Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60
https://doi.org/10.1186/s12978-019-0713-x
RESEARCH Open Access
Availability of integrated family planning
services in HIV care and support sites in
sub-Saharan Africa: a secondary analysis of
national health facility surveys
Mufaro Kanyangarara1*, Kwame Sakyi2 and Amos Laar3
Abstract
Background: Integrating family planning (FP) with HIV care and treatment programs is a strategy to expand FP
service delivery and prevent unintended pregnancies among women living with HIV. However, little is known
about the extent to which FP services are available in health facilities providing HIV services across sub-Saharan
Africa. In this study, we assessed the availability of integrated FP services and the associated factors in HIV care and
support sites across sub-Saharan Africa.
Methods: We conducted a secondary analysis of nationally representative facility-level data from Service Availability
and Readiness Assessments (SARA) and Service Provision Assessments (SPA) conducted in 10 sub-Saharan African
countries between 2012 and 2015. We used six indicators that reflect the structure and process of care essential for
FP service delivery in HIV care and support facilities to define the outcome of interest - onsite availability of
integrated FP services. Multivariate logistic regression was used to explore facility-level characteristics associated
with the outcome.
Results: Among the 3161 health facilities offering HIV care and support services, most reported also offering FP
services at the same location. The availability of three FP methods was higher than the availability of FP guidelines
and trained staff. Onsite availability of integrated FP services ranged from 10 to 61%. Results of multivariate logistic
regression indicated that the odds of having onsite integrated FP services available was higher in HIV care and
support sites that were operated by the government, classified as a tertiary level care facility, and provided services
for PMTCT, antenatal care and basic surgery.
Conclusions: Our findings indicate critical shortcomings in the preparedness of HIV care and support sites to
deliver onsite integrated FP services. Renewed efforts are needed to address these supply-side barriers and ensure
that integrated FP and HIV services meet the unique needs of HIV clients.
Keywords: HIV, Family planning, Sub-Saharan Africa, Health facility surveys
* Correspondence: mkanyan1@jhu.edu
1Department of International Health, Johns Hopkins Bloomberg School of
Public Health, 615 N. Wolfe Street, Baltimore, MD, USA
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 2 of 9
Background countries have been underexplored. The current study
Since the start of the HIV epidemic, an estimated 78 mil- aimed to assess the on-site availability of FP services at
lion people have acquired HIV, and 35 million have died HIV care and support sites in 10 sub-Saharan African
of AIDS-related causes [1]. In 2016, there were 36.7 mil- countries. We also evaluated facility-level factors associ-
lion people living with HIV/AIDS worldwide, with 25.5 ated with onsite availability of integrated FP services.
million residing in Sub-Saharan Africa. Annually about 2.1 Findings from this multi-country analysis reveal critical
million people become newly infected with HIV, including shortcomings in the implementation of integrated FP
150,000 children (< 15 years), most of whom acquire the and HIV service delivery, and provide evidence to guide
infection vertically from their mothers, during pregnancy, the implementation of effective integrated FP and HIV
childbirth or breastfeeding [1, 2]. services at scale.
The scale-up of interventions for the prevention of
mother-to-child transmission of HIV (PMTCT) and Methods
antiretroviral treatment for eligible pregnant women and Data sources
children has led to significant reductions in HIV trans- Data were obtained from the Service Provision Assess-
mission, morbidity and mortality [3]. The benefits asso- ments (SPA) and Service Availability and Readiness As-
ciated with improved access to antiretroviral therapy sessments (SARA) [26, 27]. The SPA and SARA are
(ART) may be offset by high rates of unintended preg- nationally representative, cross-sectional facility-based
nancies and low levels of contraceptive use among surveys that collect comprehensive information on the
women living with HIV in sub-Saharan Africa [4–8]. availability and functionality of health systems in the
Preventing unintended pregnancies in HIV-infected provision of essential health services, including antenatal
women is recognized an essential component of a com- care, obstetric care, HIV/AIDS care and treatment, and
prehensive response to HIV/AIDS, especially the global FP. Both surveys include a facility checklist administered
PMTCT [9, 10]. The integration of family planning (FP) to the facility in-charge. The availability of basic amen-
services into HIV/AIDS care and treatment programs is ities, equipment, diagnostics, medicines and commod-
an effective approach to simultaneously reducing vertical ities for the provision of health services is directly
transmission of HIV, increasing access to contraception, observed and verified by the interviewer. Further details
and reducing maternal deaths [11–13]. Furthermore, at about the survey design and sampling strategy can be
a health systems level, the delivery of FP services as part found in final survey reports [26, 27].
