Integra Initiative

Four different models for delivering HIV services in existing SRH facilities were evaluated in Kenya, Swaziland, and Malawi in both IPPF and government facilities. Using a combination of routine service statistics and process analysis, clinic- and cohort-based quantitative and qualitative behavioural research, community surveys and economic analysis, this project assessed the benefits and costs of these different models for delivering HIV and SRH services.

The models of integration were as follows.

• Model 1: Integrated family planning model (Kenya) - Integration of HIV counselling and testing, sexually transmitted infection (STI) screening and management, cervical cancer screening, and condom promotion within family planning consultations, as well as active referral to antiretroviral therapy units for HIV-positive clients.
• Model 2: Integrated post-natal care model (Kenya and Swaziland) - Integration of family planning services, repeat HIV testing for mother, HIV testing for infant, and referral to HIV services for HIV-positive women with post-natal care for mother and infant.
• Model 3: Integrated SRH services (Kenya, Malawi, and Swaziland) - Includes family planning, maternal and child health services, HIV testing, HIV care, STI services, cervical cancer screening, and services for youth.
• Model 4: Comparison of integrated and stand-alone HIV service models (Swaziland) - Comparison of facilities offering fully integrated SRH/HIV services with facilities offering stand-alone HIV services.

According to the Integra Initiative, the evaluation approach adopted by the Integra initiative was grounded in a kind of implementation science – "programme science" – which applies the strengths of a rigorous scientific approach to a 'real world' setting, as far as is possible. The methods of evaluation have varied by country. For example, some sites used a series of health facility assessments (using client provider observations, client, and provider interviews, and facility inventories) to measure changes in quality of – and stigma associated with – SRH and HIV care. Others used a cohort study of clients attending clinics offering integrated and non-integrated services to compare their use of services, SRH/HIV-related behaviours and health status over a 25-month period. There was also before and after surveys and qualitative research to measure perceptions and use of SRH and HIV services among community members served by clinics offering integrated and non-integrated services. As well, some study sites used a full economic evaluation to determine the unit costs of service delivery and the economic costs for service users, designed to enable a cost effectiveness comparison between integrated and non-integrated models.

The study is built around three sets of research questions:

• What are the relative benefits of different models of integrated SRH and HIV services over separately provided services? Does integration lead to: increases in the numbers of clients using services; changes in the profile of clients; increases in the range of services accessed; improvements in the quality of services?
• In the target populations, what is the impact of integrated services on: HIV-related risk behaviour; HIV-related stigma; unintended pregnancy?
• What is the cost, feasibility and cost-effectiveness of providing selected integrated services, including: costs of integrating HIV and/or SRH services with existing services; variations in costs by model of integration; utilisation of existing infrastructure and human resources?

Findings and research outputs can be found on the Integra website.

Sexual and Reproductive Health, HIV