programs. The integration of HIV and existing reproductive health services has the potential to draw on the strengths and resources of both programs in order to help women learn their HIV status and to make better informed contraceptive choices. Separate funding mechanisms often prevent important linkages between HIV and family planning. Health ministries and health service facilities are typically organized and delivered vertically — therefore clients often see a different provider for each health concern. In such a scenario, providers may lack the skills and incentives to meet clients’ dual needs. Integrating family planning services into HIV prevention and care can increase access to contraceptive methods and enhance the public health impact of HIV programs. Through the first phase of this project, the Tides Africa Fund provided grants to organizations offering integrated services in Kenya, Tanzania, Uganda, Rwanda, Mozambique and Zambia.

Meeting the contraceptive needs of HIV-infected and at-risk women requires providers who are adequately trained to seek out and understand client desires and to counsel them effectively on their reproductive choices. As in traditional family planning programs, informed-choice counseling must be the cornerstone of contraceptive services in HIV-service delivery settings. HIV-infected women, like all women, have the right to make reproductive choices for themselves, and care must be taken to ensure that they are not coerced into a particular reproductive decision. For those women who do not wish to become pregnant, providers must be able to discuss feasible, safe and effective contraceptive options. As resources (government, philanthropic and other) are increasingly diverted to the HIV epidemic, renewed political commitment and financial support for family planning is essential. Efforts to reduce unmet need will not only produce concrete gains against the HIV epidemic, but improve overall maternal and child health.

HIV prevention and care programs are expanding throughout Africa. The Tides Africa Fund is working to mainstream HIV programs into the existing reproductive health infrastructure, which may both increase access to and de-stigmatize HIV services while strengthening traditional family planning programs. Health policy-makers have begun to recognize the opportunities missed and efficiencies lost in this parallel approach.

Read the full report on the Tides Africa Fund here.

Integration a Priority Among Global Health Initiative’s Latest Plans

by Brian Baughan

Last month, the U.S. administration pushed its Global Health Initiative (GHI) a step forward by announcing the first round of “GHI Plus” countries. In addition to describing the program’s governance, the announcement identified eight countries to receive enhanced support for health programs and strategies, including the integration of family planning and HIV/AIDS services. Two of the eight countries—Rwanda and Kenya—are home to Tides Africa–funded programs.

More than 80 countries receive support through GHI, a six-year, $63 billion plan initiated in 2009 to help partner countries improve measurable health outcomes by strengthening health systems and building upon proven results. The plan will focus on a subset of as many as 20 “GHI Plus” countries that have been designated to “provide significant opportunities for impact, evaluation, and partnership with governments.” Joining Rwanda and Kenya in the first round are Bangladesh, Ethiopia, Guatemala, Nepal, Malawi, and Mali. The remaining “GHI Plus” countries will be identified by 2014. Of interest to HIV/FP integration advocates is the GHI emphasis on comprehensive care and bringing together programs, investments, and agencies that are often siloed. The composition of the GHI Operations Committee—including leaders from the U.S. Agency for International Development, the Global AIDS Coordinator at the Department of State, Centers for Disease Control, and the Department of Health and Human Services—is a key element of the initiative’s coordinated, whole-of-government approach.

In addition to its anticipated outcomes regarding HIV/AIDS, infectious diseases, and other health indicators, GHI also has laid out several targets for family planning and reproductive health, including the prevention of 54 million unintended pregnancies. Critical to reaching this goal is a strategy to increase the modern contraceptive prevalence rate to 35 percent across assisted countries. (As a point of comparison, the most recent available reports place the contraceptive prevalence rates of Kenya and Rwanda at 31 and 26, respectively.)

Details of the GHI plan are laid out in an initial report, “Implementation of the Global Health Initiative: Consultation Document.” The government has invited global health organizations, including philanthropies, to give feedback on the document, and the GHI roadmap will be revised and finalized by late summer 2010.

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Coordinated Care and Top Research:
A FACES – Kenya Profile

by Brian Baughan

“Change in general is always challenging, especially when resources are limited,” says Dr. Elizabeth Anne Bukusi, a Nairobi, Kenya–based HIV researcher and physician, on the issue of integration and its slow maturation within the public health field.

In face of obstacles both financial and general, Bukusi and her peers press on. They carry out much of their integration-focused work through Family AIDS Care and Education Services (FACES), one of six Tides Africa-funded grantees. Based in the western province of Nyanza and Nairobi, two locations deeply impacted by HIV/AIDS,the organization recognizes the untested nature of HIV/FP integration. No one has proven the best approach to integration—proponents can’t even find consensus on the proper definition of integration. Yet, FACES keeps building its case for this new model of care.

