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C-Channel Issue 17

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C-Channel header  February 2010

Dear Colleagues,

C-Channel 17 highlights family planning and reproductive health. Seven articles look at issues around family planning including unmet need, contraceptive use, and the importance of male involvement in family planning. Two other articles explore the integration of family planning and HIV. The final two articles focus on HIV prevention. Research covered in these articles was carried out in Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, Tanzania, Uganda, Zimbabwe, India, Philippines, Turkey, and Honduras.

C-Change hosted the Democratic Republic of Congo’s (DRC) National Conference to Reposition Family Planning in Kinshasa in December 2009. USAID and UNFPA sponsored the conference in cooperation with DRC’s Ministry of Health and other donor agencies. First Lady Mme. Marie Olive Lembe Kabila officially launched the conference, which marked a recommitment to family planning (FP) efforts by the DRC and others. According to the 2007 DHS, unmet need for family planning in the DRC is more than 24%. See the C-Change website for additional information about its family planning activities in the DRC and the main outcomes of the conference.

Thank you,
The Knowledge Management Team at C-Change


C-Channel, the e-newsletter from the C-Change project, features peer reviewed research on SBCC and HIV and AIDS, family planning/reproductive health, malaria prevention, and gender issues.
To view archived issues, visit www.c-changeprogram.org/c-channel


FAMILY PLANNING/REPRODUCTIVE HEALTH

1. Stall in fertility decline in Eastern African countries: Regional analysis of patterns, determinants and implications
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2. Demand and unmet need for means of family limitation in Rwanda

3. Unmet family planning need: differences and levels of agreement between husband-wife, Haryana, India
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4. Inconsistent fertility motivations and contraceptive use behaviors among women in Honduras
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5. The influence of local policy on contraceptive provision and use in three locales in the Philippines

6. Post abortion family planning counseling as a tool to increase contraception use
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7. Male involvement in family planning: women's perception

FAMILY PLANNING AND HIV

8. Integrating family planning into Ethiopian voluntary testing and counselling programmes
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9. The contribution of family planning towards the prevention of vertical HIV transmission in Uganda
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HIV PREVENTION

10. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases

11. Integration of HIV/AIDS services into African primary health care: Lessons learned for health system strengthening in Mozambique -- a case study
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OTHER RESOURCES

Straight Talk Foundation: Youth Radio for Better Adolescent Reproductive Health in Kisoro, Uganda: Final Activity Report & Impact Evaluation

This report details a program in Kisoro district of southwestern Uganda that used concepts of communication for social change to foster adolescent sexual and reproductive well-being. Activities included developing and broadcasting radio dramas and forming youth-oriented discussion clubs. The project resulted in statistically significant changes in knowledge and attitudes among young people about reproductive health issues and increased discussions between young people and parents, teachers and other adult stakeholders, such as health workers. Young people were given a voice on radio to talk about topics of critical importance to them, some of which had never been verbalized in the media. Click here to download the report.
[Main StraightTalk site: http://www.scribd.com/Straight%20Talk%20Foundation]
 


FAMILY PLANNING/REPRODUCTIVE HEALTH

1. Stall in fertility decline in Eastern African countries: Regional analysis of patterns, determinants and implications

Authors: Ezeh AC; Mberu BU; Emina JO
Institution: African Population and Health Research Center, Shelter Afrique Centre, Nairobi, Kenya
Source: Philosophical Transactions of The Royal Society of London: Biological Sciences 27 Oct 2009; 364(1532): 2991-3007. [PubMed]

