Feasibility, Acceptability, Effectiveness and Cost of Models of Integrating HIV Prevention and Counseling and Testing for HIV within Family Planning Services in North West Province, South Africa

This study was made in preparation for integrating HIV and AIDS counseling and testing (C&T) opportunities within the context of family planning (FP) services in South Africa. Integration requires the reorientation of FP services to not only integrate C&T but also to strengthen education and screening on sexually transmitted infection (STI) risks and information on dual protection. Phase I of the study, reported here, assessed the feasibility, effectiveness, and cost of two models of integrating C&T within FP services.

The study is a United States Agency for International Development (USAID) and President's Emergency Plan for AIDS Relief (PEPFAR)-funded project of the Population Council FRONTIERS programme, the National Department of Health (DOH), South Africa, and the North West Provincial Department of Health, Maternal and Child Health, Bojanala Region.

The two models studied are the Testing Model - which educated FP clients about C&T and offered C&T within the FP consultation by an FP provider - and the Referral Model - which educated FP clients about C&T and then referred interested clients for testing and post-test counseling to a specialised C&T service. "Key interventions included: (a) holding sensitization meetings at the national, provincial and district levels; (b) reviewing and developing training materials; (c) application of the Balanced Counseling Strategy Plus (BCS+) approach; (d) modification of registers for collection of FP and C&T statistics; and (e) training of health providers. The Department of Health (DOH) provided the required basic supplies such as HIV rapid test kits and the FP commodities."

BCS-Plus Toolkit, developed by FRONTIERS, "consists of a set of counseling job aids: (a) an algorithm, (b) a set of method cards, and (c) corresponding brochures for clients on each FP method. The algorithm summarizes the 19 steps a service provider should take to implement the BCS-Plus during a counseling session. There are 19 counseling cards in the toolkit. The first card contains six questions that the service provider will ask to rule out if a client is pregnant. The 13 family planning method cards then are used to help narrow down the appropriate method for the client. Each method card has an illustration of the method on the front side of the card. The back side of the card contains a description of four basic attributes or characteristics of the method. This allows the client to receive the key information about the method. Lastly four cards on STI/HIV were included: (1) STI/HIV transmission and prevention information, (2) HIV C&T, (3) STI/HIV risk assessment and (4) dual protection.... Adaptation of the BCS involved the inclusion of additional information on STI/HIV:

• The three key behavior change messages were stressed: A B C (abstain, being faithful and/or using a condom). Abstaining refers to secondary abstinence in this case as family planning users are assumed to be sexually active. In South Africa, because a quarter of FP clients are under 19, it is especially important to explain that secondary abstinence is still an option.
  
• Promotion of dual protection by providing information on the concept of dual protection, strengthened promotion of the condom, highlighting that hormonal methods and sterilization do not protect against STIs, and stressing correct and consistent condom use.
  
• Risk of STI/HIV was explored on an individual basis during the balanced counseling and dual method use and the correct and consistent use of condoms was to be stressed. The STI/HIV and dual protection messages were also reinforced during C&T counseling.
  
• This approach to FP was adapted in both models to ensure that clients are given a choice of FP methods and to ensure that standardized FP messages and integration of STI/HIV risk information are provided in both models. This was also done to minimize provider bias in the promotion of contraceptive methods."

Training workshops were held between April and June 2005: "A total of 129 service providers, including local area service managers, were trained on how to integrate C&T into FP using the BCS-Plus tool. Training focused on service integration but also included updates in FP method effectiveness, WHO medical eligibility criteria, Reproductive Tract Infections (RTIs) and HIV, reproductive rights, informed choice and consent, safe sex and dual protection, values clarification, risk assessment and reduction of risk, record keeping, logistics management, and referral....Continuous support and mentoring was provided to ensure that providers adapted to these new practices at their facilities until competency was gained and a minimum standard of quality of service was achieved. A supervisory tool was developed and used to regularly monitor both practice and to facilitate follow-up and supportive supervision." Through observation visits, clinical support visits, and on-the-spot training, gaps were identified and addressed.

The study found that both models increased the numbers of people aware of C&T and the numbers of people interested in testing. Increases in discussing the client's HIV serostatus changed from 5-6% at baseline to 62-81% at endline, although there was also a substantial increase in the control group (16% to 25%). (It was not possible to get statistics on actual numbers tested.) Both models used the BCS+ tool effectively to integrate HIV prevention activities, including education about prevention, dual protection, and counseling and testing within FP services. Providers acknowledge that the training capacitated them with the ability to discuss sexual issues with their clients freely, and it assisted in improving client-provider relation. Lastly, provider experience with clients raised a need for further training on new themes, i.e., rape assessment and guidance on how to deal with partners who refuse condom use, to be included in the BCS for better client services. The document proposes the following recommendations:

• "Counseling of all FP clients about STI/HIV/AIDS risk behaviors and prevention can address common misconceptions, and provides the opportunity to engage with clients about their sexual behavior and interest in HIV testing.
  
• Client preference for location of HIV testing should be respected and clients should be able to access services in the facility where they receive FP services or through referral.
  
• To assure the quality and effect of integrating services at the district level, it is important that records are kept and reported that describe the HIV services provided during FP consultations."