When Does It Make Sense to Consider Integrating STI and HIV Services with Family Planning Services?

By Fleischman Foreit, Karen G.; Hardee, Karen et al. | International Family Planning Perspectives, June 2002 | Go to article overview

When Does It Make Sense to Consider Integrating STI and HIV Services with Family Planning Services?


Fleischman Foreit, Karen G., Hardee, Karen, Agarwal, Kokila, International Family Planning Perspectives


The question of whether to integrate vertical primary health care programs and services (maternal health, child survival, family planning, etc.) is long-standing, and the arguments on either side have been clearly articulated. Integrated services are thought to expand access to and coverage of critical services and to improve their efficiency and cost-effectiveness by reducing duplication of service delivery functions and delivering more services per client contact. (1) Many countries have already integrated family planning services with maternal and child health services.

The 1994 International Conference on Population and Development (ICPD) and the continuing escalation of the HIV/AIDS epidemic have increased interest in integrating family planning services with those for HIV and other sexually transmitted infections (STIs). However, despite the considerable literature on the subject, there is no consensus on what it means to have integrated services, which services should be integrated or whether integration precludes continuation of stand-alone services. (2) Discussions often refer to "one-stop shopping" supported by multifunction workers. One review suggests that service integration "might involve the linkage of several provider functions at the service delivery point and would require modifications of worker roles, allocation of time and referral requirements [emphasis added]." (3)

In this commentary, we broadly define services to include the full range of provider-client interactions, from counseling and behavior-change communication to the performance of clinical procedures and delivery of medications or commodities. Any two services can be considered to be integrated when they are offered at the same facility during the same operating hours, and the provider of one service actively encourages clients to consider using the other service during that visit. According to this definition, integrated services may or may not be offered in the same physical location within the facility, and may or may not be offered by the same service provider.

"Programs" and "service delivery" are not synonymous. Programs set out broad, population-based objectives, whereas individual service delivery points may contribute to some but not all of these objectives. Family planning programs seek to stimulate demand for family planning, help individuals meet their reproductive intentions, encourage men to be more involved in reproductive health, give adequate information to allow informed choice, and provide ready access to a variety of contraceptive supplies and services. STI control programs seek to prevent new infections in the general population, treat persons with symptoms of infection, improve health-seeking behavior among those who self-diagnose infection, strengthen detection and treatment of those with an asymptomatic infection and improve the effectiveness of STI case management and treatment.

The integration of family planning into maternal and child health differs in several ways from the integration of STI and HIV services into family planning. First, unlike family planning services of 25 years ago, many public health systems have long-established STI services, sometimes under such unrelated departments as dermatology Second, STI clients often self-diagnose and self-medicate, and third, private providers--especially pharmacies--rather than public facilities are often the client's first service delivery contact point. (4)

We contend that not all services should be integrated in all situations, and that even some potentially integrable services should sometimes be offered separately. At least three compelling factors argue against totally integrating STI and HIV services into family planning.

The first of these is that family planning clients may not be at disproportionately high risk for HIV and other STIs, and that groups that are at high risk (men and young people) may not be disposed to seek services at family planning sites. …

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