ABSTRACT

We use data from the Demographic and Health Surveys to examine the patterns of stall in fertility decline in four Eastern African countries. Contrary to patterns of fertility transition in Africa that cut across various socio-economic and geographical groups within countries, we find strong selectivity of fertility stall across different groups and regions in all four countries. In both Kenya and Tanzania where fertility decline has stalled at the national level, it continued to decline among the most educated women and in some regions. While fertility has remained at pre-transition level in Uganda over the past 20 years, there are signs of decline with specific groups of women (especially the most educated, urban and those in the Eastern region) taking the lead. For Zimbabwe, although fertility has continued to decline at the national level, stall is observed among women with less than secondary education and those in some of the regions. We link these intra-country variations to differential changes in socio-economic variables, family planning programme environment and reproductive behaviour models. The results suggest that declines in contraceptive use, increases in unmet need for family planning, increasing preferences for larger families, and increases in adolescent fertility were consistently associated with stalls in subgroup fertility across all four countries. These results are consistent with models that emphasize the role of declines in national and international commitments to family planning programmes in the premature stall in sub-Saharan fertility transition.

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2. Demand and unmet need for means of family limitation in Rwanda

Authors: Ndaruhuye DM 1; Broekhuis A 2; Hooimeijer P 3
Institutions: 1 Department of Applied Statistics, National University of Rwanda, Butare, Rwanda; 2 Department of International Development Studies, Utrecht University, Utrecht, The Netherlands; 3 Department of Human Geography and Regional Planning, Utrecht University, Utrecht, The Netherlands
Source: International Perspectives on Sexual and Reproductive Health Sep 2009; 35(3): 122-30.

ABSTRACT

CONTEXT: Rwanda is the most densely populated country in Africa, with substantial annual population growth. The current government seeks new policies for family limitation as a way to facilitate more sustainable development.

METHODS: Data from the 2005 Rwanda Demographic and Health Survey were used for a two-step analysis; binary logistic regression was used to identify factors associated with desiring to stop childbearing and having unmet need.

RESULTS: Eighty-seven percent of women aged 15-49 approve of family planning, but only 64% believe that their partner approves of it. There is a high level of unmet need for family limitation; 58% of women who want to stop childbearing do not use modern contraceptives. Demand was lower among women who did not approve of family planning, those who did not know their partner's attitude toward family planning and those who had discussed family planning with their partner fewer than three times. Unmet need was higher among women who did not approve of family planning, those who believed their partner did not approve of family planning or who did not know his attitude, and those who had never discussed family planning with their partner or had done so only once or twice.

CONCLUSIONS: Negative attitudes toward family planning and failing structures of provision are the dominant constraints on the use of modern contraceptives in Rwanda. Community-based family planning services could greatly expand access, especially in underserved provinces.

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3. Unmet family planning need: differences and levels of agreement between husband-wife, Haryana, India
 

Authors: Yadav K; Singh B; Goswami K
Institution: Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
Source: Indian Journal of Community Medicine Jul 2009; 34(3): 188-91. [PubMed]

ABSTRACT

RESEARCH QUESTION: Is there agreement between husbands and wives regarding unmet need of family planning?

HYPOTHESIS: The unmet need of family planning is perceived more by women then their husbands.

OBJECTIVE: 1) To ascertain the unmet needs of family planning for husbands and wives. 2) To ascertain the level of agreement between husbands and wives regarding unmet needs of family planning.

DESIGN AND SETTING: A cross-sectional survey; Dayalpur village in Intensive field practice area of Comprehensive Rural Health Services project (CRHSP), Ballabgarh, Haryana.

STUDY PERIOD AND PARTICIPANTS: July 2003- June 2005; included 200 married couples selected by simple random sampling.

STATISTICAL ANALYSIS AND RESULTS: Level of agreement between husbands and wives was analyzed using Kappa statistics. Unmet need for family planning was 11% (22 out of 200) for husbands and 17.5% (35 out of 200) for wives. The difference was seen both in unmet need for spacing (M-3.5% vs. F-6%) as well as limiting family size (M-7.5% vs. F-11.5%). Overall, 93.5% concordance was observed amongst husbands and wives. In all the cases where disagreement was seen (6.5%), wives reported having unmet need for contraception whereas their husbands perceived none. The unadjusted Kappa statistic was 0.73 and prevalence adjusted Kappa was 0.88.

