Family Planning and HIV Integration in Malawi: A Policy Analysis

Publication date: 2015

FAMILY PLANNING AND HIV INTEGRATION IN MALAWI A Policy Analysis September 2015 This publication was prepared by Laili Irani, Sara Pappa, and Pierre Dindi of the Health Policy Project. HEALTH POL ICY P R O J E C T Suggested citation: Irani, L., S. Pappa, and P. Dindi. 2015. Fam ily Planning and HIV Integration in Malawi: A Policy Analysis. Washington, DC: Futures Group, Health Policy Project. ISBN: 978-1-59560-130-8 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activ ities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Family Planning and HIV Integration in Malawi A Policy Analysis SEPTEMBER 2015 This publication was prepared by Laili Irani,1 Sara Pappa,2 and Pierre Dindi2 of the Health Policy Project. 1 Population Reference Bureau, 2 Futures Group The information prov ided in this document is not official U.S. Government information and does not necessarily represent the v iews or positions of the U.S. Agency for International Development. iii CONTENTS Acknowledgments . iv Abbreviations . v Introduction . 1 Background .1 Rationale .2 Methodology . 3 Search Strategy .3 Search Results .3 Findings . 4 List of Policies, Guidelines, and Strategies Reviewed .4 Summary of Key Findings from the Policy Analysis.5 Discussion and Next Steps. 9 Annex A. Summary of Key Findings from Policies, Strategies, Guidelines Reviewed . 10 HIV and AIDS Policies, Strategies, Guidelines . 10 FP/SRH Policies, Strategies, Guidelines . 13 General Health Policies, Strategies, Guidelines Addressing FP and HIV Integration . 19 General Health Policies, Strategies, Guidelines Not Addressing FP and HIV Integration. 20 References. 24 iv ACKNOWLEDGMENTS The authors would like to thank Madison Mellish for her research support and technical assistance in the preparation of this report. The authors also wish to thank Erin McGinn, Betty Farrell, and Jay Gribble for their technical input in reviewing drafts of this report. v ABBREVIATIONS ANC antenatal care ART antiretroviral therapy ARV antiretroviral BCC behavior change communication DHMT District Health Management Team FP family planning HPP Health Policy Project HSA health surveillance assistant HSSP Health Sector Strategic Plan HTC HIV testing and counseling IAWG Interagency Working Group on Sexual and Reproductive Health and HIV Linkages IPPF International Planned Parenthood Federation M&E monitoring and evaluation MDHS Malawi Demographic and Health Survey MOH Ministry of Health NAC National AIDS Commission PAC post-abortion care PEP post-exposure prophylaxis PLHIV people living with HIV PMTCT preventing mother-to-child transmission RH reproductive health SBCC social and behavior change communication SRH sexual and reproductive health SRHR sexual and reproductive health and rights SSDI support for service delivery integration STI sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund WHO World Health Organization 1 INTRODUCTION Background Malawi has a high unmet need for family planning (FP) services: 26 percent of women ages 15 to 49 report wanting to space or limit their pregnancies but are not using contraception (MDHS, 2010). According to the latest (2010) Malawi Demographic and Health Survey, the current contraceptive prevalence rate is 42 percent for modern methods (MDHS, 2010). In addition, the total wanted fertility rate of 4.5 children per woman is much less than the reported total fertility rate of 5.7 children per woman. One of the reasons for the high unmet need for family planning may be due to lack of adequate FP services. A 2006 sector-wide approach report noted that only 54 percent of health facilities provided any FP services. Improving access to and quality of FP services is likely needed to address Malawi’s high unmet need for family planning. Malawi also grapples with high HIV prevalence. The HIV prevalence in 2010 was 11 percent among adults ages 15 to 49, just slightly lower than the 12 percent reported in 2004. In addition, HIV prevalence among women is higher than men (13 percent among women ages 15 to 49, compared with 8 percent among men the same age). Even though HIV prevalence has stagnated, coverage of HIV testing has increased considerably over the years, showing progress in seeking care. HIV testing among women rose from 13 percent in 2004 to 72 percent in 2010, in huge part due to testing during antenatal care (ANC) as part of preventing mother-to- child transmission (PMTCT). Among men, the prevalence of testing rose from 15 percent to 51 percent during the same time period. General studies on the contraceptive needs of HIV- positive women in Africa show that a large proportion of pregnancies (51%–84%) among HIV-positive women are unplanned (Wilcher et al., 2013). There is limited data on the contraceptive needs of HIV-positive women in Malawi specifically; one study reports an unmet need of approximately 22 percent (Habte and Namasasu, 2015). Integrating family planning into HIV services is seen as a promising practice to address unmet need for contraception as well as to reduce mother-to-child transmission. The World Health Organization (WHO) recommends that services be integrated in areas with high HIV prevalence and high unmet need for family planning (WHO, 2009). In addition, USAID recommends that family planning and HIV services be integrated in areas with generalized epidemics, i.e., where the HIV prevalence is more than 1 percent among pregnant women. Integrating services ensures that if clients were to visit the facility for one reason, providers would address several health issues at the same time. Malawi has shown tremendous political support for integrating health services. Malawi is a signatory to several global calls for action that advocate for the integration of services, such as the 1994 International Conference on Population and Development (Cairo) Program of Action and the 2006 Maputo Plan of Action. At the national level, Malawi has issued several policies and strategies that speak to integrating family planning/sexual and reproductive health (SRH) and HIV services. Likewise, donors such as USAID and the United Nations Population Fund (UNFPA) are supporting the Malawian government’s Integration of services is “an approach whereby healthcare prov iders use opportunities to engage the client in addressing broader health and social needs than those prompting the health encounter” (Farrell, 2007, pg. 3). This focus of integration involves prov ision of family planning and HIV/sexually transmitted infection prevention, treatment, and care serv ices during one v isit or in one room. In addition, integration can combine different kinds of sexual and reproductive health and HIV serv ices to improve health outcomes. Integrated serv ices do not all have to be prov ided in the same room by the same provider. They can include referrals from one serv ice to another with the aim of offering comprehensive serv ices. (IPPF et al., 2011) Family Planning and HIV Integration in Malawi: A Policy Analysis 2 efforts to integrate family planning, HIV, and other primary health services at the policy, systems, and service delivery levels through such projects as Support for Service Delivery Integration (SSDI) and SRHR and HIV Linkages. The latter, for example, promotes the linkages between HIV and sexual and reproductive health and rights (SRHR) policies and services to better strengthen the health system in Malawi and increase access to and use of a broad range of important services (IAWG, nd). The Ministry of Health (MOH) of Malawi, in collaboration with various stakeholders, sets the national agenda for health in the country (HSSP, 2011). Through its departments, the ministry develops, enforces, and reviews policies and guidelines for both the public and private health sector. This includes incorporating new and emerging issues like family planning and HIV integration. The overall responsibility for delivering health services at district and lower levels falls under the district assemblies, which report to both MOH and the Ministry of Local Government and Rural Development (HSSP, 2011). Additionally, MOH has established five zonal health support offices to support district health management teams (DHMTs) in the planning, delivery, and monitoring of health services. According to the National Sexual and Reproductive Health and Rights Policy 2009–2014 (2009), the MOH has, on the one hand, mandated the Reproductive Health Directorate with the responsibility of directing