Top-notch clinical and operational research is integral to the organization, which was founded in 2004 as a collaboration between the Kenya Medical Research Institute and the AIDS Research Institute at University of California, San Francisco (UCSF). Integration advocates celebrated in February with the announcement that UCSF had received a $1.15 million research grant from the Bill & Melinda Gates Foundation. The study, which is underway at 18 of the 64 HIV care and treatment sites supported by FACES, seeks to 1) improve family planning clinical and counseling skills of clinicians and community health workers at all the FACES-supported HIV care and treatment clinics; and 2) determine if integrating family planning into HIV treatment and care will increase contraceptive use and decrease unintended pregnancy among HIV-positive women.

“The [Gates] award will help us disseminate the integrated model, ensure local ownership of the process by the Kenyan Ministry of Health, and work/share with other Tides-supported programs,” says Dr. Craig Cohen, the study’s primary investigator and professor of obstetrics, gynecology and reproductive sciences at UCSF. All 18 sites are located in the FACES target region of Nyanza Province, which has the highest HIV prevalence rate (15.3 percent) among all of the country’s provinces. One district in particular, the Suba District, reports an infection rate between 30 and 40 percent.

One of the study’s coordinators, Dr. Maricianah Onono, looks forward to collecting data from Nyaza Province’s real-life settings, in contrast with findings from what she calls “near-ideal setups.” At some FACES sites, hundreds of HIV-positive and HIV-negative clients are often paired with only a handful of health providers. She gives the specific example of a clinic in Nyamaraga, located in the Migori District, where 2,000 inpatients receive care from only two clinical officers and one nurse. Despite the added burden on the practitioners to handle contraceptive implants and intrauterine device insertions, integration activities still have delivered results and produced demand for family planning. “Integration does not lead to greater workload,” she stresses. “The missing link is a lack of training and relevant skill sets.” Once health providers learn, for example, that a contractive implant takes under five minutes to insert, they can add that procedure to their arsenal of services.

The presence of trained volunteers is also critical to sharing the workload, adds Bukusi. FACES boasts a 180-strong cadre of Community and Clinical Health Assistants (CCHAs) handling outreach and education tasks. These volunteers, whom Onono calls “our very best ambassadors,” take advantage of public education opportunities by delivering comprehensive health talks, performing short informative plays in local languages, and marketing FACES services at barazas (Kiswahili for “chief gatherings”) and other public meetings. Once a CCHA has planted seeds of information with their peers, a clinician can then reinforce what they have learned and assist them in making informed reproductive decisions.

CCHAs do not just offer work relief in for health providers. During their curriculum trainings on FP, the trainees share the myths and beliefs around family planning that they have embraced themselves or have heard from others. Familiarity with these myths makes the process of debunking them that much easier. “With knowledge from every angle and clients who are already primed for a discussion on FP, it has made these discussions very lively,” says Onono.

As a leading organization in the integration field, the goals of FACES reach beyond raising its own numbers on contraceptive use and unintended pregnancies. The team wants to continue recording successes and pitfalls for others to observe. “From the beach hospitals in the islands to the large district hospitals, we have experience to draw from and have documented this experience,” says Onono. With the wide-scale replication the ultimate goal, FACES challenges peer organizations to hear its story and consider its findings.

Once that happens, perhaps integration won’t be as daunting as it once seemed.

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Implementing Best Practices of Integration:
A Rights-Based Approach

by Sara John

In addition to creating positive outcomes, an integration program can be an undeniably strong framework for reproductive rights. Extending the availability of family planning (FP) to all women, including the HIV-positive, would make strides for women’s rights and reduce the stigma surrounding HIV. There are also scientific benefits in addition to the social and ethical benefits of a rights-based approach to integration. Thus, the best practices of integration programs that simultaneously address health and the right to improve and maintain health should be identified and expanded upon. Implementing best practices from the existing literature has the capacity to improve health while concurrently educating and empowering women and collaboratively upholding their reproductive rights on a global scale.

Knowledge: Knowledge of HIV, paired with knowledge of family planning information, acts as a huge barricade to the continuing spread of AIDS. Specifically, this knowledge can decrease the likelihood that disease will spread from mother to child and between sexual partners. According to Bradley et al, only 21% of the Ethiopian people surveyed prior to intervention believed sexual abstinence completely protects from HIV transmission, and 95% thought “sometimes people are infected with HIV for no apparent reason.”¹ This misperception of more than three quarters of the population shows the incredible need for education in preventative measures that lay squarely at the intersection of family planning and AIDS.

