Structuring Health Services to Meet Women’s Needs

A study of linked responses between HIV/AIDS, STIs, maternal health and contraceptive services with two demonstration projects covering five districts piloted in Cambodia from 2007 to 2009 found that STI, maternal health and HIV indicators improved dramatically. The proportion of pregnant women tested for HIV increased from 6% (1,261 of 21,376) in 2007 to 86% (18,394 of 21,478) in 2009. Syphilis testing, introduced in 2009, reached 85% coverage in 2009. Antenatal coverage of at least one visit increased from 80% to 100%; public health facility delivery rates increased from 26% to 46% and contraceptive prevalence increased from 24% to 28%. Half of the HIV-positive women who participated in the demonstration PMTCT programs were referred through HIV care centers or community based activities. Of the 62 HIV-positive women, 89% (55 women) delivered at a health facility. Of the 62 HIV-positive women who delivered by 2009, 60% received antiretroviral treatment and 24% received prophylaxis. Routine data was also collected in an area with similar characteristics to the intervention area, where HIV testing among pregnant women increased from 3% in 2007 to 34% in 2009. Contraceptive prevalence increased both in the intervention area and in the comparison area, with similar increases. Nationally, in 2008, only 29% of pregnant women had been tested for HIV. In 2005, 44% of births were assisted by skilled personnel and only 22% of women gave birth in public health facilities. Since 2007, the government provides a $10 financial incentive to midwives to promote deliveries with skilled attendance. Linked responses were formalized with Standard Operating Procedures between the National Center for HIV/AIDS and the National Maternal and Child Health Center. Linked responses established strong referral and follow up between health centers with ANC, delivery care and HIV testing and hospitals with a full range of services, as well as between community based organizations and health facilities. Additional training, supervision and monitoring was provided. Prior to the intervention, only one site in each demonstration area provided HIV testing and ARV prophylaxis. Following implementation, 38 health facilities provided delivery services, with a number of additional buildings and labs constructed. In 2007, women with CD4 counts under 250 received antiretroviral treatment, changing to 350 as of 2009; in 2007, those with CD4 counts above 250 received antiretroviral prophylaxis, which in 2009 was changed to CD4 counts above 350.

Integration of family planning with one stop, same day appointments into HIV care in Kenya resulted in increased use of more effective family planning methods and condoms by HIV-positive women. For those receiving integrated family planning and HIV care, all contraceptive methods except sterilization were available. A retrospective cohort study was conducted between 2005 and 2009 by reviewing records of HIV-positive women. Among those women who received integrated HIV care and family planning, there was an increase of 16.7% in condom use, a 12.9% increase in effective contraception that included condoms; and a decrease of 3.8% of contraception that excluded condoms. For those who did not receive integrated care, they had to access contraception by scheduling an appointment at a MCH or family planning clinic which is independently run from HIV care and required a co-payment from the woman as compared to no cost HIV care. New condom use among clients without access to integrated contraceptive services was 36.9% compared to 53.4 % in the integrated clinic, new family planning use including condoms was 58.1%. Compared to 44.7% in routine care; new contraception that excluded condoms was 4.8% for integrated care but 7.8% in standard care. 

A study in Mozambique which assessed the changes between 2004, when HIV care was delivered through a vertical hospital to when HIV care was integrated into primary health care and evaluated in 2008, found that integration of HIV/AIDS services into primary care can increase the numbers of those who access HIV testing and counseling, place more patients on antiretroviral therapy more quickly and efficiently, reduce loss to follow-up, and achieve greater geographic coverage compared to the vertical model. In 2004, freestanding HIV treatment hospitals were constructed in urban centers with their own pharmacies, data systems, health workforce, waiting areas and receptions. Patients identified as HIV-positive from other sectors of the health system, such as PMTCT or HTC, were referred to HIV hospitals to register for HIV care. But in 2005, only 78% of HIV-positive patients referred to HIV hospitals returned for CD4 testing, and only 46% of those who returned for the results of their CD4 tests were found to be eligible to start antiretroviral therapy. In 2005, only 59% of those testing positive at VCT sites managed to enroll in HIV care in HIV hospitals and only 5% of TB patients had been tested for HIV. By 2008, antiretroviral treatment was provided in 67 sites (out of 222 health facilities), distributed throughout all 23 districts in the two provinces with the highest prevalence of HIV. Pharmacies for HIV care were integrated by national policy into existing pharmacies. HTC was routinely provided in TB services as well as in maternal health services, increasing the numbers of those tested from 20,000 in 2004 in 19 separate VCT sites to 100,000 tested in 2007 in 103 sites. Nearly 180,000 HIV-positive patients were registered for care. Nearly 30,000 had initiated antiretroviral therapy out of an estimated 60,000 determined to be ART eligible through CD4 counts. Compared to 2004, in 2008 a significantly greater percentage of patients initiated ART in less than 90 days. By the end of 2008, HIV-related resources had contributed to the rehabilitation or construction of 40 staff house, 22 labs, 11 pharmacies, 100 refrigerators for cold chain, and dozens of maternities. [For steps to bring ART services from the hospital to the primary care clinic level, please refer to (Decroo et al., 2009)] 