and coordinating the integration, planning, implementation, and monitoring and evaluation (M&E) of SRH services (MOH, 2009). These services include family planning and prevention/management of sexually transmitted infections (STIs), among others. On the other hand, the Department for HIV and AIDS of the MOH is principally responsible for coordinating the biomedical responses to HIV and AIDS in the areas of HIV testing and counseling (HTC), HIV treatment and care, PMTCT, and syndromic management of STIs (IPPF et al., 2011). In addition to the MOH Department of HIV and AIDS, the National AIDS Commission (NAC) coordinates the multisectoral national HIV and AIDS response under the leadership of the Office of the President and Cabinet (National HIV and AIDS Policy, 2011). NAC is the principal recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria AIDS grant. Overall, HIV programming has more partners and gets more funding than sexual and reproductive health (IPPF et al., 2011). Rationale In 2014, USAID requested the Health Policy Project (HPP) to undertake an assessment of the status and extent of FP-HIV integration in Malawi. Since integration at the policy level is important and the first step to a well-guided implementation of health service delivery (EngenderHealth, 2014), HPP undertook a policy analysis to determine the level of FP-HIV integration that appears in government policy documents and explored the extent to which the policies outline and address the integration of services. For the purpose of this review, we defined policies to include policies, strategies, guidelines, action plans, implementation plans, clinical and service delivery standards, and other similar documents. Other research components on the status of FP-HIV integration, including stakeholder interviews and a facility- level assessment, are documented in separate reports (forthcoming). 3 METHODOLOGY Search Strategy Between August and December 2014, we retrieved Government of Malawi policies, strategies, and guidelines on family planning, HIV and AIDS, and general health. We scanned Malawian government and various ministry websites, searched on web engines such as Google, and spoke to key stakeholders including government officials, implementing partners, donors, and civil society groups. Several search terms were used when searching the internet: “family planning and HIV integration,” “assessments on family planning and HIV integration,” “sexual and reproductive health and HIV integration,” “guidelines on family planning and HIV,” “PMTCT guidelines,” and “government policies on family planning and HIV integration.” The following stakeholders were consulted for literature: UNFPA, Journalists Association Against AIDS, Ministry of Health departments (Reproductive Health, HIV and AIDS, Central Monitoring and Evaluation, Health Education Unit, planning), Jhpiego (SSDI Services), Johns Hopkins University Center for Communication Programs (SSDI Communications), Abt Associates (SSDI Systems), NAC, University of Malawi–Kamuzu College of Nursing, Banja La Mtsogolo (local Marie Stopes International affiliate), John Snow International (USAID | DELIVER project), Management Sciences for Health, and the National Youth Council of Malawi. We asked the stakeholders for documents on the following topics: national SRH and HIV policies and guidelines and guidance on procurement and distribution of FP/HIV commodities. Types of Documents Retrieved A policy is developed by a government sector to share its position on a particular issue. An example of a Malawi policy document is the National HIV and AIDS Policy (2011–2016), developed by the Department of Nutrit ion, HIV and AIDS under the Ministry of Health. It offers a thorough examination of the status of HIV and AIDS in the country and includes a comprehensive discussion of the next steps the government plans to take to address HIV and AIDS issues. A policy document outlines strategic goals and objectives of the government. A strategy (also known as implementation strategy or strategic plan) is derived from the broader national development goals outlined in the policy document. It identifies specific approaches the government sector wishes to take to achieve its core agenda. Guidelines prov ide guidance and direction for effective implementation of a policy at all levels, outlining the roles and responsibilities of key persons in the process (Ghana Health Serv ice, 2005). Guidelines also set standards on how strategic approaches are operationalized. Search Results A total of 30 policy documents were retrieved during the document search. These included national policies, strategies, operational guidelines, and standards. Once relevant documents were retrieved, they were reviewed to determine the relevancy of the content. Nineteen documents were selected that addressed the provision of FP and/or HIV and AIDS services or discussed integration. Of these 19, five documents addressed the provision of HIV services and also discussed the integration of FP and HIV services; six documents provided guidance on the provision of SRH or FP services and also discussed integrating with HIV services. Of the eight overarching health policy documents, two addressed integration while six provided general guidance on implementing health services at the policy, facility, or community level. 4 FINDINGS List of Policies, Guidelines, and Strategies Reviewed Below is a list of the 19 government documents that were thoroughly reviewed and summarized. A summary of the key findings from each document is described in Annex A. Each summary includes an overview on the purpose and structure of the document, followed by any guidance on provision of FP and/or HIV services. Finally, the document highlights the components that address the integration of FP and HIV services. HIV and AIDS policies, strategies, and guidelines reviewed • National HIV and AIDS Policy, June 2011–June 2016 • Malawi National Plan for the Elimination of Mother to Child Transmission 2012–2015 • National HIV Prevention Strategy 2009–2013 • Clinical Management of HIV in Children and Adults (2014) All these HIV and AIDS policies were written by the MOH except for the National HIV Prevention Strategy and the Malawi National HIV and AIDS Strategic Plan 2011–2016, which were drafted by the NAC. FP/SRH policies, strategies, and guidelines reviewed • National Sexual and Reproductive Health and Rights Policy 2009–2014 • National Sexual and Reproductive Health and Rights Strategy 2011–2016 • Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (2007) • Community Based Injectable Contraceptive Services Guidelines (2008) • Malawi Guidelines for Family Planning Communication (2011) • Guidelines for Community Initiatives for Reproductive Health (2007) • Malawi National Reproductive Health Service Delivery Guidelines 2014–2019 All these FP/SRH policies were prepared by various departments of the MOH. General health policies, strategies, and guidelines addressing FP and HIV integration • Malawi Health Sector Strategic Plan 2011–2016 • National Plan of Action for Scaling Up SRH and HIV Prevention Interventions for Young People 2008–2012 The Health Sector Strategic Plan was drafted by the MOH and the National Plan of Action for Young People was drafted by the Ministry of Youth, Development and Sports. General health policies, strategies, and guidelines not addressing FP and HIV integration • National Youth Policy (2013) • National Health Policy (2014) • Health Promotion Policy (2013) Findings 5 • Social and Behavior Change Communications (SBCC) Strategy 2011–2016 • National Health Information System Strategic Plan 2011–2016 • National Standards for Youth Friendly Health Services (2007) The National Youth Policy was drafted by the Ministry of Youth Development and Sports while the others were drafted or endorsed by the MOH. Summary of Key Findings from the Policy Analysis The key findings of this policy analysis examine the status of FP integration into HIV services, HIV services into FP services, and the status of both family planning and HIV into other health services. In addition, this policy analysis discusses the role of PMTCT in encouraging the integration of FP and HIV services for pregnant women. The Government of Malawi has placed special attention on efforts to engage youth and provide integrated youth-friendly health services across several policy documents; as a result, this analysis summarizes key recommendations for providing integrated youth-friendly health services. Finally, a