of the HIV continuum of care can lead to improvements
in access to essential health services, efficiency of limited Study setting
resources and clinical practice [14–16]. Models to inte- Our analysis included available data from SPAs and
grate HIV and FP service delivery range from the SARAs conducted between 2012 and 2015 in 10
provision of comprehensive FP services from the same sub-Saharan African countries: Benin, Burkina Faso,
HIV service provider to referral-based approaches [17]. Democratic Republic of Congo (DRC), Malawi, Senegal,
The effectiveness of a particular model of integration de- Sierra Leone, Tanzania, Togo, Uganda, and Zimbabwe.
pends on contextual factors such as the burden of HIV The included countries represent a diversity of popula-
and unique FP needs, health system factors such as the tions with a range of sexual and reproductive health
commodity supply chain, provider level factors such as needs, and settings with varying nature of the HIV epi-
competence and attitude that influence the quality of demic (Table 1). Overall, contraceptive prevalence rate
care, and structural factors such as infrastructure, equip- ranges from 16.2% in Burkina Faso to 66.8% in
ment and commodities [18–21]. Deficiencies in struc- Zimbabwe, and unmet need for FP ranges from 10.4% in
tural inputs can hinder the delivery of integrated Zimbabwe to 34.3% in Uganda. Coverage of antenatal
services resulting in missed opportunities to address un- care (ANC) and facility deliveries is substantial, with be-
met needs. Evaluating the availability of structural inputs tween 34 and 76% of pregnant women attending at least
and processes of care necessary for integrated service four ANC visits, and between 54 and 91% of pregnant
delivery can help identify barriers to the implementation women delivering in a health facility. The incidence rate
of integrated FP and HIV services. of HIV ranges from 0.08 to 3.03 per 1000 person-years.
Many studies have examined the integration of FP ser- The burden of HIV and coverage of HIV interventions
vices with HIV programs in one or more health facilities tends to be higher in countries in the Southern and East-
in a single country [14, 22–25]. However, few studies ern Africa regions like Tanzania and Zimbabwe, com-
have examined the integration of FP services at a pared to countries in the Western and Central African
national-level or across multiple countries systematically regions like the Togo and Sierra Leone. National health
[20, 21]. Consequently, differences in the availability of expenditures per capita for 2015 ranged from US$20 to
integrated FP services in HIV programs across multiple US$170.
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 3 of 9
Table 1 State of sexual and reproductive health and the HIV epidemic in 10 sub-Saharan African countries, 2012–2015
Health expenditure per People living HIV ART PMTCTb ANC4+ (%)c Facility TFRc Unmet need CPR
capita in USba with HIVb incidence § (%)b deliveries (%)c for FPc (%)d
Benin 31 67,000 0.34 57 > 95 59 87 4.9 32.6 17.9
Burkina 33 95,000 0.19 60 83 34 66 6.0 24.5 16.2
Faso
DRC 20 370,000 0.17 42 70 48 80 6.6 27.7 20.4
Malawi 34 1,000,000 2.29 66 84 51 91 4.4 18.7 59.2
Senegal 36 41,000 0.08 52 55 47 75 5.0 25.6 23.3
Sierra 107 67,000 – 26 87 76 54 4.9 25.0 16.6
Leone
Tanzania 32 1,400,000 1.19 62 84 51 63 5.2 22.1 38.4
Togo 37 100,000 0.59 51 86 57 73 4.8 33.6 19.9
Uganda 46 1,400,000 1.50 67 > 95 48 57 6.2 34.3 30.0
Zimbabwe 94 1,300,000 3.03 75 93 76 77 4.0 10.4 66.8
- indicates no data available. DRC Democratic Republic of Congo. ANC4+: Coverage of at least four antenatal care visits. ART:
CPR Contraceptive prevalence rate. TFR Total fertility rate. PMTCT Antiretroviral therapy coverage for the prevention of mother-to-child HIV transmission
a Source: World Health Organization Global Health Expenditure Database for 2015
b Source: UNAIDS estimates for 2016
c Source: most recent Demographic and Health Surveys or Multiple Indicator Cluster Survey
d Source: United Nations, Department of Economic and Social Affairs, Population Division (2017). World Contraceptive Use 2017 (POP/DB/CP/Rev2017)
Measures HIV, including treatment of opportunistic infections,
The study outcome was the availability of on-site inte- provision of palliative care and nutritional rehabilitation.
