Benefits and Costs of Integrating Sexual-Reproductive Health and HIV Services in Kenya and Swaziland
Condition: Pregnancy; HIV
Study type: Interventional

Summary: 
      The overarching aim of the Integra Initiative is to strengthen the evidence base on the
      impact of integrating family planning (FP), postnatal care (PNC) and HIV services in
      sub-Saharan Africa. Specifically, in the study the investigators aim to test the following
      hypotheses:

      the provision of integrated services, compared to separate services, will:

        1. lead to increased uptake of a range of SRH services .

        2. attract a greater number and diversity of clients.

        3. lead to increased quality of a range of SRH services

        4. lead to healthier sexual and reproductive behavior.

        5. lead to reduced stigma at health facilities.

        6. lead to the more efficient use of resources, with a lower unit cost of provision of key
           services.

      For the purposes of this study integration is defined as offering clients both HIV and
      postnatal care (PNC) or HIV and family planning (FP) services in the same visit.

      To better understand how services can be integrated in different countries this study focuses
      on two key models of integration in Kenya and Swaziland.

        -  The first model focuses on integration of FP and HIV services (integrated FP model) and
           entails performing HIV testing, STI screening and management, cervical cancer screening,
           condom promotion within FP consultations, as well as active referral to antiretroviral
           (ART) units for HIV-positive clients. The FP model will be evaluated in Kenya only.

        -  The second model focuses on integration of PNC and HIV services (integrated PNC model)
           and will be implemented in both Kenya and Swaziland. The model focuses on the provision
           of PNC services to mother and baby, FP services, repeat HIV testing for mother, HIV
           testing for infant and referral to HIV services for HIV positive mothers and infants, as
           well as referrals for clients requiring other additional services.
    

Detailed description: 
      There are many well-established reasons that support the rationale for integrating or linking
      sexual and reproductive health (SRH) and HIV services in developing countries with
      generalized HIV epidemics - primarily in sub-Saharan Africa. Yet the evidence base for the
      impact of integrated service delivery on health outcomes and costs remains weak. Partly this
      is a result of methodological difficulties.

      There is an emerging body of literature addressing the challenges of using randomized
      controlled trials to assess the impact of public health interventions. Particularly in cases
      such as the Integra Initiative, where the causal chain (between intervention and outcome) is
      long, and where there are is a broad range of outcomes that need to be explored, and where
      there is already some a degree of integration occurring in some clinic settings, attempting
      to conduct a randomized controlled trial is not appropriate. Consistent with evaluation
      designs described by Habicht and colleagues, the Integra design includes evaluation of
      performance and impact to try to make two types of causal inference: adequacy and
      plausibility.

      Evaluation of adequacy will assess whether the expected changes in provision, service
      utilisation and cost-effectiveness have occurred in intervention facilities. Evaluation of
      impact will assess the plausibility that changes in service, health and behavioral outcomes
      are due to the Integra Initiative. The case for such plausibility will be built from the
      following strands of evidence:

        -  Comparing findings in 'intervention' facilities with those in facilities chosen as
           'comparison' sites prior to the evaluation

        -  Exploring a dose-response relationship between the measured extent of integration and
           the study outcomes

        -  Measuring changes in performance over time, to demonstrate a logical sequence between
           the intervention (integration) and outcomes.

        -  Measuring change in each step of the logic model - a prerequisite for any attribution to
           the intervention

        -  Triangulating findings from a mix of research methods to capture a range of perspectives
           and insights from different disciplines.

      The study will employ a controlled pre- and post-test quasi-experimental, or non-randomised,
      design and utilises multiple research methods (cohort study, community survey, clinic
      assessments, costing tools and qualitative interviews). Since the research is being conducted
      in real-life health delivery settings where programmatic contamination is possible due to
      ongoing health programme interventions over the study period, the control group will be
      referred to as a 'comparison group', for which outcomes will be compared over time up to two
      years after implementation.
    

Intervention name(s): Integrated FP/PNC service delivery
Intervention type(s): Procedure
Intervention description(s): The intervention uses a procedural tool building on existing MoH procedures. It has nine components: strengthening protocols, guidelines and training materials for integrated HIV-SRH care; training, mentorship; developing a mentoring and supervisory package; improving provider capacity; ensuring availability of minimum levels of equipment and supplies for integrated services; support supervision; organizational change (including reviewing use of available rooms) and role clarification; improving availability of IEC/BCC materials on FP and HIV; strengthening the referral system between FP and ART and the data collection and recording systems.
Other intervention name(s): BCS+
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: quasi experimental; evaluation; intervention; service integration; cost analysis; HIV; FP; PNC; Sub-Saharan Africa