summary of community-level efforts in support of integration is offered. Interventions for integrating FP services into HIV services The policy documents covered integrating FP into various HIV services, such as HIV testing and counseling and antiretroviral therapy (ART), across the health sector at the policy level, within DHMTs, in facilities, and within communities. The Government of Malawi has placed significant emphasis on scaling up FP interventions that address preventing unwanted pregnancies among HIV-positive women by either providing FP services at the ART clinic or strengthening referral mechanisms so women can access FP services at a different site and/or time. The guidelines in Clinical Management of HIV in Children and Adults recommend “provider-initiated family planning,” where the provider assumes that all HIV-positive clients over 15 are sexually active and counsels them on FP methods. In particular, these guidelines mention the need to provide male condoms and injectables at ART clinics. Several policy documents reviewed also refer to the importance of integrating FP services into other existing HIV services but do not explicitly outline details of how this integration should occur. A few policy documents also emphasize the need to engage the private sector in providing FP services within their existing HIV and STI services but do not specify what this integration could look like or what the public-private partnership opportunities are that could address clients’ holistic needs. The National Sexual and Reproductive Health and Rights Strategy highlights the need to expand SRH services to key populations and caretakers of orphans and vulnerable children. Male engagement in the integration of FP services into existing HIV services does not receive much attention across the policy documents, with only some mention of counseling HIV-positive men on various FP methods within the clinical setting and ensuring that condoms are available at the ART clinic. The overarching Health Sector Strategic Plan also acknowledges the need to integrate family planning with HTC services at all levels (primary, secondary, and tertiary), not just at ART clinics. Another policy document, the Malawi National Plan for the Elimination of Mother to Child Transmission, recognizes that integration is a new process in Malawi and identifies some steps that are needed to ensure integrated services, such as training providers to provide/offer comprehensive services. The importance of communicating correct messages on family planning to HIV clients, as well as the general public, is highlighted in the policy documents. For example, the Guidelines for Family Planning Communication note that ART providers need to be trained to counsel HIV-positive clients on how to discuss family planning with their partners. Some strategies also highlight the need to integrate Family Planning and HIV Integration in Malawi: A Policy Analysis 6 information on family planning and HIV prevention and treatment in their behavior change communication (BCC) messages to the public. This would provide more comprehensive information to the public while highlighting the need for dual protection. Some policies state that SRH services need to be integrated into community-based STI and HIV and AIDS services but do not provide further guidance. Integration of HIV services into FP services Fewer policy documents referenced integration of HIV services into FP services but mention was made across both FP/SRH documents and HIV policy documents. The policy documents mention various types of HIV services that should be integrated into existing FP services, such as counseling on HIV prevention, HIV testing and counseling, and dispensing antiretrovirals (ARVs). They also acknowledge that when certain HIV services cannot be provided at the same site as FP services, clear referral mechanisms should be established. The Reproductive Health Service Delivery Guidelines mention the need for “provider-initiated testing and counseling” among FP clients who do not know their HIV status. The guidelines also mention that FP providers should be trained in testing and counseling, there should be proper referral of clients to link to pre-ART/ART clinics, and HIV-negative women should be counseled on risk reduction and dual protection. The National Sexual and Reproductive Health and Rights Policy discusses making post-exposure prophylaxis (PEP) available, free of charge, after any high-risk exposure where medically indicated, thus noting the importance of training all providers on PEP. This policy’s corresponding guidelines describe the “balanced counseling strategy,” an interactive, client-friendly strategy that describes the steps a provider should take when counseling a client on family planning; one of the steps of the strategy describes the process of providing information to FP clients on HIV prevention. Finally, the policy documents recognize the necessity of engaging districts and the decentralized structure. Several times, the policy documents make mention that integration can be successful if district health plans include it and develop clear processes for integration, for which facilities and healthcare providers will be accountable, and if district budgets reflect allocations for integrated service implementation. An example of this is in the Community Based Injectable Contraceptive Services Guidelines, where a key focus is on mobilizing resources for injectable contraceptives and HIV supplies, reflecting FP-HIV integration at the community level, to ensure availability at all times, especially in hard-to-reach areas. Integration of FP services into other non-HIV services National policies related to reproductive health (RH) discuss integrating FP services into other services that are not HIV-related. For example, the National Sexual and Reproductive Health and Rights Strategy states that FP services should be an integral part of the essential healthcare services package. It also discusses the importance of addressing FP within a broader context through advocacy and policy change across various sectors, thus strengthening multisectoral collaboration and commitment to family planning. As a guiding principle, the strategy calls for strengthening public-private partnerships to better address determinants of health. Similarly, many other policies highlight the need for multisectoral collaboration. However, these policies do not explicitly outline what ministries should be working together and what steps they should follow to integrate services. Family planning services are a key component of post-abortion care (PAC); as such, the National Reproductive Health Service Delivery Guidelines stress the need to implement family planning among PAC clients. These guidelines focus on ensuring that all PAC clients receive voluntary HIV and STI screening along with guidance on protecting themselves from further infection and are counseled on the various FP methods available. Findings 7 Integration of HIV services into other non-FP services The HIV policies and plans note the need to integrate HIV and AIDS programs into all policies, health sector planning, and workplaces and other environments within the public and private sector. This guidance emphasizes the need to make HIV services (prevention and treatment) available to all and through any potential avenue. In addition to HIV policy documents, other health documents also described the need for integrating HIV services into other services. For example, the MOH’s Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity suggests that the essential health package of services include HIV services along with all other maternal and neonatal services. This includes providing adequate HIV services to infants born of HIV-positive mothers. A few policies provided vague guidance on integrating HIV prevention activities in other existing programs, especially behavior change programs. PMTCT PMTCT is provided as part of the minimum package of ANC services. It is an FP-HIV integrated service as it promotes voluntary HIV testing and counseling of pregnant women and includes the provision of FP counseling and services to women and their partners living with HIV, as well as education and counseling for HIV-negative women on how to prevent future infection. The National Plan for the Elimination of Mother to Child Transmission acknowledges that HIV-related commodities, such as HTC kits and ARVs, as well as FP commodities, need to be made available