grated FP services at the facility level, which was based Facilities offering HIV care and support services may
on six ‘structural’ and one ‘process of care’ inputs. ‘Struc- offer other HIV services and ancillary health services,
ture’ refers to characteristics of the health system in which may influence the availability of onsite integrated
which care is being delivered, while ‘process of care’ de- FP services. Therefore, we examined facility-level mea-
scribes the care delivered to patients [28]. In line with sures of the availability of other HIV services (PMTCT,
World Health Organization definition of FP readiness, HIV testing and counselling, and HIV/AIDS antiretro-
the structural inputs examined were guidelines on FP, viral prescription and client management) and ancillary
blood pressure apparatus, oral contraceptive pills, inject- services (antenatal care, child immunizations, obstetric
ables, condoms, and trained staff (at least one staff and newborn care, diagnosis and treatment for sexually
member received training in FP in the previous 1–3 transmitted infections, and basic surgical services).
years) [29]. The ‘process of care’ input was the routine Other facility-level characteristics assessed included type
provision of FP counselling to HIV/AIDS clients as re- of health facility (tertiary versus secondary and primary
ported by the facility-in-charge. level), location (urban versus rural), and managing au-
Facilities with all the structural and process of care in- thority (public versus private).
puts were classified as having onsite integrated FP ser-
vices; those that did not have one or more inputs were Analysis
classified as not having onsite integrated FP services. This Using descriptive statistics, we summarized the availabil-
classification was selected based on the data available in ity of FP services, and structural and process of care in-
both the SPA and SARA, and did not include other as- puts across the 10 sub-Saharan African countries.
pects related to the provision of integrated services, such Bivariate and multivariate logistic regression analyses
as quality of counselling, patient satisfaction, and provider were conducted with availability of onsite integrated FP
competence. While the SPAs include other data collec- services as the outcome; backwards stepwise logistic re-
tions tools (client-provider observations, client exit inter- gression was used to determine the facility-level factors
views and health worker interviews) that might reflect a associated with the outcome. Analyses included fixed ef-
broader range of processes of care, the analysis was lim- fects for each country. To account for the dependence
ited to the selected inputs to allow the inclusion of several between facilities within the same country, we used gen-
countries with a recent SARA (n = 7). eralized estimating equations to obtain robust standard
The analysis was restricted to health facilities offering errors [30]. Associations were presented as odds ratios
‘HIV care and support’ services defined as any service di- (OR) with 95% confidence intervals (95% CI), and p < 0.05
rected towards improving the life of a person living with was considered statistically significant. Multicollinearity
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 4 of 9
among independent variables was assessed using variance higher odds of having integrated FP services available
inflation factors (VIF). All statistical analyses were appro- than secondary and primary level sites, though this was
priately weighted for sample design and performed using only marginally statistically significant (aOR 1.49; 95%
STATA 14.2 (College Station, Texas). CI 1.00–2.22). There was no association between the
availability of onsite integrated FP services and
Results rural-urban location (aOR 0.95, 95% CI 0.59–1.54). The
Of the 6209 sampled health facilities, 3161 (51%) offered odds of having integrated FP services available was
HIV care and support services and were included in our higher among HIV care and support sites that provided
analytical sample (Table 2). FP services were offered at services for PMTCT (aOR: 3.66, 95% CI 1.10–12.17),
most HIV care and support sites (across country median: antenatal care (aOR: 2.95, 95% CI 1.22–7.14) and basic
93%). As an enabling environment is critical to the surgery (aOR: 1.88, 95% CI 1.03–3.43), compared to sites
provision of integrated FP services, we assessed the that did not provide these services. With the exception
availability of structural inputs in HIV care and support of Togo and Sierra Leone, the odds of having integrated
sites. Whereas blood pressure equipment was widely FP services available were significantly higher in Burkina
available (median: 92%), guidelines on FP and staff Faso than the remaining countries.