CONCLUSION: Unmet need for family planning was significantly higher for wives compared to husbands. Despite high degrees of agreement amongst the couples, the nature of disconcordance reinforces the need for policy makers to take into account the perspective of men.

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4. Inconsistent fertility motivations and contraceptive use behaviors among women in Honduras
 

Authors: Speizer IS 1,2; Irani L 1; Barden-O'Fallon J 2; Levy J 1,2
Institutions: 1 Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; 2 MEASURE Evaluation Project, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
Source: Reproductive Health 19 Nov 2009; 6:19. [BioMed Central]

ABSTRACT

BACKGROUND: Recent studies have demonstrated that it is common for women to report inconsistent fertility motivations and family planning behaviors. This study examines these inconsistencies among urban Honduran women interviewed at two points in time and presents reasons for inconsistent fertility motivations and contraceptive behaviors at follow-up.

METHODS: Data come from a one-year panel study conducted in Honduras from October 2006 to December 2007. A total of 633 women aged 15-44 years were interviewed at baseline and follow-up and have non-missing information on the key variables of interest. At baseline and follow-up, women were asked how much of a problem it would be (no problem/small problem/big problem) if they got pregnant in the next couple of weeks. At follow-up, women were asked an open-ended question on reasons it would be no problem, a small problem, or a big problem. The open-ended question was recoded into a smaller set of response categories. Univariate and bivariate analyses are presented to examine inconsistencies and reasons for stated inconsistencies.

RESULTS: At follow-up, over half the women using a contraceptive method said that it would be no problem if they got pregnant. Nearly half of the women changed their perceptions between baseline and follow-up. Common reasons for reporting no problem among contraceptive users were that they accepted a child as God's will or that children are a blessing, their last child was old enough and they wanted another child. Common reasons for reporting a big/small problem among non-users of family planning (who have an unmet need for family planning) were that they were not in a stable relationship, the husband was not present, and they would expect a negative response from their family.

CONCLUSION: Inconsistent fertility motivations and contraceptive behaviors are common among effective contraceptive users. Women who are using contraception and become pregnant will not necessarily report the pregnancy as unintended, given the widespread acceptance of unintended pregnancies in Honduras. Family planning providers need to recognize that fertility motivations vary over time and that women may not have firm motivations to avoid a pregnancy.

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5. The influence of local policy on contraceptive provision and use in three locales in the Philippines
 

Authors: Lee RB; Nacionales LP; Pedroso L
Institutions: a Department of Global Health and Epidemiology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan; b Population Commission, Welfareville Compound, Acacia Lane, Mandaluyong City, Philippines; c Population and Development Strategy Programme, Population Commission, Welfareville Compound, Acacia Lane, Mandaluyong City, Philippines
Source: Reproductive Health Matters Nov 2009; 17(34): 99-107.

ABSTRACT

The Philippines has a family planning programme, but modern contraceptive prevalence has been moderate. Among low-income women, fewer are using modern methods, resulting in a fertility rate among them of 5.9. This limited use is due to lack of consistent national and local government support for modern methods because of religious opposition. Following devolution of responsibility for health services to local government in 1991, three local leaders - in Laguna Province and the cities of Manila and Puerto Princesa - passed anti-modern contraceptive policies. This paper analyses the status and impact of these policies, using information from interviews with local government officials and family planning officers, published data and studies, and accounts in national newspapers. In Laguna Province and Puerto Princesa, the policies were ineffectually implemented or short-lived. The strictly-enforced Manila law, however, has severely disrupted the city's provision of free contraception to and method use by low-income women. The great majority of Filipinos (89%) approve of modern contraceptives. There is an urgent need to improve low-income women's access to modern contraceptives through itinerant and community-based distribution, especially in poor neighbourhoods in Manila, but also throughout the country. Strategies for increasing local government support for and provision of modern methods are also needed.