at ANC clinics; moreover, the PMTCT guidelines highlight the need to continuously discuss and emphasize the importance of family planning with women during ANC visits, as well as during postnatal and all other follow-up visits. The National Plan calls for strong referrals to be established if FP services are not available at ANC clinics and emphasizes the need to train providers since PMTCT is specialized care. Youth-friendly health services Several policy documents emphasize the need for providing youth-friendly health services. They specifically refer to providing SRH services catered toward youth and adolescents, including HIV services, such as counseling and testing. The National Standards for Youth Friendly Health Services (2007) complement clinical standards developed by the Reproductive Health Unit by helping to improve the youth friendliness of services. The Standards emphasize health promotion, delivery of health services, and referral and follow-up for a multitude of services that youth should have access to, such as HIV and AIDS, STIs, family planning, PAC, treatment for sexual abuse, maternal and neonatal healthcare, PMTCT, etc. The purpose of these standards is to create a youth-friendly environment where young people will be comfortable accessing and receiving all the information and services they need in a nonjudgmental environment. The National Plan of Action for Scaling Up SRH and HIV Prevention Interventions for Young People discusses training providers and creating a space where youth are comfortable. It also discusses developing policy advocacy plans and conducting advocacy campaigns to encourage youth to access such services. The plan further acknowledges that success can only be achieved by engaging youth themselves in planning and implementing programs at the national, district, and local levels. Integration at the subnational level A few policy documents acknowledged at many instances that integration would only be possible if they were reflected in district implementation plans. They also acknowledged that health surveillance assistants (HSAs) were the front-line workforce of the healthcare system who could provide services at people’s doorsteps. Hence, they were the key to providing information to clients on FP methods and HIV Family Planning and HIV Integration in Malawi: A Policy Analysis 8 services. HSAs can also provide actual FP methods such as pills, condoms, and injectables to all groups in the community, including people living with HIV and AIDS (PLHIV). Finally, a few policy documents provided suggestions on engaging community members, such as religious leaders and community leaders, as a means to garner support and spread knowledge and awareness on integrated services. For example, the Community Based Injectable Contraceptive Services Guidelines document focuses heavily on the need for community engagement for family planning and FP- HIV integration through behavior change communications, community mobilization, and engagement of community leaders. More specifically, the guidelines suggest sensitizing communities on the availability of injectable contraceptives and HIV services, providing information on service availability, and forming male community groups as well as youth community groups to discuss family planning and HIV and promote male involvement. 9 DISCUSSION AND NEXT STEPS This policy analysis finds that all RH and HIV policies, strategies, and guidelines discussed integration of FP/SRH and HIV services to some degree. There was significant mention on the need to integrate FP services into HIV services, for example through ART clinics. On the other hand, very few general health policies addressed FP-HIV integration explicitly. The policy documents are well aligned, providing supplementary guidance and information, but the fact that various elements of integration of FP-HIV services are spread out across a dozen health documents likely results in a disjointed vision for FP-HIV integration in Malawi, as well as inconsistent implementation. Furthermore, although these documents mention multisectoral collaboration, either in the development of policies or the implementation of programs, specific details on how to increase and strengthen multisectoral collaboration efforts are unclear. Other components of HPP’s exploration of the status of FP-HIV integration in Malawi, including stakeholder interviews and a facility-level assessment, are forthcoming and will be documented in separate reports. These data may provide additional insight on the policy needs to provide an enabling environment for effective FP-HIV service integration. As a specific next step, the MOH and other key stakeholders could consider convening to discuss the interrelation of these policies and how best to streamline their effective implementation. Since the different policies use a variety of approaches to FP-HIV integration, the MOH may want to consider developing an implementation and monitoring plan that will outline the various elements of integration noted across all the policy documents and identify how they should be measured. This plan should outline the specific indicators that measure integration, the various sectors and departments responsible for coordinating and compiling those data, the data sources from where they can collect the information, and the frequency of reporting. This routine monitoring process will enable the health system to get a better picture of how integration is being carried out and what can be done to improve this process. 10 ANNEX A. SUMMARY OF KEY FINDINGS FROM POLICIES, STRATEGIES, GUIDELINES REVIEWED HIV and AIDS Policies, Strategies, Guidelines National HIV and AIDS Policy, June 2011–June 2016 (2011), Office of the President and Cabinet, Department of Nutrition, HIV and AIDS, Lilongwe, Malawi Overview The National HIV and AIDS Policy was developed to guide the implementation of the national HIV and AIDS response. It facilitates the scale-up of evidence-based programming, recognizing and addressing current issues, gaps, and challenges. Operationalized through the National HIV and AIDS Strategic Plan, the policy is guided by eight priority areas that address prevention of HIV, providing comprehensive multisectoral management and empowering PLHIV and other vulnerable populations while building the capacity of service providers. Each priority area includes a corresponding policy statement addressing associated challenges, an implementation plan, and an M&E strategy. FP The policy does not mention family planning. HIV Guided by eight priority areas, HIV and AIDS are addressed at multiple levels in this policy document, including at the community level. The policy iterates the need to empower PLHIV and other vulnerable and marginalized populations to participate in relevant programs. At the health facility level, prevention measures to avert further spread of HIV are the main focus of the policy. These include ensuring universal access to HIV treatment and care, including nutrition services. In addition, the policy outlines the need to provide other related services, such as treatment for STIs, tuberculosis, and other HIV-related illnesses. A legal and policy framework that is firmly aligned with human rights obligations is stressed. Furthermore, the policy underscores the need for a multisectoral response to HIV and AIDS, whereby all sectors, public and private, take strides to integrate and align HIV and AIDS in their key policies, programs, strategic plans, and budgets. FP-HIV Integration The policy makes no mention of FP-HIV integration; however, the strong emphasis on multisectoral coordination and the call for other sectors to address HIV and AIDS in their programs and policies could be interpreted as a need for FP-HIV integration. The policy encourages integrating HIV and AIDS programs into the policies, workplaces, and core businesses of all private and public enterprises. Even though the policy does not explicitly discuss FP-HIV integration, the corresponding National HIV and AIDS Strategic Plan, which guides the management and implementation of this policy, discusses strengthening the integration of HTC services in FP services. Annex A 11 Malawi National HIV and AIDS Strategic Plan 2011–2016 (2011), National AIDS Commission, Lilongwe, Malawi Overview The National HIV and AIDS Strategic Plan guides the management and implementation of the countrywide HIV and AIDS response. Operationalizing the National HIV and AIDS Policy, the Strategic Plan focuses on