Integrating family planning into Ethiopian voluntary testing and counselling programmes
Duff Gillespie a, Heather Bradley a, Metiku Woldegiorgis b, Aklilu Kidanu c & Sabrina Karklins a
a. The Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street (W4509), Baltimore, MD, 21205, United States of America.
b. Pathfinder International, Addis Ababa, Ethiopia.
c. Miz-Hasab Research Center, Addis Ababa, Ethiopia.
Correspondence to Duff Gillespie (e-mail: email@example.com).
(Submitted: 13 March 2009 – Revised version received: 04 September 2009 – Accepted: 12 October 2009.)
Bulletin of the World Health Organization 2009;87:866-870. doi: 10.2471/BLT.09.065102
Voluntary counselling and testing (VCT) is a core part of HIV/AIDS prevention and treatment programmes. Because both VCT and family planning programmes help clients avoid unwanted consequences of their sexual behaviour – HIV and unintended pregnancies – many policy-makers believe that integrating these two services will increase coverage and efficiency.
Ethiopia’s population of 80 million is increasing rapidly at an annual rate of 2.5%, meaning it will double in 29 years.1 Contraceptive prevalence is only 15%.2 It is estimated that the adult HIV prevalence rate is 2.1%, with over 1.1 million people infected.3 Despite challenging circumstances, and with significant donor support, Ethiopia has dramatically increased its VCT coverage. The number of VCT facilities increased from just 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled in just one year, from 1.7 million tests in 2007 to 3.5 million in 2008.4 With this significant increase in coverage, the large network of VCT clinics has the potential to greatly increase access to family planning information and services.
After attending a WHO-sponsored meeting on international best practices in Uganda, Ethiopian government officials and representatives developed a plan to introduce family planning into VCT programmes. They developed a steering committee, which was led by Pathfinder International, Ethiopia. This committee aimed to train public sector VCT counsellors in family planning provision and to initiate integrated services in 20% of service sites for VCT and prevention-of-mother-to-child transmission of HIV in four focus regions. These sites were chosen based on available human resources, interest in participating and proximity to Pathfinder’s local implementing partners.
Despite this initiative to integrate HIV and family planning services, there was no empirical evidence that Ethiopian VCT clients had an unmet need for family planning or that service integration would improve access or quality of care for clients. Pathfinder, the Miz-Hasab Research Center, an Ethiopian research firm and the Johns Hopkins Bloomberg School of Public Health joined forces to evaluate the integration programme in eight of Pathfinder’s service sites. This research, the “Voluntary HIV Counselling and Testing Integrated with Contraceptive Services” Study, assessed the impact of adding quality family planning services into VCT facilities.
Between November 2006 and February 2008, Pathfinder introduced family planning services into semi-urban hospitals and health centres in Oromia region. First, administrative staff and health providers at all levels were sensitized about the importance of integrating family planning and HIV services, and then VCT service providers were trained in family planning. Pathfinder held five-day training courses on three separate occasions to account for frequent provider turnover. Training curriculum included basic information on the benefits of family planning, contraceptive options and side-effects.
Additionally, facilitators introduced counselling messages and protocols developed specifically for VCT clients, such as men, young people and HIV-positive individuals.
VCT counsellors were authorized to counsel clients on family planning and to offer condoms and contraceptive pills during VCT sessions. Nurse counsellors were also authorized to provide injectable contraceptives. Pathfinder provided a full-range of contraceptive supplies to both VCT and family planning units in all eight facilities. Monthly monitoring visits helped to ensure contraceptive availability within the facilities and resolve problems faced by the VCT counsellors. VCT providers’ logbooks were modified to facilitate collection of information about family planning counselling and services, and these data were routinely assessed by Pathfinder, in addition to contraceptive stocks.
Before and after the family planning intervention was implemented, we conducted cross-sectional client interviews. In 2006, 4019 clients receiving standard-of-care VCT were interviewed about their contraceptive practices and needs. Approximately 18 months after introduction of family planning services, 4027 additional clients were interviewed using the same survey instrument.
The VCT client profile had some unexpected characteristics. Table 1 outlines the characteristics of female clients who were interviewed at the second point in time, after family planning services were introduced. These VCT clients were young and well-educated. Their average age was 22 years, and more than 74% were younger than 25 years. Over 60% of women had a secondary or higher education and more than 40% were still in school. Most women were single with no children; 64% of them had never married and 71% had no children. This is also a very urban population, with 86% living in urban areas.
Table 1. Characteristics of female clients after introduction of family planning in voluntary counselling and testing facilities
The clients in this sample are quite different from the general Ethiopian population, but the most surprising client characteristic was the low level of sexual activity. More than 40% of these women had never had sex, and an additional 32% had not had sex during the last month. HIV prevalence was nearly 8%, which is considerably higher than in the general Ethiopian population, as expected among clients seeking HIV tests.
