Integration of HIV and
Nutrition Services –
Action and Measurement
Barbara Engelsmann, Sweden Chiruka, Charity Zvandaziva, Fitsum Assefa,
Diana Patel
Abstract No MOAE0102
Session Title: Integrated HIV, Health and Human Development Programs
20th International AIDS Conference Melbourne, Australia
20-25 July 2014
What is Integration?
Integration means different things to different
people:
 Integration of type of services
 Integration referring to service delivery
points
 Integration of services over time
 Integration of vertical levels of service
 Integration at policy/management level
WHO definition: “The management and delivery of health services so
that clients receive a continuum of preventive and curative services,
according to their needs over time and across different levels of the
health system.”
Why Integration?
 Resource constraints – available resources
have to be used as efficiently as possible
 Rise of single disease funding or population
group specific programs
 Different disease goals based on common
service delivery resources
 Client oriented, closer to the goal of
universal access
 For smaller programs integration might be
survival
Why NOT Integration?
 Risk of reduced quality of service provision
 Challenges to showcase achievements
 AIDS exceptionalism –
“it is important to regard HIV/AIDS services as a
special case which needs to be well-resourced,
expanded quickly and protected from the
inefficiencies of the broader health system”
Integration of HIV (PMTCT/ped. HIV)
and Nutrition (IYCF/CMAM) services
IYCF
CMAM
PMTCT
Pediatric
HIV
• Mutual dependence of HIV and
nutrition services
Yet
Largely vertical implementation of
their programs to date
• Potential to maximise on different
entry points for service provision
• PILOT PROGRAM to integrate service delivery for HIV and nutrition
• WHERE: Three country program (in Zimbabwe, Malawi and
Mozambique)
• SUPPORT: Funded by DFATD through UNICEF
• WHEN: Over three years (July 2011 to June 2014)
In Zimbabwe:
•
32 sites in two rural districts
(Marondera and Hwedza)
Implementation:
by the Organization for Public Health Interventions and
Development (OPHID) trust in Zimbabwe linked to/leveraged
by existing PMTCT program
Integration - Activities
At national/provincial level
Stimulation of policy dialogue at national level
Sensitization at provincial level
At service delivery level
Skills building
Encouragement of bi-directional linkages and
referral systems
Supervision and mentoring
Development of job-aides
At outreach level
Capacity building of outreach teams
Training and sensitization of village health workers
At community level
Mobilization of
Voluntary community cadres
Traditional leaders
Mother-baby support groups
Integration - Monitoring & Evaluation
 To monitor the delivery of service integration
specific integration indicators were defined
measuring the concurrent provision of HIV and
nutrition services at different service
delivery points
 Examples:
 % of children with SAM receiving HIV
testing
 % of children in pediatric ART program
screened for SAM
Indicator 1: % PMTCT clients with children under 2 years of age receiving at least 2
IYCF counselling sessions
Indicator 2: % HIV exposed infants attending DPT3 immunization who are exclusively
breastfed
Indicator 3: % children in pediatric ART program screened for SAM
100
90
80
70
60
Indicator 1
50
Indicator 2
40
Indicator 3
30
20
10
0
Jan-Jun 2012 Jul-Dec 2012 Jan-Jun 2013 Jul-Dec 2013
Indicator 4: % children with SAM receiving HIV-testing
Indicator 5: % of HIV positive children at CMAM enrolling on ART
80
70
60
50
Indicator 4
40
Indicator 5
30
20
10
0
Jan-Jun 2012
Jul-Dec 2012
Jan-Jun 2013
Jul-Dec 2013
Integration – Success
Outcome: Integrated service provision increased
Baseline
integrated
service
delivery
Program
interventions
to promote
service
integrations
Recording of
indicators to
define and
prompt
integrated
service
delivery
Integration
now
measurable
Integration – Challenges
Action Challenges:
 In particular at higher level
Monitoring and Evaluation Challenges:
 Information required for integration indicators originating
from different source registers (CMAM register, ART
register, EPI register) at different service delivery points
over a period of time
 Enumerators and denominators were not always
routinely available as part of the national M&E
system eg IYCF counseling provided, currently
breastfeeding
Integration – Recommendations
 Support of integration efforts at national level
(even if different departments are involved)
 More attention to national routine M&E tools to
include measures for integration and set targets
for integration indicators
Next Steps:
 Impact analysis
 Cost-effectiveness analysis
Acknowledgements
UNICEF HQ, regional and country office
Department of Foreign Affairs, Trade and
Development Canada
President’s Emergency Plan for AIDS Relief through USAID
under the terms of Families and Communities for Elimination of
Pediatric HIV in Zimbabwe (AID-613-A-12-00003)
And many more….
Zimbabwe Ministry of Health and Child Care
Disclaimer
“This study was made possible by the generous
support of UNICEF and the American people through
the U.S President’s Emergency Plan on AIDS relief
(PEPFAR) and United States Agency for International
Development (USAID). The contents are the
responsibility of OPHID and do not necessarily reflect
the views of UNICEF, DFATD, PEPFAR, USAID or the United
States Government”