prevention, access to quality treatment and care, integration of HIV and AIDS policies and programs in the public and private sectors, multisectoral and multidisciplinary coordination, and sustaining the HIV and AIDS research agenda. FP A priority strategy of the plan is to promote modern FP methods among women and men infected with HIV, increase male involvement in family planning, and ensure the availability of male and female condoms to all PLHIV. HIV The main goals of the plan are to reduce new HIV infections among children and adults, reduce deaths from AIDS with a special focus on children, and reduce new HIV infections among young people ages 15 to 24. The plan identifies high-priority actions that need to be implemented, such as reducing transmission, timely HIV testing and counseling, implementing SBCC programs, and ensuring timely access to ART. The plan also focuses on improving service provision for key and vulnerable populations. Additional actions outlined focus on increasing the capacity of program planners and health providers to provide the necessary services and monitor and evaluate the national response to HIV and AIDS. FP-HIV integration The plan highlights the need to scale up FP interventions that address prevention of unwanted pregnancies among HIV-positive women. In addition, the plan also discusses strengthening the integration of HIV testing and counseling in FP services. Along similar lines, the plan states that PMTCT needs to be scaled up and provided as part of the minimum package of ANC services. Malawi National Plan for the Elimination of Mother to Child Transmission 2012–2015 (2012), Ministry of Health, Lilongwe, Malawi. Overview The National Plan for the Elimination of Mother to Child Transmission works toward elimination of mother-to-child transmission by eliminating new pediatric HIV infections and improving the quality of life of mothers. The plan focuses on the four prongs of PMTCT: HIV prevention in women of reproductive age, preventing unintended pregnancy in women with HIV, prevention of HIV transmission from mother to child, and provision of care and support to mothers, their children, and families. Key focus areas include HIV prevention, family planning, treatment and care services, and supply chain capacity and management. FP The second prong of PMTCT is geared toward providing FP counseling and services to women living with HIV. A key target of the plan is to reduce unmet need for family planning to zero among all women, thus enabling them to safely plan desired pregnancies regardless of HIV status. The plan focuses on expanding the availability of FP services for women, particularly women testing HIV-positive, and men at the facility and community level. These can be achieved by strengthening the overall capacity of health providers, better managing the supply of condoms and FP commodities in facilities, training community-based distribution agents to effectively distribute FP commodities, and Family Planning and HIV Integration in Malawi: A Policy Analysis 12 improving the ability of HSAs to provide community-based FP services, including provision of Depo- Provera. HIV The plan seeks to reduce HIV incidence in women and children under 5. Strategic objectives focus on strengthening HIV prevention for women and men of reproductive age, increasing coverage and accessibility of PMTCT services, widely implementing WHO option B+, and increasing the coverage of pediatric HIV care services. An overarching objective is to improve supply chains and management of HIV-related commodities, as they are critical to ensuring the provision of quality PMTCT services. FP-HIV integration A strategic objective of the plan is to accelerate the national scale-up of PMTCT services and its integration into RH and FP services. In addition to building capacity of health facilities and communities to offer FP services, the plan calls for the training of ART and PMTCT service providers to provide integrated FP services. One way the plan recommends measuring integration is to assess the number of PMTCT facilities with no stockouts of FP commodities (Depo-Provera, pills, condoms, Norplant, intrauterine contraceptive devices). Another goal of the plan is to engage men and boys to participate in PMTCT, maternal and child health, SRH, and FP programs and hence make the programs more responsive to their needs. National HIV Prevention Strategy 2009–2013 (2009). National AIDS Commission, Lilongwe, Malawi Overview The National HIV Prevention Strategy guides the planning and implementation of countrywide interventions for HIV prevention in order to reduce new infections and further mitigate the burden of HIV and AIDS. The strategy places a renewed emphasis on HIV prevention efforts that are evidence-based and data-driven, programming approaches that are human rights–based and gender-responsive, and a multisectoral approach to HIV prevention policies and programming. Furthermore, the strategy calls for an adherence to the “Three Ones” principle (one national coordinating authority, one national action framework, one M&E plan). FP The strategy focuses on increasing community-level access to FP services, in addition to RH, HTC, and PMTCT services. HIV The strategy highlights the need for both biomedical and behavioral HIV prevention interventions and includes HIV testing and counseling, PMTCT, blood and injection safety, medical male circumcision, timely initiation of ART, and condom programming. The strategy recognizes the need to increase capacity and strengthen health systems to respond to the epidemic and the importance of monitoring and evaluating the national HIV and AIDS response. The strategy also addresses structural and cultural factors that increase vulnerability to HIV infection, such as stigma and discrimination, and the promotion of legal and human rights to reduce HIV risk and vulnerability. FP-HIV integration The strategy calls for increased access to family planning and HIV prevention services for HIV-positive women of reproductive age and strengthening referral mechanisms. Furthermore, the approach calls for an increase in HIV testing and PMTCT service provision at all FP Annex A 13 service delivery points. This is done by identifying best practices for integrating HIV prevention with other services and developing referral guides to link people to different services in the health centers and communities. Clinical Management of HIV in Children and Adults (2014), Ministry of Health, Lilongwe, Malawi Overview The Clinical Management of HIV in Children and Adults offers practical guidance to health providers in public and private sector facilities on the implementation of integrated HIV services. It aims to provide high-quality services to everyone in need. It offers these services by establishing a framework to all national HIV programs by standardizing clinical management of HIV-positive patients and HIV-exposed children. Furthermore, the document offers standardized, simplified protocols for all HIV interventions to aid health workers in different service delivery settings. FP Family planning is identified as a key service for patients with HIV. The guidelines promote provider- initiated family planning to prevent unwanted pregnancies, regardless of HIV status. The guidelines emphasize the need for couples to use dual protection and identify the following FP methods as safe with ART treatment: Depo-Provera, intrauterine contraceptive devices, tubal ligation, and vasectomy. The guidelines further call for providers to advise women that certain hormonal methods, such as pills or implants, may become less effective with ARVs (though this information may not be accurate since the publishing of these guidelines). Moreover, the guidelines stress that health providers should encourage HIV-positive women to make an informed choice about their pregnancy and should not discourage pregnancy; instead, providers should instruct women on how to reduce the risk of mother-to-child transmission. HIV The document offers a series of detailed service delivery protocols/guidelines covering ART eligibility, preventive services, starting and continuing ART, and post-exposure prophylaxis. All intervention guidelines are broken down by children and adults. FP-HIV integration The guidelines ask providers to assume that all clients age 15 years and above are sexually active and directs the provider to initiate FP services accordingly, regardless of their HIV infection status. Male clients should be counseled and given condoms, and