In Zambia from 2007 to 2008, 581 HIV-positive pregnant women were successfully identified and initiated on HAART in primary health centers. Of 14,815 HIV-positive pregnant women registered in the 60 primary health care centers, 1,660 had their CD4 counts available at primary health care clinics. Of these, 796 had CD4 counts under 350 and were eligible for treatment and 581 of them were initiated on HAART at the primary care level.

Integration of family planning and HIV services in Nigeria, in 71 health facilities with strengthened referral links, provider training, co-located services, same staff and parallel supply chain management systems, resulted in the mean attendance at family planning clinics increased significantly from 67.6 pre-integration to 87 post-integration. The mean couple years of protection increased significantly from 32.3 pre-integration to 38.2 post-integration. 

A study in Tanzania found that a two-part referral form, a transportation allowance, and a community escort increased referral uptake at HIV clinics and reduced delays in seeking care. Of referred patients, 72% of men and 66% of women registered at the HIV treatment clinic within six months. Transport allowances of US$ 2 roundtrip were provided. The cost of covering transport to the HIV treatment clinic was US$ 25 to 30 per year, a small fraction of the total costs for an HIV-positive patient. Patients also reported that the referral system facilitated their arrival at the HIV clinic. The study also included in-depth interviews with 11 health care workers and 42 patients, as well as four focus group discussions with referred patients. The benefits of an escort included physical support, encouragement, and familiarity by the escort of the city and the hospital to which they had to go to get HIV treatment. Referral forms allowed patients who had already received their HIV test results to avoid retesting at the HIV treatment center. Providers at the HIV treatment center found the referral forms helpful as they signaled patient willingness to access and adhere to treatment, as well as providing useful information. Patients who tested HIV-positive but did not access HIV treatment clinics were follow up by counselors to discuss treatment options. The referral form had two detachable parts, with matching unique numbers to facilitate reconciliation of the two parts. One side had basic socio-demographic information on the patient and the referral date and was given to the patient to present at the HIV treatment clinic. The second part was retained by the referring party.

A pre-post intervention study in 23 public sector hospitals, health centers and dispensaries in two districts in one province in Kenya found that provider-initiated testing and counseling was feasible and acceptable in family planning services, did not adversely affect the quality of the family planning consultation and increased access and use of HIV testing in a population which benefited from knowing their serostatus. All clients were female. 538 pre-intervention and 520 post-intervention were randomly selected to be observed and interviewed. The policy environment in Kenya has been conducive to linking HIV/AIDS services with reproductive health service, with a Reproductive Health and HIV/AIDS strategy. Counseling guidelines were updated for providers to discuss HIV transmission and prevention, conduct risk assessment, discus dual promotion and offer HTC. Staff received training on contraceptive methods, HIV, reproductive rights, informed choice and consent, safe sex, values clarification, risk assessment and reduction, record keeping and logistics management. One group of 28 family planning providers were trained for nine days in the integrated family planning and HIV counseling intervention and in providing HIV testing and counseling to family planning clients requesting a test during the consultation. Another group of 47 family planning providers were trained for five days in the intervention and referred clients interested in an HIV tests. Implementing the intervention added two to three minutes per consultation for those who wanted a referral and seven minutes for those wanting on-site rapid testing. The incremental cost per family client ranged from $5.60 in hospitals to $9.53 in dispensaries. Dual method use increased from 1% to 6%. For those who were tested on site, 35% of clients were tested; for those referred, 20% were tested for HIV. One-third of the family planning clients who chose to have an HIV test had never had an HIV test before.

