What Works—Structuring Health Services to Meet Women’s Needs

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, with strengthened referral links, provider training, co-located services, same staff and parallel supply chain management systems, resulted in monthly consultations of family planning increasing from a range of 1 to 161 per month pre-integration to 3 to 410 post-integration. 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. There was an increase of 34 referrals per 1,000 ART users and an increase of 42 per 1,000 PMTCT clinic users.

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. Of 1,357 with incomplete abortion, 708 admitted unsafe abortion. 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”.

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 the Western Cape Province of South Africa, all HIV-positive women identified through PMTCT services undergo immunologic testing. Pregnant women with CD4 counts greater than 200 receive a two drug short course of zidovudine and nevirapine for PMTCT, whereas those with CD4 counts of 200 or lower are immediately referred to separate HIV treatment facilities for a ‘fast-track’ evaluation and HAART initiation . Instituted in 2004 and now implemented on a wide scale, this has contributed to low rates of PMTCT, estimated at between 6 to 8% (Abrams et al., 2007).

Integrating HIV/AIDS treatment in 53 health facilities in 23 districts in Mozambique with 80,000 people resulted in 70% decline of loss to follow up from antenatal care to ART services over one year . (Abstract)

A study at a hospital in Kenya found that integration of PMTCT, ANC and MCH services reduced PMTCT, increased women’s retention in HIV care and improved follow-up of infants born to HIV-positive women. Women who tested HIV-positive were given HAART if appropriate. Prior to the integration project, women who tested HIV-positive did not report to the HIV clinic even when personally escorted by hospital staff. Pregnant women reported feeling out of place in the HIV clinic. . (Abstract)

A 2008 study from Swaziland showed that integrating HAART into preexisting maternal and child health (MCH) services increased the number of HIV-positive pregnant women initiating HAART (no numbers given). MCH services began offering HAART for HIV-positive pregnant women and their families in February 2007. After 10 months, 28% of pregnant women eligible for HAART initiated treatment in comparison to only 5% initiating HAART during the 10 months previous to the integration. Over 300 patients initiated HAART post- integration, 45% of which were pregnant women. Additionally, 25 family units enrolled in HAART services during this time demonstrating the usefulness of integrated MCH/HAART services for women and their families . (Abstract)

A 2004 to 2007 project in Ethiopia and Ukraine conducted by UNFPA and EngenderHealth that integrated HIV prevention interventions into maternal and child health programs increased the numbers of women receiving HIV counseling and testing, and syphilis screening, as well as women’s intentions regarding HIV risk during pregnancy. Interventions to support the introduction of integrated services included whole site training, minor upgrades to facility infrastructure and provision of necessary supplies. Pre- and post-test training questionnaires were conducted with 307 health providers and 64 women receiving services . (Abstract)

A study in Rwanda found that provision of HIV care at VCT and PMTCT sites effectively enrolls more patients earlier in their illness and more effectively refers those eligible for HAART. In five health centers in 2007, 119 clients tested HIV-positive, of whom 118 were referred to the nearest treatment site. Of the 118 patients referred, only 33% arrived at the treatment site within three months. In the program which consisted of standard pre-antiretroviral therapy HIV care, 100 patients (74% female and 26% male) were immediately enrolled and staged during a three months period following their seropositive HIV test. Of these, 26% were eligible for HAART and were referred to the nearest treatment site where 91% of them were started on HAART . (Abstract)

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” . 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 2007 study in Nigeria found that extending PMTCT services from large regional comprehensive ART centers “Hubs” to include smaller secondary hospitals and primary health care centers “Spokes” resulted in a fourfold increase in the number of women accessing PMTCT. An evaluation of 3 “Hub” sites and 13 “Spoke” sites showed that at “Hub” sites 6,882 new women received antenatal care, 74% of whom were counseled, tested for HIV, and given results, while at “Spoke” sites 33,119 new women received antenatal care, of which 87% were counseled, tested for HIV, and given results. Women who tested HIV- positive at “Spoke” sites and required HAART for their own health were provided transportation to a “Hub” site, while women who did not require HAART were given short course ARTs at the same “Spoke” site. However, women were more likely to return for delivery at “Hub” sites (61.2% of women returning) compared to “Spoke” sites (48.5% of women returning) . (Abstract)

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.

In Zimbabwe, distribution of HIV tests was integrated with successful distribution of condoms and contraceptives. Delivery trucks act as a rolling warehouse visiting all 1,600 public sector health facilities once every four months and sites are topped up to maximum stock levels and logistics data is captured. Stock out of HIV tests kits dropped from 35% to 2% and stock reporting rates increased from 30% to 97% . (Abstract)

A mathematical model based on TB transmission patterns in Tugela Ferry district and at Church of Scotland Hospital in the Kwa Zulu Natal district in South Africa, was created to simulate TB transmission in high TB/HIV prevalent settings. If no new infection control interventions were introduced, about 1300 new cases of XDR-TB were predicted to occur by the end of 2012, more than half of which would likely be noscocomially transmitted or transmitted within health care settings. The model showed that masks alone would prevent 10% of new transmission in an overall epidemic, but could prevent a large proportion of XDR-TB cases among hospital staff. The combination of mask and reduced hospitalization with a shift to outpatient treatment could prevent nearly one- third of XDR-TB cases. Approximately 48% of XDR-TB cases could be averted by the end of 2012, if a combination of mask, reduced hospitalization with shift to outpatient treatment, improved ventilation, rapid drug resistance testing, HIV treatment and TB isolation facilities for highly infectious patients were implemented.

Surveys using the same standardized questionnaire given to 250 patients on one day in 2005 and 400 patients on one day in 2007 found that improvements made based on the 2005 survey resulted in significantly reduced waiting time for patients in Uganda (no sex disaggregated data). Nurse visits, rather than assessments by clinicians were instituted for minor complaints. Group counseling was instituted. A pharmacy only refill program was initiated for patients on ART for at least 12 months, who were asymptomatic with good adherence levels and CD4 counts above 200, with patients seeing a doctor or nurse very three months and monthly pharmacy visits. The median time spent at the clinic decreased from 157 minutes in 2005 (ranging from 22 minutes to 426 minutes to 124 minutes (15 minutes to 314 minutes).