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6. Post abortion family planning counseling as a tool to increase contraception use 

Authors: Ceylan A 1; Ertem M 1; Saka G 1; Akdeniz N 2
nstitutions: 1 Department of Public Health, Medical Faculty of Dicle University, Diyarbakir, Turkey; 2 Department of Obstetrics and Gynecology, Medical Faculty of Dicle University, Diyarbakir, Turkey
Source: BMC Public Health 15 Jan 2009; 9:20.

ABSTRACT

BACKGROUND: To describe the impact of the post-abortion family planning counseling in bringing about the contraceptive usage in women who had induced abortion in a family planning clinic.

METHOD: The Diyarbakir Office of Turkish Family Planning Association (DTFPA) is a nonprofit and nongovernmental organization which runs a family planning clinic to serve the lower socio-economic populations, in Diyarbakir-Turkey. Post abortion counseling is introduced by using proper communication skills and with using appropriate methods to women. In this study we introduced contraceptive usage of women who had induced abortion one year ago and followed by DTFPA's clinic.

RESULTS: 55.3% of our clients were not using contraceptive methods before abortion. At the end of the one year, 75.9% of our followed-up clients revealed that they were using one of the modern contraceptive methods. There was no woman with IUD before induced abortion. At the end of one year 124 (52.3%) women had IUD. "A modern method was introduced immediately after abortion" was the most important factor increasing modern method usage.

CONCLUSION: Our results advocate that post-abortion counseling may be an effective tool to increase the usage of contraceptives. Improved and more qualified post-abortion family planning counseling should be an integral part of abortion services.

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7. Male involvement in family planning: women's perception
 

Authors: Nte AR; Odu N; Enyindah CE
nstitution: Department of Paediatrics/Child Health College of Health Sciences, University of Port Harcourt, Port Harcourt, Nigeria
Source: Nigerian Journal of Clinical Practice Sep 2009; 12(3): 306-10. [African Journals OnLine]

ABSTRACT

OBJECTIVES: To assess the knowledge of mothers of under-five children brought to immunisation centres of contraceptive methods applicable by males and their perceptions of the roles of males in family planning.

SUBJECTS AND METHODS: This cross-sectional descriptive study involved a questionnaire interview of mothers who came to immunise their children at five public immunisation centres in Port Harcourt. Data entry and analysis employed EPI-Info version 6.

RESULTS: Amongst the 558 mothers interviewed, the contraceptive prevalence rate was 5.6% and 85.6% of them knew at least a family planning method for males. About 15.8% would depend on their spouses for choice of contraceptive methods and 52.7% would discontinue family planning if their spouses objected. About 33.5% of the spouses had used some form of contraception while only 22.1% of the females recognised that male involvement could impact on the acceptance rate of family planning services. Despite their knowledge of safe child spacing, about 53% of the respondents delivered within shorter intervals and had significantly more pregnancies/children that they would have had if they were in 'control' of their reproductive health decisions. The spouses, despite being significantly older, more educated, with higher level jobs, and in-charge of the reproductive health decision in the home, did not contribute to the knowledge of the women and their practices of family planning.

CONCLUSION: Despite the advantaged position of males in family matters, their roles in family planning remains largely unutilised. If the acceptance of family planning must improve, males should also be targeted by family planning programmes.

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FAMILY PLANNING AND HIV

8. Integrating family planning into Ethiopian voluntary testing and counselling programmes  

Authors: Gillespie D a; Bradley H a; Woldegiorgis M b; Kidanu A c; Karklins S a
Institutions: a The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; b Pathfinder International, Addis Ababa, Ethiopia; c Miz-Hasab Research Center, Addis Ababa, Ethiopia
Source Bulletin of the World Health Organization Nov 2009; 87(11): 866-70.

ABSTRACT

PROBLEM: Governments and donors encourage the integration of family planning into voluntary testing and counselling (VCT) services. We aimed to determine if clients of VCT services have a need for and will accept quality family planning services.

