“What are your challenges of providing family planning services to HIV positive patients?” I would ask of all our study participants, who were nurses and clinical officers working at 21 different health facilities throughout Nyanza region around Kisumu. We were trying to determine how HIV and family planning integration was faring in different health clinics, which ranged from large district hospitals with plenty of resources and surgical theaters to perform surgical family planning services like tubal ligation to small dispensaries with one staff member and insufficient electricity to properly sterilize equipment used to insert long term family planning methods, like the implants or IUDs.
In June this year, Kenya implemented a new policy to start antiretroviral treatment for HIV for patients who have a CD4 cell count of less than 500 cells/mm3 as opposed to less than 350 cells/mm3 (essentially treating individuals earlier in their infection when they are less sick). However, the government has said nothing of how they will support health center staff with the increased workload and job responsibilities of caring for not just for the HIV care needs of these patients, but all of their other health needs, including family planning. Since the HIV prevalence in Nyanza region is 15.1%, this increase in patient load is very significant. This increase in workload prompted my research question, and I spent two months in various sites talking to health providers about the family planning services they provided to HIV positive clients and the challenges of providing those services.
Some of the answers to the question were ones I could have predicted even back in the United States – providers had high workload, not enough staff, and not enough supplies (both the family planning commodities, and other supplies like syringes and lidocaine used to insert some of the family planning methods). Yet a few of the answers in particular struck me as challenges that were specific to the context that could be easily addressed to improve the family planning provision in the region.
The first answer I started hearing was that providers were not trained appropriately in long-term methods of family planning, even though they desired that knowledge. Providers currently recommend that HIV positive individuals start on long term family planning methods like the IUD or implants that last 3 to 5 years, so that the individual’s immunity can rise again before having a child to prevent both opportunistic infections for the mother and the potential of infecting the new infant with HIV. Additionally, these methods require very little active adherence, so the individuals don’t have to worry about additional pill burden on top of their already high pill count from their antiretroviral medications. Unfortunately few providers have been trained to provide these methods because some methods require surgical skills. Here was a group of people who were willing to spend the extra time to get the training to give the services that their clients needed, but that training wasn’t happening.
The second answer I heard was that these providers wanted to counsel their clients appropriately on different family planning methods, but many times the providers were not from Nyanza region, and thus couldn’t speak Dholuo, the local dialect, fluently. The providers had difficulty counseling their clients on sensitive issues around HIV and family planning because using Kiswahili or their own limited Dholuo resulted in many individuals not getting the information they needed to make an informed choice about what family planning method was best for them. The providers were also very willing to address this problem – either through language lessons before they transferred to sites, or getting translators to work at the health facilities. However, since most health providers work an average of two years in a health facility, there isn’t much time for them to learn the local community and be able to speak about these issues using the right language.
I wish I had more time in Kenya to talk about the best way forward from here – how do we get more health providers trained, both in providing long term family planning methods, and in the appropriate means of communication for talking to clients about their family planning needs? Who is best to do that training? Where will the resources for training come from? How do we get training to those small dispensaries that only have one staff member (because if they go to an all day training, suddenly that health facility has no provider)? I have more questions than answers, but what I do know is that there is a dedicated health force in Kenya that can do the work, if they have this support. And that’s definitely a start.