Structuring Health Services to Meet Women’s Needs
The manner in which health services are structured has an impact on HIV prevention, treatment and care services for women and girls. Women often need multiple reproductive health services such as family planning in addition to HIV prevention, treatment and care, but most health care facilities are not structured to provide integrated services. Integration can be defined broadly as “1) co-location of different services within the same facility, even if those specific services remain separately staffed; 2) training of personnel to provide multiple services; 3) provision of tools, processes and training to better link separate services; 4) strengthening of linkages, referral and follow up between facility levels; and 5) harmonization of logistics systems, such as data collection, drug and material distribution, transport and supervision across services” (Pfeiffer et al., 2010: 3). Integration of services, especially HIV and family planning, provides a way to capture the missed opportunities to counsel women and couples on contraceptives and other sexuality issues as well as provide HIV services.
“I feel like mothers benefiting from PMTCT must be assisted quickly at the antenatal clinic, unlike what we see today. We keep waiting from early in the morning to late in the evening without being attended to. We remain hungry all day long and our children keep crying out of hunger as well. At the ANC there is not even a place to lay down and rest.” —Woman attending PMTCT program, Malawi (Bwirire et al., 2008: 1997)
Sexual and reproductive health services are also excellent locations for providing HIV services and reaching potential ART users (WHO, 2003a; Interact Worldwide et al., 2008). If family planning is offered separately or if HIV service providers cannot counsel about contraceptives and sexuality issues, women may not be getting the full range of services they need. Consideration must be given, however, to the woman’s experience when integrating services (Stevens, 2008). For example, when women initiate antiretroviral therapy, they may be overwhelmed with information on disclosure and adherence and therefore this may not be the ideal time to address issues of contraception. But once treatment is initiated, ongoing counseling on contraceptive options may be warranted (King et al., 2011). A key question for women is how can services be offered to best ensure full respect for women’s autonomy in decision-making (Luciano et al., 2011), at the same time providing the ability to involve partners or family members should the woman so desire. In some countries, the private health sector provides over 50% of care (Rao et al., 2011), and therefore the private sector must be engaged and regulated to structure services to meet women’s needs.
Integration of Services is Key To Ensuring Women Receive Comprehensive Health Care
“Women are willing to use sexual and reproductive health clinics and outreach services because they do not attract the stigma” (Titus and Moodley, 2009: 138) often attached to HIV services such as HIV testing. “Women already attend clinics or community-based distribution programs for contraceptive advice, and when pregnant, millions of women in under-resourced countries make at least one visit to a prenatal clinic and a significant proportion make at least one postnatal clinic visit” (Titus and Moodley, 2009: 138). Recent studies in Kenya and Zambia found that family planning providers, antenatal care and family planning clients, and women living with HIV identified the need for family planning in a context of high HIV prevalence (Banda et al., 2004; Gichuhi et al., 2004). However, in some sites, no changes in contraceptive use were seen following integration of family planning into ART services (McCarraher et al., 2011), as many providers focus only on condom use for HIV-positive women (Mwaikambo et al., 2011; Orner et al., 2011b).
A recent review of PMTCT program failures in developing countries concluded that key factors include “the lack of linkages between prevention of mother-to-child transmission programs and primary prevention, family planning, and most importantly, the provision of care and treatment” (McIntyre and Lallemant, 2008a: 139). However, it is critical that policymakers and program managers know and understand the client population before deciding whether service integration is likely to be effective (Gillespie et al., 2009).
TB screening as part of antenatal and postpartum care is also important due to the increased risk of maternal and infant mortality associated with TB and HIV co-infection during pregnancy and postpartum (Mofenson and Laughton, 2007). However, in much of rural sub-Saharan Africa, maternal child health clinics are the primary health care facilities, with HIV testing and care introduced largely through these clinics, resulting in a strain on limited resources and overworked staff (Hayford and Agadjanian, 2010).
Women should be viewed as individuals with health care needs. Access to antiretroviral treatment for pregnant women in ANC clinics should not be seen to emphasize prevention of perinatal transmission at the expense of the women’s own health (Eyakuze et al., 2008). Focus on HIV for women only during pregnancy often shifts services to only preventing HIV transmission to the babies and neglects the health needs of the women themselves. Importantly, health care providers must practice in a respectful, non-discriminatory manner.
Health Care Providers’ Needs Must Also Be Met
Nurses occupy a pivotal position in relation to the HIV/AIDS epidemic, especially in Africa, where they face a disproportionate risk of infection, the largest burden of caring for sick family or orphans, and as health care workers, risk of occupational exposure (Zelnick and O'Donnell, 2005). Many health care workers are themselves living with HIV, suffer from stigma and cannot afford the services or treatment they prescribe for others.