APPROACH: 'Voluntary HIV counselling and testing integrated with contraceptive services' is a proof-of-concept study that interviewed 4019 VCT clients before the addition of family planning services and 4027 different clients after family planning services were introduced. Clients attended eight public VCT facilities in the Oromia region, Ethiopia. The intervention had four components: development of family planning counselling messages for VCT clients, VCT provider training, contraceptive supply provision and monitoring.

LOCAL SETTING: Ethiopia's population of 80 million is increasing rapidly at an annual rate of 2.5%. Contraceptive prevalence is only 15%. The estimated adult HIV prevalence rate is 2.1%, with more than 1.1 million people infected. The number of VCT facilities increased from 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled from 1.7 million tests in 2007 to 3.5 million in 2008.

RELEVANT CHANGES: Clients interviewed after the introduction of family planning services received significantly more family planning counselling and accepted significantly more contraceptives than those clients served before the intervention. However, three-quarters of the clients were not sexually active. Of those clients who were sexually active, 70% were using contraceptives.

LESSONS LEARNED: The study demonstrated that family planning can be integrated into VCT clinics. However, policy-makers and programme managers should carefully consider the characteristics and reproductive health needs of target populations when making decisions about service integration.

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9. The contribution of family planning towards the prevention of vertical HIV transmission in Uganda
 

Authors: Hladik W 1; Stover J 2; Esiru G 3; Harper M 4; Tappero J 1
Institutions: 1 Global AIDS Program, National Center for HIV, Hepatitis, STD & TB Prevention, Centers for Disease Control and Prevention (CDC), Entebbe, Uganda; 2 Futures Institute, Glastonbury, CT; 3 AIDS Control Programme, Ministry of Health, Kampala, Uganda; 4 UNAIDS, Kampala, Uganda
Source: PLoS One 2 Nov 2009; 4(11): e7691.

ABSTRACT

BACKGROUND: Uganda has one of the highest total fertility rates (TFR) worldwide. We compared the effects of antiretroviral (ARV) prophylaxis for the prevention of mother-to-child HIV transmission (PMTCT) to that of existing family planning (FP) use and estimated the burden of pediatric HIV disease due to unwanted fertility.

METHODOLOGY/PRINCIPAL FINDINGS: Using the demographic software Spectrum, a baseline mathematical projection to estimate the current pediatric HIV burden in Uganda was compared to three hypothetical projections: 1) without ARV-PMTCT (to estimate the effect of ARV-PMTCT), 2) without contraception (effect of existing FP use), 3) without unwanted fertility (effect of unmet FP needs). Key input parameters included HIV prevalence, ARV-PMTCT uptake, MTCT probabilities, and TFR. We estimate that in 2007, an estimated 25,000 vertical infections and 17,000 pediatric AIDS deaths occurred (baseline projection). Existing ARV-PMTCT likely averted 8.1% of infections and 8.5% of deaths. FP use likely averted 19.7% of infections and 13.1% of deaths. Unwanted fertility accounted for 21.3% of infections and 13.4% of deaths. During 2008-2012, an estimated 131,000 vertical infections and 71,000 pediatric AIDS deaths will occur. The projected scale up of ARV-PMTCT (from 39%-57%) may avert 18.1% of infections and 24.5% of deaths. Projected FP use may avert 21.6% of infections and 18.5% of deaths. Unwanted fertility will account for 24.5% of infections and 19.8% of deaths.

CONCLUSIONS: Existing FP use contributes as much or more than ARV-PMTCT in mitigating pediatric HIV in Uganda. Expanding FP services can substantially contribute towards PMTCT.

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HIV PREVENTION

10. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases

Authors: Swendeman D a; Basu I b; Das S b; Jana S b; Rotheram-Borus MJ a
Institutions: a Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, CA; b Durbar Mahila Samanwaya Committee, Kolkata, India
Source Social Science & Medicine Oct 2009; 69(8): 1157-66.