A 2001-2002 study of 706 women in Tanzania who accessed post-abortion services found that most accepted HIV testing and condoms. In Tanzania, abortion is illegal and women have unsafe abortions to terminate unplanned pregnancies. Women were offered HIV testing and counseling about contraception and HIV and, 407 (58%) accepted HIV testing. Prior to the study, condom use during the past six months before hospital admittance was low, with 61% never using condoms. Among women who accepted being tested for HIV, 73% accepted to use condoms either alone or in combination with hormonal contraception after having been provided with contraceptive counseling. Of the 407 women who accepted HIV testing, 14% were HIV-positive. “… Women who have an unsafe abortion comprise a vulnerable group who are at high risk of repeated unsafe abortion and HIV infection” (Rasch et al., 2006: 703).

A study in South Africa found that providing HAART at primary care clinics with adequate support for health facilities resulted in a four-fold increase in new HAART initiations with a high rate of viral load suppression of over 85% and a twenty fold increase in CD4 cell count testing in HIV-positive adults. Systems improvements included immediate CD4 cell count determination if HIV test results are positive, with multiple processes at the same visit, such as counseling, lab testing, clinic staging, etc.; nurses designated to follow-up on basis of CD4 cell counts; increased reliance on clinical judgment of health workers who know the clients well, such as deferring home visits based on logistics; patients are referred back from secondary and tertiary HAART initiation sites to primary care clinics for care.

In Uganda, a project from 2006 to 2007 integrated family planning and HIV treatment, resulting in a three-fold increase in the number of HIV treatment patients accessing family planning. Evaluation data included 105 client exit interviews, 30 provider client observations, 37 self-administered provider questionnaires, six key informant interviews with program staff, three group discussions with people living with HIV and three group discussions with providers showed that two-thirds of clients interviewed in exit surveys reported that they used condoms every time they had intercourse in the past six months. Four contraceptive methods were provided: condoms, oral contraceptives, injectables and emergency contraceptive pills. Referrals were made for long acting and permanent contraceptive methods to the hospital a few yards from the TASO clinic. A performance needs assessment and an integrated training curriculum to provide family planning and antiretroviral therapy were developed and utilized. Prior to the intervention, only 16% of HIV-positive women were counseled on their family planning needs because providers were concerned that providing family planning would encourage women living with HIV to have sex. Condoms were provided for HIV prevention but not for family planning and HIV-positive men were excluded from family planning activities. By the end of the project, 62% of providers reported that adding family planning services did not adversely affect the provision of antiretroviral therapy while 35% of clients reported that adding family planning services improved the provision of antiretroviral therapy and 41% experienced no change. In Uganda, approximately one million people live with HIV and adult HIV prevalence is 6.7%, with the highest levels among women in urban areas. Nearly 25% of all new HIV infections result from perinatal transmission. Although the mean ideal number of children is 5.3, the total fertility rate is 6.7 lifetime births per woman. Only 18% of married women use a modern effective family planning method.

Focus group discussions with four HIV-positive women and four HIV-positive men at a public health facility in Cape Town, South Africa found that they felt that HIV/AIDS services provided good non-judgmental, respectful, informative and confidential care as compared to facilities that provided reproductive health services and contraception where, as one woman noted, “that crew make you feel scared to go to the clinic” (Orner et al., 2008: 1218). In addition, “integrating services would mean not having to repeatedly explain themselves to others, thus decreasing instances of stigma and prejudice directed towards them. For women who needed to access contraceptives, access to ‘everything you need under one roof’ was unambiguously desired” (Orner et al., 2008: 1220). 

