Global Forum on MTP for Reproductive Health: Involving end users and providers. MBATIA Redempta ICAP, Columbia University 11 th -12 th Jan 2012

Transcription

1 Global Forum on MTP for Reproductive Health: Involving end users and providers MBATIA Redempta ICAP, Columbia University 11 th -12 th Jan 2012

2 Background Rationale for having Multiple Prevention Technologies (MTP) In less developed countries modern contraceptive methods are used by only 43% of women of reproductive age overall. A wide gap is seen between the highest and lowest wealth quintiles 52% versus 35%, respectively. (Source Creanga et al 2011) Modern contraceptive use in Tanzania for all women of reproductive age is 24%(DHS 2010) Same countries with a high burden of HIV and STI Additionally high MMR and IMR partly due to unwanted/unplanned pregnancies INTERGRATION of services is cost effective and sustainable

3 Unmet Family Planning need among PLHIV Experiences from Prevention in Care and Treatment Settings (PiCTS) study intervention package (Bachanas et al 2011) A group randomized intervention trial assessing integrated HIV prevention at 18 HIV clinics in Kenya, Namibia, Tanzania (6 per country) Eligible participants <50 years N=3,475 (men 1,483,women 1,992) living with HIV, sexually active, attending care and treatment (not couples, not pregnant)

4 PiCTS study intervention package HEALTH CARE PROVIDERS 1. Give basic prevention recommendations: disclosure, partner testing, safer sex, and alcohol reduction 2. Assess and support adherence 3. Provide family planning and safer pregnancy counseling 4. Assess and treat STI symptoms 5. Distribute condoms Refer for behavioral prevention counseling, positive living, adherence, and alcohol reduction Refer for provision of family planning, pregnancy advice and STI management LAY COUNSELORS 1. Conduct Group Education Basic Education on HIV/AIDS Protecting Your Partner Protecting Your Children Treatment Adherence Positive Living 2. Provide Individual Counseling 3. Provide HIV Counseling and Testing, where permitted Individuals (both walk-in and partner(s) of clinic patients) Couples (concordant and discordant)

5 Number and proportion of men and women who report a health care provider talked to them about family planning in the HIV clinic 70% 60% 50% 68% 46% of women compared to 28% of men, overall countries, talked to a provider about FP; gender differences in all countries were statistically significant 40% 30% 20% 10% 41% 40% 23% 32% 21% 0% -10% women men women men women men Kenya Namibia Tanzania

6 women men women men women men women men 100% 90% 80% 70% 60% Unmet need for FP and dual protection among respondents not desiring pregnancy 30% 23% 44% 17% 14% 11% 30% 18% 14% 7% Unmet need for dual method -- below the green bars 50% 44% 40% 30% 20% 10% 0% 67% 47% 42% 6% 4% 80% 25% 70% 44% 73% cdm + hi effect (dual) hi effect only condom only other/natural only no FP method Kenya Namibia Tanzania Overall

7 Key messages from PiCTs baseline data analysis High levels of condom (male and female) use were reported and high unmet need for dual method was observed. HIV-positive clients may over-report condom use. If so, actual unmet need for FP is severely under-estimated. Over-reported condom use may be a barrier to identification of unmet need for effective pregnancy prevention.

8 Multiple Prevention Technologies- Users and Providers Perspectives Key dimensions of product acceptability from the point of view Health Providers: Need to build capacity to understanding rationale, need for prevention,advantages, side effects of MTPs at all service units(rch, HIV/STI/TB clinics). However cautious staff shortage (nurse midwifes) use more on job trainings. Possibility to be done by less skilled providers Community based distribution agents/lay Counselors, Ensure appropriate skill in counseling of the providers (IUCD) Men and Communities: Key decision makers -must be engaged and understand rationale, advantages, costs and undesirable effects of new products

9 Users and Providers Perspectives..2 Women: Understanding by users of the interrelationship between HIV, Family Planning, Sexually Transmitted Infections, TB and multiple benefits, side effects, interference with sex, decisive power, acceptability (female condom- too noisy, somehow unpopular) adherence to method, affordability In HIV and RH clinics target couples for combined counseling, pregnancy planning, family planning method selection, HIV prevention to enhance adherence

10 Community perspective Effort must be spent in engaging communities (as individuals and in groups) considering gender/age during development with awareness creation as well as during distribution to enhance acceptability Need to get inputs on any anticipated product with transparent discussions, clear definitions of benefits and risks, alternative methodologies Address myths/suspicions/gossips of communities facing new RH technologies by involving local leaders See this as the first step before spending much money in marketing Successful TZ programs have all been community based e.g. IMCI, Immunization

11 MPT-Timing to involve users and providers When in product development? Throughout from the beginning and at every stage(as above) What should be the optimal timing of involving providers? -Typically RH services are delivered by nurses but decisions are being made by managers at ministries of health mostly doctors. The two need to be brought together with constructive ways on reviewing and testing new methods. Doctors may be?deferring too much RH service delivery to nurses, not conducive for integration in STI and TB clinics. Hence ONGOING INVOLVEMENT! Also consider lessons leant from PEPFAR to avoid staff drainage into vertical programs. -Need for policy change to institutionalize lay providers (PiCTS study experience)

12 Lessons from the introduction of other Sexual Reproductive Health products: Need to develop user-friendly products Ensure providers are skilled to empower users with basic understanding of products, rationale, their side effects Engagement of users from beginning [e.g. how much were users involved in female condom development? Starting from bottom up may have taken much longer but may have led to more utilization?] Integration of FP services to existing services HIV/STI/RCH/TB clinics ; avoiding vertical interventions Use both community based and facility based approaches in introducing new products

13 Lessons from the introduction of other SRH products Availability of appropriate and culturally sensitive IEC materials at every point of service to complement knowledge and understanding Reliable product supply chain system Need to assess use consistently at every contact with provider to ensure appropriate use and address barriers early enough Ability for women to use without knowledge/approval of partners an advantage due to gender dynamics

14 Successful introduction of an MPT and impact measurement Impact to be measured at both community and facility level through routine M&E assessment of target populations and evaluate provider perspectives Using interim feedback from communities during early implementation??using impact indicators e.g. fertility; PMTCT effect i.e. infections averted, unwanted pregnancies

15 Possible programmatic challenges to scale up MTP use Integration of HIV prevention as a routine service; alcohol use and disclosure have direct effect on acceptability. Difficulty to get health providers to adapt this approach. Concordant HIV + couples may respond differently to dual MTPs compared to discordant couples Make process of using product not too complicated Inappropriate use of product due to ignorance, lack of understanding. Need to provide constant supportive supervision

16 ACKNOWLEDGEMENTS Wellcome Trust Initiative for Multipurpose Prevention Technologies (IMPT) ICAP Columbia University MOHSW Tanzania, CDC PiCTS study team PEPFAR