females should be offered condoms and Depo- Provera, if they choose. The guidelines also stipulate that clients should be referred to FP clinics for further services. Furthermore, the guidelines emphasize the need for service providers to respect women’s choice to conceive. The guidelines also state that the HIV program should procure and distribute condoms and Depo-Provera as part of the service package offered to HIV clients. FP/SRH Policies, Strategies, Guidelines National Sexual and Reproductive Health and Rights Policy 2009–2014 (2009), Ministry of Health, Lilongwe, Malawi Overview The National Sexual and Reproductive Health and Rights Policy addresses SRHR issues among various age groups and provides a framework for implementing SRHR programs throughout the country. The Family Planning and HIV Integration in Malawi: A Policy Analysis 14 revised policy includes emerging issues, i.e., basic emergency obstetric and neonatal care, community- based neonatal care, cervical cancer screening, youth-friendly health services, ART, and PMTCT. The policy guides decisionmakers and program managers in the implementation of effective SRHR programs with a focus on building the capacity of health systems to deliver high-quality SRHR services. FP A main goal of the policy is to reduce unmet need for family planning through the provision of voluntary comprehensive FP services at all levels and for all men, women, and young people of reproductive age. Key strategies focus on strengthening availability of, access to, and use of FP services at the facility and community levels as individual and integrated services. Specifically, long-acting and permanent methods should be made available at all levels of the health system; injectable contraceptives should be made available through community-based distribution systems; and emergency contraception should be made available for women who have had unprotected sex. A special emphasis is placed on involving men in reproductive health by empowering them to access services and take shared responsibility for SRH decisions. In addition, the policy aims to achieve universal coverage by engaging with men and women at the community level. HIV The policy pays special attention to reducing the incidence of new HIV infections. Key strategies focus on strengthening integration of HIV services with STI services and on implementing behavior change interventions to reduce high-risk behaviors among women, men, and youth. In addition, the policy emphasizes the need to provide youth-friendly health services to jointly reduce incidence of HIV and AIDS and unplanned pregnancies among youth. FP-HIV integration The policy explicitly states the need to integrate SRH services into existing HIV and AIDS services so that they are provided as a package to HIV clients. In addition, the policy states that post-exposure ARVs shall be made available, free of charge, after any high-risk exposure where medically indicated. The policy also promotes dual protection among sexually active populations. The policy also encourages the provision of PMTCT within ANC services. National Sexual and Reproductive Health and Rights Strategy 2011–2016 (2012), Ministry of Health, Lilongwe, Malawi Overview This strategy is aligned with the SRHR policy and guides the implementation of high-quality, integrated SRH services. Broad objectives are organized by specific SRH components which include family planning and prevention and management of STIs and HIV and AIDS, among others. FP The strategy aims to reduce unmet need for family planning through the provision of voluntary comprehensive FP services at the health facility and community levels. The strategy also outlines measures that can be taken to improve the provision of services, such as integrating FP services into other essential healthcare services, improving the policy environment, strengthening multisectoral collaboration for the promotion and delivery of FP services, and enhancing advocacy activities. Furthermore, the strategy emphasizes the need to secure and promote adequate and sustainable funding for contraceptives and condoms, including through budget line items for contraceptives and earmarked funds from the government and donors. Annex A 15 HIV The strategy focuses on strengthening the integration of SRH services into existing HIV and STI services. It also discusses providing FP services to vulnerable groups, including PLHIV, young people, key populations, and caregivers of orphans and vulnerable children. At the community level, the policy highlights the need to strengthen community-based SRH services, which include STI and HIV and AIDS services. FP-HIV integration A key strategy is to strengthen the integration of family planning in PMTCT and HIV services in an effort to raise the proportion of HIV-positive women currently using FP methods. This can be achieved through establishing referral mechanisms between SRH and HIV-related services, including the private sector, which could be encouraged to distribute condoms and other FP methods. The strategy also ensures integrated BCC messaging to the public. Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (2007), Ministry of Health, Lilongwe, Malawi Overview Based on the findings of an assessment, this road map offers a range of strategies to improve maternal and neonatal health programs resulting in improved health outcomes. The audience for this document includes policymakers, development partners, training institutions, and service providers. It strives to increase accessibility to quality obstetric care and to strengthen institutional capacity to provide better services. FP Strengthening FP services is a key tenet of this road map and is identified as a high-impact intervention. This document contains a list of indicators to measure the provision of services and improve maternal and neonatal health outcomes, which include assessing the percentage of postnatal mothers receiving modern contraceptives, uptake of family planning among adolescents, contraceptive prevalence rate, and percentage of health facilities providing youth-friendly services. Furthermore, the road map suggests roles and responsibilities for various ministries, highlighting the importance of multisectoral collaboration. HIV The road map highlights the need to provide PMTCT, with a focus on providing voluntary counseling and testing and ART to pregnant women. The road map also highlights the need to provide adequate HIV services to infants born of HIV-positive mothers. In suggesting roles and responsibilities for various ministries, the road map calls on the Ministry of Education and Vocational Training to strengthen school clubs to better address RH issues, including HIV and AIDS. It further directs the Ministry of Youth, Sports and Culture (now called the Ministry of Youth Development and Sports) to raise awareness on cultural practices that increase HIV risk among youth, particularly girls, while also creating peer education programs to address HIV risk and vulnerability among both in- and out-of-school youth. FP-HIV integration The road map encourages the MOH to undertake a more integrated approach to providing maternal and neonatal health services with HIV and AIDS services. It can achieve this by providing the essential health package, which includes FP and HIV and AIDS services. Furthermore, the road map calls for United Nations agencies and other development partners to promote provision of integrated SRH and HIV and AIDS services. Family Planning and HIV Integration in Malawi: A Policy Analysis 16 Community Based Injectable Contraceptive Services Guidelines (2008), Ministry of Health, Lilongwe, Malawi Overview The Community Based Injectable Contraceptive Services Guidelines are intended to guide the scale-up of providing injectable contraceptives at the community level. This is primarily achieved by building the capacity and skills of HSAs to provide contraceptives. This should be done in a way that promotes information and access to method choice and strong client-provider interpersonal relationships. The guidelines are intended to assist managers, program implementers, and supervisors to effectively manage and support these community interventions. FP The key objectives of the guidelines are to promote a broad method mix at the community level, including access to injectable contraceptives. The guidelines aim to increase the number of FP service providers at the community level and strengthen the knowledge and skills of HSAs to provide