Not only were many clients sexually inactive, many of the sexually active clients were already using contraception. Among married and other sexually active women, 70% were using contraceptives. Of women in current sexual unions, 17% had unmet contraceptive need, meaning they did not want to have children soon but were having unprotected sex. This is about half of the unmet need that exists in the general Ethiopian population (34%).2
Despite the relatively low need for family planning services among study clients, there was an impressive increase in the provision of family planning information in VCT. Fig. 1 shows some of the family planning and HIV topics discussed before and after family planning services were introduced. Four times as many women received information on their contraceptive options after the intervention and, importantly, this improvement in family planning counselling had no negative impact on HIV counselling. Indeed, significant improvements were also found in this area.
Fig. 1. Change in information provided and contraceptive use before and after introduction of family planning services to clients of voluntary counselling and testing
While overall contraceptive uptake was low, there were significant improvements in family planning distribution for women, as almost none of the VCT clients received contraceptive methods, including condoms, at baseline. The largely sexually inactive client population and the percentage of sexually active clients who were already using contraceptives are likely explanations for the low number of clients accepting contraceptive methods.
In-depth analysis was conducted to better understand the kinds of clients who received contraceptive counselling and methods, revealing that clients with higher risk for HIV and unintended pregnancy were much more likely to obtain family planning services. The benefits of integrating family planning and VCT services may thus be more pronounced among higher risk populations.
One of the most unexpected findings from this study was the low level of sexual activity among VCT clients. Based on our survey and in-depth interviews with clients, it seems many low-risk clients seek HIV tests because of their beliefs about modes of HIV transmission. Clients know HIV is transmitted by sexual activity, but they think that it is equally probable that HIV can be transmitted via other unlikely, or even impossible, means.
The major limitation of the study is that its principal data sources are two cross-sectional surveys. Because clients are not followed up, we can say nothing about attitudinal and behaviour changes over time. Additionally, the study’s client population and service sites may not be representative of other parts of Ethiopia. While such representation is not necessary for a proof-of-concept study, it does mean that it is difficult to extrapolate from the surprising findings of high contraceptive use among the sexually active clients and the very high percentage of non-sexually active clients.
In conclusion, most of the surveyed clients were at relatively low risk for HIV and unintended pregnancy, either because they were not having sex or were already using contraceptives. Importantly, however, the quality of both HIV and family planning counselling improved dramatically, indicating, at the very least, that service integration is possible in the Ethiopian context. Because our facilities were not sampled using probability methods, they may have performed better or been different in terms of client catchment populations than other VCT facilities; therefore, one should exercise caution in generalizing the findings.
The incremental cost of integrating family planning is modest in the country’s present funding environment. In 2008, Ethiopia received over US$ 630 million for combating HIV/AIDS. More than half of this amount was from the President’s Emergency Plan for AIDS Relief (PEPFAR), which is the major source of funds for the country’s VCT programme.5 The cost for family planning training was US$ 325 per trainee. The only major recurring cost was the regular monitoring visits by Pathfinder, which had an annual cost of US$ 1562 per facility. To have a comparable level of monitoring for all of the country’s VCT facilities, the annual cost would be US$ 1.5–2.0 million.
The most salient finding from this study, however, is that policy-makers and programme managers should know and understand the target client population before deciding whether service integration is likely to be efficacious or cost-effective. The reproductive health needs of the target population should be the single most important factor underlying decisions to scale up integrated services. This study suggests that an integrated VCT programme targeting populations at risk for HIV or unintended pregnancy may be an effective programmatic option (Box 1). ■
Box 1. Lessons learned
- Family planning can be integrated into voluntary counselling and testing clinics.
- The incremental cost of integrating family planning is modest.
- Policy-makers and programme managers should know and understand the characteristics and reproductive health needs of target populations when making decisions about service integration.
We thank Chandrakant Ruparelia.
Funding: This study was funded by The David and Lucile Packard Foundation, The William and Flora Hewlett Foundation, and The Bill and Melinda Gates Institute for Population and Reproductive Health. The funders had no role in the design or conduct of the study.
Competing interests: None declared.
- 2008 world population data sheet. Washington, DC: Population Reference Bureau; 2008. Available from: http://www.prb.org/pdf08/08WPDS_Eng.pdf [accessed on 12 October 2009].
- Ethiopia Demographic and Health Survey 2005. Addis Ababa/Calverton, MD: Central Statistical Authority Ethiopia / ORC Macro; 2006.
- Epidemiological fact sheet on HIV and AIDS: core data on epidemiology and response – 2008 update (Ethiopia). Geneva: Joint United Nations Programme on HIV/AIDS/United Nations Children’s Fund/World Health Organization; 2008. Available from: http://www.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_ET.pdf [accessed on 12 October 2009].
- FY2008 country profile: Ethiopia. Washington, DC: The President’s Emergency Plan for AIDS Relief (PEPFAR); 2008. Available from: http://www.pepfar.gov/documents/organization/116219.pdf [accessed on 12 October 2009].
- Poate D, Balogun P, Attawell K. UNAIDS: second independent evaluation 2002-2008. Country visit to Ethiopia: summary report. Geneva: Joint United Nations Programme on HIV/AIDS; 2008. Available from: http://data.unaids.org/pub/BaseDocument/2009/20090502_sie_countrysummaryreport_ethiopia_en.pdf [accessed on 12 October 2009].