trained in FP were less available (median: 65 and 50% re-
spectively). By and large, injectable contraceptives, oral Discussion
contraceptive pills, and male condoms were largely avail- Women living with HIV face disproportionately higher
able (median: 89, 83 and 82% respectively). However, rates of unintended pregnancies and the integration of
there was a relatively lower supply of implants and intra- FP and HIV services is a strategy to meet FP needs, re-
uterine devices (IUDs), which offer long-acting reversible duce the risk of unintended pregnancies, and prevent
contraception (median: 62 and 41% respectively; Fig. 1). mother-to-child HIV transmission. This study evaluated
The availability of female condoms and emergency the availability of integrated FP services and associated
contraception varied widely across countries (range: 10– factors in HIV care and support sites across 10
97% and 10–82%, respectively). Across countries, a me- sub-Saharan African countries between 2012 and 2015.
dian of 95% of the HIV care and support sites had one Whereas the majority (93%) of HIV care and support
or more contraceptive methods in stock (range: 85– sites reported offering FP services in the same location,
100%), and 80% had three or more contraceptive only 29% of these sites were classified as having onsite
methods in stock (range: 57–97%, Fig. 1). Most HIV care integrated FP services available based on the availability
and support sites reported routinely providing FP coun- of structural and process of care inputs. FP commodities
selling to HIV/AIDS clients – an indicator of the process and blood pressure equipment were widely available;
of care (median: 94%). however, the availability of guidelines on FP and trained
Based on the availability of structural inputs and staff were limited. Of note, there were no rural-urban
process of care indicators, the onsite availability of inte- differences in the onsite availability integrated FP ser-
grated FP services varied between 10 and 61%, with a vices (aOR 0.95, 95% CI 0.59–1.54). This finding is indi-
median of 29% across all countries (Table 2). Notably, cative that global efforts to ensure the widespread
countries with similar onsite availability of integrated FP availability of such services may be gaining traction in
services showed varying availability of HIV care and sup- both rural and urban settings in sub-Saharan Africa [31].
port services. Whereas about 26% of HIV care and sup- That said, the lack of trained staff is concerning given
port sites in DRC and Uganda were classified as having the indicator for trained staff, defined as at least one
onsite integrated FP services available, only 8% of all staff member had been trained in any aspect of FP in the
sampled facilities offered HIV care and support services previous 1–3 years, represents a minimum requirement.
in DRC compared to 54% in Uganda. Given the chronic shortage of all cadres of health
In the bivariate analyses, the availability of integrated personnel in the sub-Saharan Africa region and the
FP services at HIV care and support sites was associated current rhetoric of double-duty actions, efforts for dual
with several facility-level characteristics (Table 3). Except training and supervision of providers should be consid-
for HIV testing and counselling and diagnosis and treat- ered [32, 33]. Barriers to the provision of integrated FP
ment of sexually transmitted infection, offering another services specifically training and supervision must be ad-
HIV or ancillary health services was independently asso- dressed if the comprehensive needs of people living with
ciated with higher odds of having integrated FP services. HIV are to be met.