In order to provide quality care, health care workers must have access to the means of universal precautions (e.g. gloves, masks and other protective equipment) so they can protect themselves from HIV transmission. Health care workers must be assured of the use of this personal protective equipment, which can reduce fear of treating people with HIV and thus reduce stigma and discrimination against women living with HIV who access health services. [See also Reducing Stigma and Discrimination]
“Where workers have the potential to encounter blood or other body fluids in the course of their work, employers have an obligation to train them in infection control and to ensure ready access to protective equipment and post-exposure prophylaxis” (UNAIDS, ND). “All national HIV prevention programmes must promote adherence to sound infection control practices in healthcare settings. Risk of HIV infection can be significantly lowered through workers’ adherence to universal precautions, the routine use of gloves and other protective equipment to prevent occupational exposures, safe disposal of needles and other sharp instruments, and timely administration of a four-week prophylactic course of antiretroviral drugs” (UNAIDS, ND). Importantly, in case of needle stick injuries, post-exposure prophylaxis should be used. Post-exposure prophylaxis guidelines can be found at: http://whqlibdoc.who.int/publications/2007/9789241596374_eng.pdf. The following WHO and ILO documents provide information on standards in health care services in the context of HIV: http://www.who.int/hiv/pub/priority_interventions_web.pdf and http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/publication/wcms_116563.pdf.
More Health Care Workers Are Needed
Health personnel are a critical component to effective health services and are in extremely limited numbers in many parts of the world. Only 5 of 49 low-income countries have the minimum of 23 doctors per 10,000 inhabitants recommended by WHO (WHO, 2010 cited in IOM, 2011: 107). Africa bears 25 percent of the world’s burden of disease but is home to only 1.3 percent of the world’s health workforce (IOM, 2011: 107). Malawi has nurse vacancy rates of 55% and only 1.7 physicians per 100,000 population (Massaquoi et al., 2008b). Additionally, in order to provide adequate care, health care workers need to be equitably distributed within the country, in both urban and rural areas. The shortage of health personnel increases the waiting time and reduces the quality of service for women.
While human resources is beyond the scope of this website, it is critical to recognize the role of people living with HIV not just as patients but also as health providers, and in providing social support for adherence as well as in reducing transmission. As authors Odetoyingo Morolake, David Stephens and Alice Welbourn stated: “We invite [you] to come on a journey of what it means to be living with HIV and... to experience to know that we have so much to offer our communities; how it feels for that offer to be ignored, forgotten or rejected; and how it feels to be stigmatized and criminalized as ‘carriers of HIV’ or treated as vectors of transmission… Official recruitment of HIV-positive people into the health system is limited, and where it does happen, HIV-positive people are mainly employed as peer supporters and counselors. These jobs are important, but the lack of... recruiting and supporting staff in more senior positions… reinforces stigma and discrimination” (Morolake et al., 2009: 1 and 3).
Health Care Systems Must Be Strengthened
Considerable controversy exists on whether AIDS programs have strengthened health care systems or led to increased fragmentation, with different viewpoints presented (Sidibe and Buse, 2010; Biesma et al., 2009; Amico et al., 2010; Atun and Bataringaya, 2011; Shiffman et al., 2009; Accorsi et al., 2010; Duber et al., 2011; Brugha et al., 2010; Grepin, 2011; El-Sadr et al., 2011b). Addressing the HIV/AIDS pandemic will impact many of the other Millennium Development Goals, such as poverty, education, gender, child mortality, maternal health and the environment (Kim et al., 2011). However, “the success of each field is dependent on continued progress in the other. An HIV-infected woman who receives PMTCT care but suffers an emergency obstetric complication will only survive if she has access to an appropriately equipped clinic… Similarly, an HIV-infected woman who receives high quality maternal health services is... not offered appropriate HIV services may die of avoidable HIV complications…” (McNairy et al., 2011: S83). Task shifting of non-medical tasks to less highly trained staff, is one way the human resources crises in health care has been addressed. Although this approach can improve access to services and increase uptake of antiretroviral and other treatments, this can also increase the burden on community and lay health workers who are predominantly women. Identifying a full range of solutions to resolve the human resources crisis is beyond the scope of this resource but other organizations such as Physicians for Human Rights (www.physiciansforhumanrights.org) have thoroughly reviewed this topic.
Strong service delivery systems, such as supportive supervision, training programs and logistics systems to ensure supplies are also essential for structuring health services in a way that meets women’s needs, but interventions addressing these issues are also beyond the scope of this document. Further information on this topic can be found at www.who.int/healthsystems/topics/en/.