In cases where integrative counseling is an option, the number of women and men who receive counseling to clarify such blatant fallacies increases by 20-fold and 40-fold, respectively. There are parallel increases in contraceptive use as well.² In a study of a Rwandan population, women receiving voluntary counseling and testing were shown a family planning video that was followed by an informative session and group discussion. Afterwards, the number of women using hormonal contraceptives almost doubled.³ All these mechanisms of dissemination— integrative counseling, information sessions, and videos—contribute to educating men and women and thus impede the spread of AIDS.

Empowerment: Some methods of education are better than others when creating a successful integration program. One effective approach is facilitating group and peer learning, which empowers women to act on their own thoughts and identify their educational capacities. A post-integration survey revealed that group counseling sessions were judged by women to be the most positive feature offered of all available counseling methods.⁴ Group learning environments catered to the sharing of experiences and peer educating, both of which gave women ownership of their learning.

The proven effectiveness of group counseling is as compelling as its popularity. Knowledge of sexuality and HIV/AIDS issues was increased by 50% following group counseling, and condom use doubled as well.⁵ Education does not have to stop with the group sessions. Participation in group counseling facilitates FP-related communication between partners, as evidenced by one study reporting that 51% of attending women talked to their partners about the groups afterwards.⁶

Inclusion: Women are most directly impacted by the failure to integrate HIV treatment and family planning, but men can be a huge part of the solution. Although women are at risk for unwanted pregnancies and direct transmission to their children, men can utilize family planning along with women to reduce the risk of HIV transmission to their partners, wives, children, and families. Vast improvements in the use of contraceptives have been seen in integration programs that involved both men and women. In a study by Bradley et al, men were more than twice as likely to use condoms regularly after the introduction of family planning services to the HIV clinic.⁷

In addition, targeting men in integration programs upholds men’s reproductive rights and serves as an indirect way to protect women’s rights. Integration is especially valuable for men with AIDS, as men who are HIV-positive are three times more likely to take advantage of family planning information than those who test negative.⁸ Integration programs targeting women and men result in increased observance of women’s reproductive wishes, increased use of contraceptives, and greater protection of men’s rights to family planning.

Implementing family planning services in conjunction with HIV treatment has a truly enormous capacity to create real global change. The positive health outcomes are apparent, and a rights-based approach to integration unquestionably has the capacity to better current norms for all women and men living with AIDS.

Footnotes

1 Bradley, H., Gillespie, D., Kidnau, A., & Karklins, S. (2009). Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: Client, counselor and facility-level considerations. AIDS, 23, 105-113.

2 Ibid.

3 King, R., Estey, J., Allen, S., Wolf, W., Valentine, C., Serufilira, A. & Kegeles, S. (1995). A family planning intervention to reduce vertical transmission of HIV in Rwanda. AIDS, 9, 45-51.

4 Becker J, Leitman E. (1997). Introducing sexuality within family planning: The experience of three HIV/STD prevention projects from Latin America and the Caribbean. Quality/Calidad/Qualité Series, no. 8, 1-26.

5 Badiani, R., Souza, C., & Becker, J. (1997). Sexual health STD/HIV prevention: An evaluation of integrating clinical and educational services in Brazil. Sociedade Civil Bem-Estar Familiar no Brazil (BEMFAM) and International Planned Parenthood Foundation, Western Hemisphere Region.

6 Scott, P., & Becker, J. (1996). HIV prevention and FP: Integration improves client services in Jamaica. AIDS Captions, 2, 15-18.

7 Bradley, H., Gillespie, D., Kidnau, A., & Karklins, S. (2009). Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: Client, counselor and facility-level considerations. AIDS, 23, 105-113.

8 Ibid.

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Resources on HIV/AIDS Care, Treatment and Prevention

U.S. Government Support for Global Health Efforts, June 18, 2010 Press Release

Website for the XVIII International AIDS Conference Vienna, Austria, July 18–23 '10

PEPFAR's Operational Plan with Individual Country Profiles

Articles on the Integration Model

Li, J. (2005). Integration of HIV/AIDS and family planning.The Lancet, 366, 1076-1077.

This Lancet article outlines and then expands upon the traditional benefits and challenges associated with integration programs

Spalding, A., Brickley, B., Kennedy, C., Almers, L., Packel, L., Mirjahangir, J., Kennedy, G., Collins, L., Osborne, K., & Mbizos, M. (2009). Linking family planning with HIV/AIDS interventions: a systematic review of evidence. AIDS, 23, 79-88.

This study reviews past studies centered on HIV/FP integration, ranking the success and rigor of each study, and summarizes important outcomes where applicable.