injectable contraceptives. The guidelines also focus on the need to engage men in FP decision making through couple counseling. The guidelines also highlight the need for community mobilization and engagement with traditional and religious leaders to promote method mix and choice. HIV Providing HIV services is addressed within the context of FP-HIV integration. FP-HIV integration A core principle of the guidelines is to integrate FP and HIV services. The guidelines call for HSAs to provide injectable contraceptives alongside other health services, including HIV testing and counseling. The guidelines aim to maximize management of service delivery and simplify logistics through sharing of infrastructure and personnel. The guidelines state that district implementation plans should reflect FP-HIV integration at the community level. This will ensure that funds are available for commodities and supportive supervision of HSAs, especially in providing integrated services in hard-to-reach areas. The guidelines also focus on sensitizing communities on the availability of injectable contraceptives and HIV services, while engaging religious leaders and other influential community members to support the activities. The guidelines encourage the formation of male community groups to discuss family planning and HIV and promote male involvement. Furthermore, the guidelines emphasize couple counseling in FP and HIV services and the formation of youth groups to facilitate dialogue on family planning and HIV. Malawi Guidelines for Family Planning Communication (2011), Ministry of Health, Health Education Unit, Lilongwe, Malawi. Overview The Malawi Guidelines for Family Planning Communication are intended to assist DHMTs and community organizations to understand the specific barriers to FP uptake and develop effective interventions to reach target audiences. The guidelines are intended to help promote participatory action planning between the government and nongovernmental organizations at the central, district, and community levels in order to utilize available resources and reach all communities. The guidelines support the National Reproductive Health Strategy, which emphasizes the important role of communication and behavior change to improve FP uptake. FP The guidelines outline various ways in which FP communication can be improved. They highlight the need for community programs that openly discuss the barriers to FP uptake and ways to improve access. Annex A 17 The guidelines pay special emphasis to social mobilization and advocacy to increase public discussion of family planning. Furthermore, the guidelines focus on integrating FP communication programming into existing programs and increasing political will and commitment from district health offices. HIV PLHIV are a target audience of the guidelines, which encourage programs to address the specific FP communication needs of this specific population. The guidelines note that couples where one or both partners are HIV-positive should freely discuss FP issues among themselves while freely declaring HIV status. FP-HIV integration As mentioned above, a key objective of the guidelines is to promote dialogue about family planning for PLHIV among couples and the community at large. The guidelines also touch on the need to consider the integration of family planning into other heath areas —for example, by providing adequate FP information alongside other HIV services. This can be achieved if district action plans focus on integration. Guidelines for Community Initiatives for Reproductive Health (2007), Ministry of Health, Lilongwe, Malawi Overview The Guidelines for Community Initiatives for Reproductive Health offer guidance on how to increase awareness of, demand for, and utilization of RH services in an effort to reduce maternal and neonatal mortality. The guidelines are intended to be implemented by DHMTs at the community level. FP Family planning is identified as one of the RH interventions to be implemented at the community level. The guidelines mainly focus on the process of community entry and implementation rather than the specific FP interventions to be implemented. In mobilizing communities, the guidelines identify key target groups for engagement and the expected roles of various stakeholders in engaging each of the target populations. HIV HIV and AIDS are identified as a part of the package of interventions to be implemented at the community level. In focusing on the process for community entry and implementation, the guidelines focus on the roles of different community groups and individuals in providing HIV and AIDS services. FP-HIV Integration The guidelines outline specific roles each community group can undertake to promote the uptake of FP and HIV services. The community groups include traditional birth attendants, traditional healers, religious leaders, and peer educators. Each of these groups can counsel its clients and community members on various FP methods; provide information on STI, HIV and AIDS, and safe motherhood; refer clients to facilities for further services; and pay special attention to the needs of youth. Malawi National Reproductive Health Service Delivery Guidelines 2014–2019 (2014), Ministry of Health, Lilongwe, Malawi Overview Linked to the National Sexual and Reproductive Health and Rights Strategy 2011–2016, the Malawi National Reproductive Health Service Delivery Guidelines are intended to equip service providers with current tools and guidance on RH matters, including family planning, HIV and AIDS, and PMTCT. Developed by the MOH, the guidelines are intended for use by management, policymakers, and training institutions. Family Planning and HIV Integration in Malawi: A Policy Analysis 18 FP The guidelines provide technical guidance on RH methods and practices while guiding providers on how to manage clients and hence ensure quality service provision. Detailed information on FP methods is shared in these guidelines. In addition, guidance on how to conduct individual and couples counseling for family planning is shared. The guidelines encourage providing youth-friendly services as well. HIV The guidelines share general information on HIV and the key components of provider-initiated testing and counseling, such as the client’s ability to opt out of testing, ensuring client privacy and confidentiality, referral, ascertaining HIV exposure or infection of children under age 5 of HIV-positive clients, and preventing HIV-related bias, discrimination, and stigmatization. The guidelines further cover PMTCT, providing home-based care for patients with HIV, and the importance of dispensing youth- friendly HIV services. FP-HIV integration The guidelines discuss FP-HIV integration under various contexts: integration of HIV services in FP clinics, integration of FP services in HIV care clinics, strengthening the FP element within PMTCT, and providing integrated services to adolescents and PAC clients. When integrating HIV services in family planning, the guidelines promote the balanced counseling strategy, an interactive client-friendly strategy that follows four stages of FP counseling, one of which provides information on HIV prevention, risk assessment, and counseling and testing. The guidelines focus on training providers to offer provider-initiated testing and counseling to FP clients who do not know their status and referral, if needed. They also encourage providers to counsel HIV-negative women on risk reduction and dual protection. The guidelines also share the latest evidence on the interaction between various FP methods and HIV status, whether clients are on ART or not. At HIV clinics, the guidelines state that providers should routinely offer provider-initiated family planning to all clients aged 15 and older while ensuring that the right of HIV-positive women to have children is respected. They should counsel clients on the need for dual protection. The guidelines also state the importance of establishing strong referral mechanisms so that clients have easy access to both FP and HIV services. At ANC clinics, the guidelines state that pregnant women should receive PMTCT services and should be referred to the FP clinic if services do not exist at the ANC clinic. The guidelines reiterate the importance of counseling youth on a range of RH services that include family planning and HIV. In addition, the guidelines ensure that clients receiving comprehensive PAC services undergo voluntary STI and HIV screening and receive contraceptive counseling, FP