A study in Côte d’Ivoire from 2004 to 2005 showed that implementation of a comprehensive PMTCT program in urban health facilities significantly increased HIV testing, PMTCT and also improved the quality of some antenatal and delivery health services. Before implementation of the PMTCT intervention, five urban health facilities underwent renovation, or new buildings were constructed in order to meet PMTCT program standards that included adequate room for individual counseling and group sessions. Additionally, a standard set of equipment was supplied to each facility and all maternity care staff was provided PMTCT training. After PMTCT program implementation the number of pregnant women offered HIV testing increased from 0% to 63%, 83% of HIV-positive mothers and 78% of infants received nevirapine, health facility staff in favor of recommending HIV testing increased from 82% to 98% and the proportion of staff who would be willing to be tested during their own pregnancy increased from 59% to 86%. Further, interpersonal communication improved significantly with women receiving a friendly greeting increasing from 44% to 70% and an invitation to sit from 69% to 99%. Confidentiality also improved with the number of women asked questions individually without another patient present increasing from 63% to 81%. Individual counseling showed an increase in family planning counseling from 3% to 28% and prevention of STI counseling from 7% to 36%. The number of women participating in information sessions where prevention of STIs, HIV and HIV testing was addressed increased from 39% to 75%. Washing of hands before or after an examination by clinic staff increased from 3% to only 11%. During the medical interview at first antenatal care, the frequency of retrieving a history of previous pregnancies increased from 44% to 58%, history of cesarean sections from 35% to 55% and last menstrual period from 38% to 55%. During the antenatal care clinical examination, checking of uterine height increased from 95% to 98%, checking of fetal heart rate from 67% to 79% and checking of fetal position from 67% to 81%. Inter-personal relationships improved significantly with women receiving information on labor progression from 8% to 41%, having someone present for support from 19% to 27% and delivering privately without being visible to other patients from 65% to 81%. Safe obstetric procedures demonstrated a marked decrease in episiotomies from 24% to 14% for all women and 64% to 25% in primiparous women. Infection prevention showed that washing the perineum before delivery increased from 9% to 27% and sterile instruments available for each delivery increased from 57% to 69%. At the first exam checking of blood pressure, pulse and conjunctiva all increased (41% to 65%, 3% to 16% and 47% to 61% respectively) and during examination at admission for delivery checking women’s antenatal card increased from 91% to 98%, asking about onset of labor pain from 27% to 50%, asking if uterine membranes had ruptured from 33% to 43%, determining uterine height from 65% to 80%, determining position of the fetus from 53% to 84% and measure of fetal heart rate from 60% to 80%. After delivery the use of oxytocics increased from 83% to 90% and checking for uterine retraction increased from 28% to 50%. However, several indicators appear to be negatively impacted by the PMTCT intervention. Information sessions addressing family planning decreased from 30% to 10%, professional attendance at delivery by both doctors and midwives decreased (2% to 1% and 86% to 79% respectively) and manual exploration of the uterus after delivery increased from 32% to 64%. Overall the marked improvement in quality of maternal care after implementation of the PMTCT program was attributed to intensive staff training, supervision and adequate equipment.

A study reviewed quantitative and semi-qualitative national level PMTCT and pediatric HIV care and treatment data in 71 countries in 2005 and 58 in 2004 to track progress in scaling up interventions to prevent mother-to-child transmission of HIV in maternal and child health services. The near universal acceptance (90%) of HIV testing among pregnant women who received counseling for PMTCT illustrates that women desire this important bridge to HIV treatment and prevention services. The fact that only 11% (10.3 million) of the women in 71 countries in 2005 were counseled on PMTCT demonstrates the many missed opportunities for ensuring necessary services for healthy mothers and newborns. In countries with generalized epidemics, rapid expansion of provider-initiated HIV testing and counseling in maternal-newborn-child health (MNCH) settings and particularly antenatal care has been an effective way to increase uptake of PMTCT services. Botswana introduced routine offer of HIV testing in 2004. Within three months, the proportion of pregnant women tested for HIV increased from 75% to 90%. Scaling up efforts for PMTCT has started to show an impact. The proportion of HIV-positive pregnant women receiving antiretroviral treatment for PMTCT increased from 7% in 2004 to 11% in 2005, a more than 50% increase.

The Cameroon Baptist Convention Health Board implemented a program to prevent mother-to-child transmission of HIV-1 (PMTCT) as part of its routine antenatal care, with single-dose maternal and infant peripartum nevirapine (NVP) prophylaxis of HIV-positive mothers and their babies. Nurses, midwives, nurse aides, and trained birth attendants counseled pregnant women, obtained risk factor data, and offered free HIV testing with same-day results. From February 2000 through December 2004, this program rapidly expanded to 115 facilities in 6 of Cameroon's 10 provinces, not only to large hospitals but also to remote health centers staffed by trained birth attendants. Staff trained 690 health workers in PMTCT and counseled 68,635 women, 91.9% of whom accepted HIV testing. Of 63,094 women tested, 8.7% were HIV-1-positive. Independent risk factors for HIV-1 infection included young age at first sexual intercourse, multiple sex partners, and positive syphilis serology. Staff counseled 98.7% of positive and negative mothers on a posttest basis. Of 5,550 HIV-positive mothers, 5,433 (97.9%) received single-dose NVP prophylaxis. Consistent training and programmatic support contributed to rapid upscaling and high uptake and counseling rates.

