Liambila W, Askew I, Mwangi J, et al. Feasibility and effectiveness of integrating provider-initiated testing and counselling within family planning services in Kenya. AIDS. 2009 Nov;23 Suppl 1:S115-21.
To determine whether integrating onsite HIV counseling and testing (HCT) in family planning clinics can increase the uptake of testing and other HIV-related services
Public health-sector hospitals, health centers and dispensaries in two districts of central Kenya
Operational research design, with pre- and post-comparison of two different intervention models
Family-planning providers and their clients
Two districts were purposively sampled in central Kenya. Nine facilities from one district (2.4% HIV prevalence and primarily rural) that had few stand-alone HIV testing clinics were assigned to the "on-site testing" arm. In another district (10% HIV prevalence and peri-urban/urban) in which standing HIV testing clinics were widely available, 14 facilities were assigned to the "referral" arm. All facilities needed to have a minimum of 100 family planning clients per month and at least two providers. All family planning providers were trained in how to discuss sexually transmitted infection (STI) and HIV transmission and prevention, conduct a risk assessment, discuss dual protection, and offer opportunities for HCT.(1, 2) The evaluation period was 10 months in 2006-2007.
In the referral model, interested clients were referred to an HCT clinic, on site or elsewhere. In the testing model, providers were trained in providing HCT directly, using a rapid testing algorithm. There were 47 providers trained in the referral model and 28 in the testing model. District health management teams were supported to ensure commodity supply chains, logistics, and recordkeeping. A trained nurse observed provider interactions with clients using a structured checklist to record quality of care. On exit, clients completed an interviewer-administered structured questionnaire. Focus group discussions were held with providers and clients to assess acceptability of the intervention.
A total of 538 clients were evaluated pre-intervention and 520 post-intervention. Of these, 13% and 19%, respectively, were new visits, meaning that they were obtaining family planning services for the first time; the remainder was re-visits. Using a composite index of 26 indicators (range 0-26), the quality of care increased from a mean score of 9.7 to 15.8 per client. Median consultation time increased by two to three minutes in the referral and testing arms. For those who consented to HIV testing by the family planning provider, the median consultation time (including performing the test and post-test counseling) increased from seven minutes to 10-17 minutes. Improvement in counseling about HIV/STIs was observed (five items, range 0-5), from a score of 1.24 to 1.68 in the testing model and from a score of 0.83 to 2.46 in the referral model. In post-intervention, however, only 16% of providers in both districts discussed numbers of sexual partners, 28% discussed client history of STIs, 28% told clients that STIs increase the risk of HIV, and 62% discussed risk factors generally. Provider discussion of condom use improved from a score of 0.51 to 2.88 in the referral model and from 0.8 to 1.7 in the testing model, although in post-intervention in either arm, the proportion of providers discussing condom use was around 50%. Post-intervention, 74% of providers in the testing arm offered new clients a test and 56% offered revisit clients a test. In the referral arm, only 34% of new and 27% of revisit clients were referred. In both arms, the proportion of clients who eventually tested (35%) or who were referred (20%) was low.
The authors conclude that provider-initiated testing and counseling is feasible and acceptable in family planning services, does not appear to reduce the quality of the services, and can increase access to HIV testing in areas where stand-alone testing is not readily available.
This study was of good quality. The conclusions were limited by the nature of the study design, which was non-randomized with purposeful selection of districts and significant differences in characteristics of the study arms. These differences are likely to affect client responses. It would have been helpful to see analyses that evaluated offers for or referrals by those who had been tested previously, which might help explain low uptake of HIV testing.
Both the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have promoted testing and counseling in health facilities, including family planning clinics.(3) However, few data are available on the feasibility and utility of integrating services within family planning,(4) and concerns have been raised about whether integrated services might adversely affect the quality of family planning services. Kenya has moved forward with setting guidelines and recommendations for bi-directional linkages.(5, 6, 7)
Equipping family planning providers and facilities with the ability to offer onsite HIV testing seems a reasonable approach to improve uptake of testing, and there appears to be no reason why it should not be attempted when alternative HIV testing sites are not available. What this study could not evaluate is whether integrated services within family planning sites are better or equal to referral for HIV testing. There was no follow-up of referred clients, so whether these clients went to HIV testing sites is not known. Programs that are working with family planning clinics to improve referral must be aware that one of the main concerns is that clients do not follow up. The proportion of providers who discussed dual protection, condom use, or risk factors, or who referred clients for HIV testing was surprisingly low. Program managers should be aware that even if training, supplies, and district support are supplied, provider competencies might not be adequate. It is particularly concerning because the length of client visits was short, although the total number of clients seen per month per provider was modest.
- Ministry of Health. Integrating counseling and testing for HIV within family planning services, participants manual. 1st ed. Nairobi, Kenya; 2008.
- Ministry of Health. Integrating counseling and testing for HIV into family planning services, national training manual. 1st ed. Nairobi, Kenya; 2008.
- World Health Organization (WHO)/Joint United Nations Programme on HIV/AIDS (UNAIDS). Guidance on Provider Initiated HIV Testing and Counselling in Health Facilities. Geneva: WHO/UNAIDS; 2007.
- UNAIDS Reference Group on HIV and Human Rights. Seventh Meeting Issue Paper: provider-initiated testing and counseling in health facilities; 12-14 February 2007.
- Ministry of Health. The National Health Sector Strategic Plan 2005 - 2010. Nairobi: Ministry of Health; 2004. Abstract not available.
- Ministry of Health. National Reproductive Health Policy: Enhancing reproductive health status for all Kenyans. Nairobi: Ministry of Health; 2007. Abstract not available.
- Ministry of Health. National Reproductive Health and HIV/AIDS Integration Strategy. National AIDS and STI Control Program (NASCOP) and the Division of Reproductive Health (DRH); Nairobi, Kenya; August 2009. Abstract not available.