In the multivariate analyses, public HIV care and sup- We documented variation across countries in the avail-
port sites had higher odds of having onsite integrated FP ability of integrated FP services in HIV care and support
services available compared with private sites (aOR 1.95, sites. Differences in the burden of HIV, FP needs and
95% CI: 1.12–3.40; Table 3). Tertiary level sites had other health system factors may drive the heterogeneity in
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 5 of 9
Table 2 Availability of family planning services in HIV care and support facilities in 10 sub-Saharan African countries, 2012–2015
Among facilities offering HIV/AIDS care and support, facilities with
Health Facilities Facilities offering Offering Guidelines Staff Blood Oral Injectable Male Routine provision of family Onsite availability
facility sampled HIV/AIDS care and family on FP (%) trained pressure contraceptive contraceptives condoms planning counselling to of integrated FP
survey support (%) planning in FP apparatus pills (%) (%) (%) HIV/AIDS clients (%) services (%)
services (%) (%) (%)
Benin SARA 189 21 98 63 49 86 69 97 62 63 15
(2013)
Burkina SARA 766 88 96 84 75 98 93 93 92 96 61
Faso (2014)
DRC SARA 1555 8 66 47 50 94 58 58 91 83 26
(2014)
Malawi SPA 977 67 85 33 49 87 75 77 60 91 10
(2013)
Senegal SPA 483 6 92 74 74 100 86 86 84 95 51
(2012–
14)
Sierra SARA 455 30 94 67 81 91 95 93 97 99 52
Leone (2013)
Tanzania SPA 1200 35 89 56 42 92 79 79 68 92 15
(2014–
15)
Togo SARA 100 34 88 70 41 86 68 83 77 86 29
(2012)
Uganda SARA 209 54 93 47 53 86 98 92 79 95 27
(2012)
Zimbabwe SARA 275 98 97 67 49 96 97 97 99 100 37
(2014)
Median 35 93 65 50 92 83 89 82 94 29
DRC: Democratic Republic of Congo
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 6 of 9
Fig. 1 Contraceptive methods available at HIV care and support sites in 10 sub-Saharan African countries
the availability of HIV/FP integration. Furthermore, quality of ANC, obstetric care, and child immunization
the strengthens and limitations of one model integra- services [35–37]. For instance, one study of health facil-
tion over another in different contexts has not been ities in Kenya found that the presence of PMTCT pro-
fully explored [34]. grams was associated with increased quality of prenatal
Our findings also suggest that HIV care and support and postnatal care, specifically the availability of structural
sites offering other HIV or ancillary services, specifically inputs [37]. Together, these studies and our findings sug-
PMTCT, ANC and basic surgery services were more gest that investments in supplies, equipment, diagnostics,
likely to have integrated FP services available. Notably, human resources, medicines and commodities to support
offering PMTCT services was associated with a 3.6-fold the provision of PMTCT services may have substantial in-
increase in the likelihood of onsite integrated FP ser- direct benefits on health systems.
vices, suggesting that HIV care and support sites already We also found that onsite integrated FP services were
equipped with PMTCT units were also inclined to offer more available in HIV care and support sites that were
integrated FP, or vice versa. Several studies have also doc- government operated and provided tertiary level care.
umented the positive spillover effect of HIV programs on These findings are consistent with studies that have doc-
broader health systems, including the provision and umented supply side deficiencies in the provision of
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 7 of 9
Table 3 Univariate and Multivariate analyses of factors associated with onsite availability of integrated family planning services in
HIV care and support sites in 10 sub-Saharan African countries, 2012–2015
Univariate Multivariate
Facility-level characteristic OR 95% CI aOR 95% CI
Urban 1.32 0.92–1.90 0.95 0.59–1.54
Tertiary level 1.28 0.95–1.73 1.49 1.00–2.22
Public 2.43 1.55–3.83 1.95 1.12–3.40
Offers other HIV ancillary health services
PMTCT services 10.36 4.22–25.44 3.66 1.10–12.17
Antenatal care 9.20 5.66–14.96 2.95 1.22–7.14
Basic surgery 2.37 1.52–3.69 1.88 1.03–3.43
Obstetric and newborn care 6.89 3.03–15.65 –
Child immunization 3.47 2.34–5.14 –
HIV testing and counselling 3.36 0.73–15.47 –
HIV/AIDS antiretroviral prescriptions 2.73 1.60–4.63 –
Sexually transmitted infections 0.44 0.10–1.86 –
Country
Burkina Faso – Reference
Benin – 0.13 0.05–0.37
Democratic Republic of Congo – 0.23 0.14–0.40
Malawi – 0.09 0.06–0.12
Senegal – 0.53 0.27–1.05
Sierra Leone – 0.75 0.50–1.13
Tanzania – 0.11 0.08–0.16
Togo – 0.42 0.18–1.03
Uganda – 0.35 0.19–0.64
Zimbabwe – 0.59 0.37–0.95
CI confidence interval, OR odds ratio, aOR adjusted odds ratio
essential health services across sub-Saharan African care received by these clients. The availability of struc-
countries, particularly lower level facilities [36, 38, 39]. tural inputs and processes of care is a requirement but
In light of efforts to decentralize HIV programs to lower not a guarantee of provision of integrated FP services.
