The 1994 International Conference on Population and Development (ICPD) was a watershed in the family planning community. In the years leading up to the conference, it became clear that fertility rates in many developing countries were falling faster and farther than had been expected, and policymakers were beginning to shift the emphasis of programs from controlling fertility to improving women's reproductive health. However, the rapid spread of HIV presented a major challenge to this goal, especially in countries with limited health infrastructure and financial resources. The high incidence of sexually transmitted infections (STIs) further complicated the problem, because evidence was mounting that the risk of HIV transmission and acquisition is elevated in persons with certain STIs. The groups most likely to acquire and transmit HIV--sex workers, men and sexually active adolescents--are also the most difficult groups to reach with prevention programs. With no cure or vaccine on the horizon, what could be done? The recommendation that emerged from the deliberations at ICPD was to provide a comprehensive package of reproductive health services--including prevention of HIV and prevention, diagnosis and management of other STIs--to women through existing maternal and child health and family planning programs.
With support from international donors, national programs and nongovernmental organizations in numerous countries moved to integrate STI and HIV services into antenatal and family planning programs. These efforts, however, have raised many questions about the feasibility and efficacy of service integration that remain unanswered eight years after ICPD. The editors of International Family Planning Perspectives have therefore asked a group of international experts to address these critical questions in our second Issues in Perspective.
To Integrate or Not to Integrate?
In her overview of integration policy developments, Louisiana Lush notes that control of HIV and STIs seems a natural fit with reproductive health, because both types of services deal with issues arising from sexual intercourse and are provided at the primary care level of health systems [see article]. She points out, however, that although maternal and child health and family planning services consist of simple, cost-effective measures that have been provided to childbearing women for many years, HIV and STI control activities are sensitive, involve other population groups and have unconfirmed effectiveness and costs, especially for women.
A literature review by Ian Askew and Ndugga Baker Maggwa [see article] expands on this issue by examining the findings of research on integrated services. The authors find little evidence that integration of either STI prevention or control into family planning or antenatal services is feasible or effective. They suggest, first, a reorientation of routine consultations toward protection against the dual risks of infection and unwanted pregnancy, and involvement of clients in deciding how best to protect themselves. Second, they recommend the implementation of strategies to reach male partners and to improve access to services for adolescents.
Two articles look at dual-protection initiatives in Sub-Saharan Africa. According to Lawrence Adeokun and colleagues, who report on the addition of dual-protection counseling and female condom promotion to family planning services in Ibadan, Nigeria [see article], integration of these activities is feasible, but interventions need to reach male partners as well to have a strong impact. The second study, however, raises questions about how well clinic clients retain information on STI/HIV prevention given them in consultations [page 96]. Davy Chikamata and colleagues, who analyzed data from a 1998 situation analysis of public family planning clinics in Lusaka, Zambia, found that less-educated clients are less likely to retain such information and suggest that providers need to make special efforts to ensure that these clients are processing the information.
Taking the commonsense view that service integration is not appropriate in all circumstances, Karen Foreit and colleagues provide a framework that specifies the minimum requirements for the delivery of each component of family planning, STI/HIV prevention and STI diagnosis and treatment services [page 105]. By using this framework, family planning programs can determine which, if any, STI services it is feasible to add in their particular setting. In contrast to this broad view, John and Pat Caldwell focus on the cultural appropriateness of integration for Sub-Saharan Africa [page 108]. Arguing that the region's family planning and AIDS prevention programs are not integrable because they have different structures, motivations and histories, and employ different kinds of staff, they offer instead messages for an effective African campaign against HIV and AIDS. Finally, Meiwita Budiharsana reports on integration of STI detection and management services into family planning settings in Indonesia, concluding that the addition of such services is feasible but will need time for the reorientation and training of providers [see article].
No Easy Answers
The debate over integration of services is unlikely to end soon; as these articles make clear, there are no easy answers. Clinics that decide to add STI- and HIV-related services will need to consider carefully which ones are feasible for their facility and their clientele. As Louisiana Lush concludes, "Patterns of integration...depend on local situations. A single blueprint is unlikely to be appropriate." We hope, however, that by bringing together this diverse collection of research findings, observations and expert opinions, we have helped both to define the questions and to begin the process of answering them.