ABSTRACT

The Sonagachi Project was initiated in Kolkata, India in 1992 as a STD/HIV intervention for sex workers. The project evolved to adopt strategies common to women's empowerment programs globally (i.e., community mobilization, rights-based framing, advocacy, micro-finance) to address common factors that support effective, evidence-based HIV/STD prevention. The Sonagachi model is now a broadly diffused evidence-based empowerment program. We previously demonstrated significant condom use increases among female sex workers in a 16 month replication trial of the Sonagachi empowerment intervention (n=110) compared to a control community (n=106) receiving standard care of STD clinic, condom promotion, and peer education in two randomly assigned rural towns in West Bengal, India (Basu et al., 2004). This article examines the intervention's impacts on 21 measured variables reflecting five common factors of effective HIV/STD prevention programs to estimate the impact of empowerment strategies on HIV/STD prevention program goals. The intervention which was conducted in 2000-2001 significantly: 1) improved knowledge of STDs and condom protection from STD and HIV, and maintained STD/HIV risk perceptions despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This study's results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs.

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11. Integration of HIV/AIDS services into African primary health care: Lessons learned for health system strengthening in Mozambique -- a case study
 

Authors: Pfeiffer J 1,2; Montoya P1,2; Baptista AJ 3; Karagianis M 4; Pugas MM 5; Micek M 2; Johnson W 1,2; Sherr K 1,2; Gimbel S 2; Baird S 2; Lambdin B 2; Gloyd S 1,2
Institutions: 1 University of Washington Department of Global Health, Harborview Medical Center, Seattle, WA; 2 Health Alliance International, Seattle, WA; 3 Mozambique Ministry of Health Ministério da Saúde, Maputo, Republica de Moçambique; 4 Provincial Health Directorate, Sofala Province, Ministério da Saúde, Maputo, Republica de Moçambique; 5 Provincial Health Directorate, Manica Province, Ministério da Saúde, Maputo, Republica de Moçambique
Source: Journal of the International AIDS Society 20 Jan 2010; 13:3. [BioMed Central]

ABSTRACT

INTRODUCTION: In 2004, Mozambique, supported by large increases in international disease-specific funding, initiated a national rapid scale-up of antiretroviral treatment (ART) and HIV care through a vertical "Day Hospital" approach. Though this model showed substantial increases in people receiving treatment, it diverted scarce resources away from the primary health care (PHC) system. In 2005, the Ministry of Health (MOH) began an effort to use HIV/AIDS treatment and care resources as a means to strengthen their PHC system. The MOH worked closely with a number of NGOs to integrate HIV programs more effectively into existing public-sector PHC services. Case Description: In 2005, the Ministry of Health and Health Alliance International initiated an effort in two provinces to integrate ART into the existing primary health care system through health units distributed across 23 districts. Integration included: a) placing ART services in existing units; b) retraining existing workers; c) strengthening laboratories, testing, and referral linkages; e) expanding testing in TB wards; f) integrating HIV and antenatal services; and g) improving district-level management.

DISCUSSION: By 2008, treatment was available in nearly 67 health facilities in 23 districts. Nearly 30,000 adults were on ART. Over 80,000 enrolled in the HIV/AIDS program. Loss to follow-up from antenatal and TB testing to ART services has declined from 70% to less than 10% in many integrated sites. Average time from HIV testing to ART initiation is significantly faster and adherence to ART is better in smaller peripheral clinics than in vertical day hospitals. Integration has also improved other non-HIV aspects of primary health care.

CONCLUSION: The integration approach enables the public sector PHC system to test more patients for HIV, place more patients on ART more quickly and efficiently, reduce loss-to-follow-up, and achieve greater geographic HIV care coverage compared to the vertical model. Through the integration process, HIV resources have been used to rehabilitate PHC infrastructure (including laboratories and pharmacies), strengthen supervision, fill workforce gaps, and improve patient flow between services and facilities in ways that can benefit all programs. Using aid resources to integrate and better link HIV care with existing services can strengthen wider PHC systems.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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