level facilities to ensure improved access and support Nevertheless, these findings are still useful in character-
rapid scale up [40, 41], our results underscore the need izing the environment in which integrated FP and HIV
for further investments in lower level facilities where a services are being provided and are relevant for
substantial number of patients are expected to receive national-level policy and program planning.
HIV care and FP in the near future. Second, the present analysis was restricted to assessing
There are several limitations worth noting. First, the the availability of FP services in the same site to
analysis was based on a secondary analysis of data col- HIV-infected women in HIV care and support sites. Due
lected through health facility surveys. Health facility sur- to the nature of the data, it is unclear whether the FP
veys such as the SPA and SARA provide nationally services were provided by the same health provider, or
representative information on the state of the health sys- another health provider in the same facility through for-
tem at one moment in time, and the surveys used reflect mal or informal referral. The study did not consider
service provision between 2012 and 2015. As some HIV other models of service delivery (e.g. referral based ap-
care and support sites may provide integrated FP ser- proaches) or the availability of other reproductive ser-
vices to few or many HIV clients, without adjustment vices (e.g. those targeted for men and adolescent boys).
for care-seeking patterns and health facility caseloads, Data available in the SPA and SARA do not permit the
our data cannot identify the proportion of HIV clients assessment of all integrated service delivery mechanisms
receiving integrated FP services in HIV care and support operating in HIV care and support sites or other HIV
settings, nor specify the actual content and quality of programs like HIV counselling and testing, PMTCT and
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 8 of 9
ART. However, other HIV programs are likely to face of Health and other stakeholders in the region on efforts
parallel challenges in the delivery of integrated FP and to implement integrated FP and HIV services at scale.
HIV services. Further research is needed to better under- A French translation of this article has been included
stand the broader spectrum of activities in which HIV as Additional file 1.
care and support sites are engaged to meet the FP needs A Portuguese translation of the abstract has been in-
of both male and female HIV clients. cluded as Additional file 2.
Third, the definition of availability of onsite integrated
FP services was based on the availability of structural in- Additional files
puts and process of care. While the availability of struc-
tural inputs was based on direct observation and Additional file 1: Translation of this article into French. (PDF 674 kb)
verification, the indicator for process of care – routine Additional file 2: Translation of the abstract of this article into
provision of FP counselling to HIV clients was based on Portuguese. (PDF 176 kb)
report by facility staff, which is prone to misreporting.
Also, the definition only considered one indicator of the AbbreviationsAIDS: Acquired immunodeficiency syndrome; ANC: Antenatal care;
process of care and may be too crude a measure to rep- aOR: Adjusted odds ratio; ART: Antiretroviral therapy; CI: Confidence interval;
resent all dimensions of integrated FP service delivery. DHS: Demographic and Health Surveys; DRC: Democratic Republic of Congo;
Several other indicators have been proposed to track the FP: Family planning; HIV: Human immunodeficiency virus; IUD: Intrauterinedevice; OR: Odds ratio; PMTCT: Prevention of mother-to-child HIV transmis-
integration between FP and HIV services at the health sion; SARA: Service Availability and Readiness Assessment; SPA: Service
facility level with more depth and breadth [42–44]. In Provision Assessment
addition to service readiness, these evaluation frame- Acknowledgements
works also consider demand for services, provider train- None.
ing, knowledge and competence, client reports of service
provision, and monitoring and evaluation. The use of Funding
The journal supplement is made possible by the generous support of the
standard indicators and data collected from client exit American People through the United States Agency for International
interviews and client observations would facilitate the Development (USAID) in partnership with United Nations Population Fund
monitoring and evaluation of integrated service delivery (UNFPA) and The Joint United Nations Program on HIV/AIDS (UNAIDS).
