Feasibility, Acceptability, Effect and Cost of Integrating Counseling and Testing for HIV within Family Planning Services in Kenya

This study was made to obtain evidence on the effectiveness expanding HIV and AIDS counseling and testing (C&T) opportunities within the context of family planning (FP) services in Kenya. The study 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 and Family Health International Frontiers programme and the National Department of Health (DOH), Kenya, Division of Reproductive Health (DRH) and the National AIDS and STI [sexually transmitted infection] Control Program (NASCOP), Division of Reproductive Health, and Provincial and District Teams.

This integration strategy required the reorientation of FP services to not only integrate C&T but also to strengthen education and screening on  STIs risks and information on dual protection. "Introduction and implementation involved: (a) holding sensitisation meetings at national, provincial and district levels; (b) reviewing and developing training materials; (c) application of the Balanced Counseling Strategy (BCS) Plus approach; (d) modification of facility registers to record the required data; and (e) training of health providers. The MOH provided all required equipment and supplies, including HIV rapid test kits and FP commodities."

The testing model and the referral model both educated FP clients about HIV prevention generally, and CT in particular. The testing model offered HIV C&T during this consultation by the FP provider. The referral model referred clients to a specialised C&T service, either within the same facility or to another C&T service (at another health facility or a stand-alone C&T centre). As stated here, "The study demonstrated that both models were feasible and acceptable to providers and to clients as means of integrating and linking HIV prevention counseling, condom promotion and counseling and testing with FP services, and are effective in increasing quality of care and service utilization."

The BCS-Plus toolkit, from a version adapted in South Africa and then revised by trainers in Kenya, consists of:

1. an algorithm to guide the provider through a semi-structured consultation in three stages: pre-choice; method choice; and post-choice;
   
2. a set of method-specific cards to facilitate counseling - The first card contains six questions that the service provider will ask to rule out if a client is pregnant. The 13 method-specific cards are used to help narrow down choice of the appropriate method for the client. Each method card has an illustration of the method on the front side of the card. The backside of the card contains a description of several basic attributes or characteristics of the method; and
   
3. brochures to be taken away by the client that describe the chosen method in detail.

National policies, guidelines, and training manuals relevant to HIV testing and family planning were reviewed and 3 sets of new materials were developed: a trainers' manual; a trainees' manual; and a national protocol. All topics in the training manuals were prepared as PowerPoint presentations to standardise the training package for future use during scale-up.

Seventy-five health providers were trained at a residential training of five days for the referral model and nine days for the testing model, which included an additional four days for training in HIV C&T and conducting and interpreting rapid HIV tests. Participants developed implementation action plans. Planning for and procurement of key supplies were undertaken with district-level mechanisms for sourcing, storage, distribution and replenishment of supplies. Routine data collection on FP and volunary counselling and testing (VCT) services was strengthened. To better understand patterns of VCT utilisation, clients in both models were given a set of VCT vouchers during their FP visit. The vouchers had two parts; the front part contained information about the referring institution, while the back side contained information about the receiving institution - date of test, name of testing health facility, whether the test was performed by FP provider or not, whether client received results or not, sex of the client, and age in complete years. Once completed, the voucher was handed over to the midwife in charge of the FP clinic who then filed it. Information on the number of vouchers received was then compiled on monthly basis. Specific sites were studied with pre-post intervention research without a control group, through facility assessments, focus group discussions with FP providers and with FP clients, observations of provider-client interactions, and client exit interviews, as well as a cost analysis.

Specific findings showed that:

• "Integrating counseling and testing for HIV into FP services is feasible and acceptable: ...Provision of both services jointly was perceived by clients to be beneficial and attractive and was welcomed by providers as an opportunity to provide a comprehensive service that better meets their clients’ needs....
  
• Quality of family planning counseling improved: Significant improvements were observed in the quality of FP counseling and in the rapport established with clients in both models. Discussion of reproductive intentions remained a weakness however.
  
• Quality of counseling on STI/HIV issues improved: ...After introduction of the BCS Plus approach, there were marked increases in discussions about STIs and HIV/AIDS generally and about the risk factors, but discussions of the clients’ personal sexual history and behaviors remained low.
  
• Counseling on condoms and dual protection and their use improved: ...Training and use of the BCS-Plus significantly increased discussions around condoms and their use...
  
• Counseling on HIV CT increased during FP consultations: [39 percent overall at baseline to 88 percent of all consultations at endline] Discussions of the client serostatus increased from 24 to 81 percent of consultations.
  
• Clients’ offered and obtaining HIV CT increased.
  
• Incremental costs for integrating CT into FP services are affordable."

Recommendations include the following:

• Ensuring that national-, provincial-, and district-level managers and trainers lead training activities builds capacity for introducing new service delivery protocols.
  
• District and facility action plans can ensure resource mobilisation and secure commitment to provide integrated services.
  
• The BCS-Plus approach and tools can enhance client services.
  
• On-the-job updates by MOH trainers rapidly expanded the number of health providers able to provide HIV C&T for FP clients, but for sustainability the existing FP service delivery protocols need to be reviewed and revised to integrate the HIV service procedures. FP and HIV C&T commodities need to be continuously available.
  
• Both models are effective in increasing the number of women being tested for HIV, both for the first time and for a repeat test.
  
• Clinics that can offer HIV testing on-site should also consider offering clients the option of being referred elsewhere for the test, given the evidence suggesting that anonymity is important for these FP clients who may meet the same provider on several occasions.