A cross-sectional survey was conducted in Cameroon from 2006 to 2007 using a random sample of 3,151 patients who had been diagnosed as HIV-positive for at least 3 months and were attending HIV services. The impact of the Cameroon’s decentralized health care system on HIV was assessed and the survey indicated that adherence to ART was significantly higher at the provincial and district level, as was patient satisfaction. The delay between a HIV diagnosis and consultation was shorter at the district level and CD4 counts were higher when initiating treatment. Additionally, ART coverage among females was 62% which was significantly higher compared to the male coverage rate at 51.1%.

As study in rural Malawi of 8,093 patients (63% women) from 2004 to 2008 of whom 43% who received their HIV care in decentralized HIV centers found that those patients managed at health centers had lower mortality and lower loss to follow-up, i.e. defaulted from treatment. Services in this area are provided at one central hospital and 33 health centers. During the first ten months of follow-up, those decentralized to health centers were approximately 60% less likely to default than those not decentralized even when adjusted for sex, age, clinical stage at initiation, type of regiment and duration of treatment and follow-up. Receiving HIV treatment and care at decentralized HIV centers was significantly associated with a reduced risk of death through 25 months of follow-up. However, those who received HIV care at decentralized HIV centers were stable patients and complicated cases were referred. The tertiary hospital clinic was located far from the majority of rural poor. Decentralized health centers were chosen if they had medical assistants or nurses who then received ongoing supportive supervision; testing and counseling services; adequate counseling and consulting rooms; and were capable of safely storing drugs. Staff was trained. ART follow-up was integrated with primary outpatient care services at health centers. To qualify for services in decentralized HIV centers, patients had to stable on first line ART for at least three months with no active opportunistic infections and who lived closer to the center than to the hospital.

A study in rural South Africa that reviewed data from 2004 to 2008 found that outcomes were not affected by rapid expansion of decentralized HIV treatment. HIV treatment and care was provided through a network of 16 primary health care clinics. Data included all adults who initiated ART between 2004 and 2008 and were analyzed by whether they received care in a 1) hospital-based setting; 2) an urban setting; 3) a rural setting with more than 200 patients on ART; and 4) a small rural clinic with under 200 patients on ART. A total of 5,719 adult patients were initiated on ART between 2004 and 2008; of these 2,509 patients were eligible for ART, with a ten-fold increase in the number of patients initiating ART. Females constituted 67.9% of all patients initiated on ART and men had a lower median CD4 cell count at initiation of 91 than females at 128. More men (29.6%) than women (18.2%) initiated ART with a CD4 count below 50. Of 3,010 patients included in analysis, retention in treatment was 84% at 12 months and mortality was 10.9%. The mortality rate peaked in the first three months of ART initiation. The decentralized program of ART delivered through primary care has led to rapid scale-up with 5,179 patients initiated on ART in four years. “Success in scale-up may be partly attributed to growth in the programme’s financial and human resources, which increased by about 20-fold in the first four years as a result of PEPFAR support” (Mutevedzi et al., 2010: 595). Active tracking with phone contact, including home visits may have increased the success of keeping patients on ART.

A cross-sectional study from Brazil found that mask use by health care workers, HEPA filters and biosafety cabinets in lab areas, isolation of TB patients with respirators and a negative pressure isolation room, along with rapid diagnosis and treatment of TB patients, resulted in a significantly lower rate of the incidence of LTBI in initially tuberculin-negative health care workers. The study compared two hospitals with infection control with two hospitals with no TB control measures in place. The incidence of LTBI in hospitals without prevention measures was 16 per 1,000 person months; and with prevention measures 7.75 per 1,000 person-months, a statistically significant rate (Roth et al., 2005 cited in Joshi et al., 2006).