The views expressed in this publication are solely the opinions of the
and quality. Nevertheless, the definition used in the authors and do not necessarily reflect the official policies of the USAID,
present study for onsite availability of integrated services UNFPA or UNAIDS, nor does mention of the department or agency names
reflects the minimum level of service readiness required imply endorsement by the U.S. Government, UNFPA or UNAIDS.
to provide integrated FP services, which makes it the Availability of data and materials
more concerning that few health facilities met these All data used in this manuscript can be requested at: https://dhsprogram.
requirements. com/Data/ and http://www.who.int/healthinfo/systems/sara_introduction/en/
.
Despite these limitations, our study included health fa-
cilities representing a diverse array of settings and con- About this supplement
texts, including private, lower level and rural health This article has been published as part of Reproductive Health, Volume 16
Supplement 1, 2019: Effective Integration of Sexual Reproductive Health and HIV
facilities in 10 sub-Saharan African countries. The in- Prevention, Treatment, and Care Services across sub-Saharan Africa: Where is the
cluded countries represent varying trends in HIV trans- evidence for program implementation? The full contents of the supplement,
mission and sexual and reproductive health needs, published as a joint collaboration between Reproductive Health and BMC Public
Health, are available online at https://reproductive-health-journal.biomedcentral.
increasing the generalizability our findings. Together, the com/articles/supplements/volume-16-supplement-1 and https://bmcpublichealth.
10 countries represent about 23% of the people living biomedcentral.com/articles/supplements/volume-19-supplement-1.
with HIV in sub-Saharan Africa.
Authors’ contributions
MK, AL and KS jointly conceived the study. MK conducted the analysis and
Conclusions wrote the first draft of the paper. AL and KS provided critical review and
Our findings demonstrate that the availability of on-site comments. All authors read and approved the final manuscript.
integrated HIV care and FP services in sub-Saharan Af- Ethics approval and consent to participate
rica is low, despite the provision of FP services being Not applicable.
one of the four pillars of the global effort to prevent
Consent for publication
mother-to-child transmission. There are deficits in the Not applicable.
components necessary to provide integrated services,
particularly the training of providers. Our findings call Competing interests
The authors declare that they have no competing interests.
for the expansion of integrated FP services to privately
owned facilities, lower level facilities and facilities lack-
Publisher’s Note
ing a range of other HIV and ancillary services. The re- Springer Nature remains neutral with regard to jurisdictional claims in
sults of this study provide evidence to inform Ministries published maps and institutional affiliations.
Kanyangarara et al. Reproductive Health 2019, 16(Suppl 1):60 Page 9 of 9
Author details 23. Phiri S, Feldacker C, Chaweza T, Mlundira L, Tweya H, Speight C, et al.
1Department of International Health, Johns Hopkins Bloomberg School of Integrating reproductive health services into HIV care: strategies for
Public Health, 615 N. Wolfe Street, Baltimore, MD, USA. 2Department of successful implementation in a low-resource HIV clinic in Lilongwe, Malawi.
Public and Environmental Wellness, School of Health Sciences, Oakland BMJ Sex Reprod Heal. 2016;42(1):17–23.
University, Rochester, MI, USA. 3Department of Population, Family, and 24. Haddad LB, Feldacker C, Jamieson DJ, Tweya H, Cwiak C, Bryant AG, et al.
Reproductive Health, School of Public Health, College of Health Sciences, Medical eligibility, contraceptive choice, and intrauterine device acceptance
University of Ghana, Accra, Ghana. among HIV-infected women receiving antiretroviral therapy in Lilongwe,
Malawi. Int J Gynaecol Obstet. 2014;126(3):213–6.
Published: 29 May 2019 25. Haddad LB, Feldacker C, Jamieson DJ, Tweya H, Cwiak C, Chaweza T, et al.
Pregnancy prevention and condom use practices among HIV-infected
women on antiretroviral therapy seeking family planning in Lilongwe,
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