methods based on their fertility needs, and guidance on HIV and AIDS protection. Annex A 19 General Health Policies, Strategies, Guidelines Addressing FP and HIV Integration Malawi Health Sector Strategic Plan 2011–2016 (2011), Ministry of Health, Lilongwe, Malawi Overview The Malawi Health Sector Strategic Plan 2011–2016 guides the implementation of health interventions, thereby contributing to the social and economic development of the country. The plan was developed following the Sector-Wide Approach Program of Work (2004–2010). The objectives of the plan are geared toward strengthening the health system to provide more and better services while addressing risk factors for acquiring certain health conditions. FP The plan mentions steps that need to be taken to promote FP services at the national, facility, and community levels. At the national level, the plan proposes that family planning should be highlighted in policies, standards, and guidelines. In addition, the provision of FP services should be monitored and evaluated in addition to adequate research and advocacy activities. At the facility level, FP counseling and methods should be made available. Community-based family planning should include the provision of contraceptives through social marketing, village clinics, and general outreach, as well as outreach through youth-friendly health services and HIV home-based care. HIV The plan notes that targeted and routine screening for HIV should be available at the primary, secondary, and tertiary healthcare levels. In addition, basic CD4 diagnostics should be available at secondary- and tertiary-level hospitals and facilities. FP-HIV integration The plan focuses on integration of FP services into HIV services such as ART centers and service points providing HIV testing and counseling. In this manner, it aims to prevent unwanted pregnancies among HIV-positive women. It further notes the need for strengthening PMTCT among vulnerable populations. National Plan of Action for Scaling Up SRH and HIV Prevention Interventions for Young People 2008–2012 (2008), Ministry of Youth Development and Sports, Lilongwe, Malawi Overview The National Plan of Action for Scaling Up SRH and HIV Prevention Interventions for Young People provides a framework for improving the sexual and reproductive health of young people (ages 10 to 24) and protecting them from HIV. The plan is intended to facilitate the participation of youth with national institutions, civil society organizations, and donors to meet the diverse SRH needs of young people. Furthermore, the plan offers coordination mechanisms to assist the scale-up of SRH and HIV prevention– related programs in Malawi. The plan focuses on creating and sustaining an enabling and supportive policy environment, increasing knowledge and demand for services, and strengthening coordination while integrating other efforts such as livelihood skills building. The plan also calls for biannual youth development conferences to share information on sexual and reproductive health and HIV prevention among youth and ways to reach youth. FP Family planning is a component of sexual and reproductive health and is addressed within that context. Provision of FP services is noted as a measure to increase contraceptive prevalence and hence improve health outcomes. Family Planning and HIV Integration in Malawi: A Policy Analysis 20 HIV The plan calls for improving the policy environment to better address HIV prevention needs among young people. This involves training staff of relevant ministries in advocacy and lobbying skills, developing a policy advocacy plan, and conducting advocacy campaigns. The plan also states the importance of engaging faith and community leaders and the media to support HIV prevention programs. Finally, the plan highlights the need for M&E of HIV programming in order to ensure that they are youth- friendly. FP-HIV integration The plan emphasizes integration of SRH services into HIV programs as a way to increase access and use of SRH services. It calls for a review of all existing laws and policies on sexual and reproductive health and HIV in order to highlight linkages. It further states the need for service providers to be adequately trained and supportive of integrated services for youth. The plan further ensures coordination and joint planning meetings at the national, district, and local levels with youth development organizations to ensure youth-friendly services are integrated. The plan suggests accomplishing this through frequent planning meetings and development of joint workplans, which help ensure the active involvement of SRH committees, coalitions, and networks. General Health Policies, Strategies, Guidelines Not Addressing FP and HIV Integration National Youth Policy (2013), Ministry of Youth Development and Sports, Lilongwe, Malawi Overview The National Youth Policy provides a framework to guide the design and implementation of meaningful youth development programs and services. The policy is intended to facilitate an enabling environment where youth enjoy full participation in society, their concerns and issues are adequately addressed, and they can contribute to national development processes. The policy also focuses on guiding policymakers on youth-related issues, advocating for the active participation of youth in the formulation of legislation, policies, and programs affecting them while providing guidelines for M&E of youth programs. FP The policy emphasizes the need for comprehensive sexuality education that promotes uptake of FP services. In addition, the policy calls for contraceptives, including condoms, to be readily accessible to sexually active young people. HIV The policy recommends improving access of youth to HTC and ART services. In addition, the policy recommends promoting and sustaining education programs on comprehensive sexual and reproductive health and rights and HIV prevention among youth in school and out of school. The policy emphasizes the need to discourage sexual and cultural practices that increase HIV risk among youth and to promote programs on gender equity and equality, male involvement, and girls’ and young women’s empowerment to reduce HIV transmission. FP-HIV integration The policy does not mention FP-HIV integration. Annex A 21 National Health Policy (2014), Ministry of Health, Lilongwe, Malawi Overview The National Health Policy is intended to serve as an overarching policy to guide health sector policy coordination and implementation. The policy states that national ownership and leadership are vital to improving the health status of Malawians. It is based on the primary healthcare concept and promotes a human rights approach to provide equitable services to all. The policy promotes that all decisions be made keeping in mind gender sensitivity, ethical considerations, efficiency and effectiveness, transparency and accountability, community participation, evidence-based decision-making, and intersectoral and intraministerial collaboration. FP The policy promotes the provision of comprehensive SRHR services, which include family planning. HIV HIV falls under the essential health package of services. The policy calls on the MOH to ensure that HIV prevention programs are promoted at various levels, including the workplace. FP-HIV integration The policy does not mention FP-HIV integration. Health Promotion Policy (2013). Ministry of Health, Lilongwe, Malawi Overview The Health Promotion Policy is intended to guide the implementation of health education and promotion interventions in health and other sectors. The goal of the policy is to reduce preventable deaths and disability through effective health promotion interventions. It can achieve the development and implementation of successful health promotion interventions by focusing on six thematic areas: strong leadership, coordination, and public policy; capacity building; individual empowerment and self-efficacy; health systems strengthening; multisectoral collaboration; and community empowerment. FP The policy does not explicitly mention family planning. HIV The policy does not explicitly mention HIV and AIDS. FP-HIV integration The policy does not explicitly mention FP-HIV integration. Social and Behavior Change Communications (SBCC) Strategy 2011–2016 (2012), Support for Service Delivery and Integration in Malawi, Lilongwe, Malawi Overview The Social and Behavior Change Communications (SBCC) Strategy offers a unified strategy for communicating across six major health areas, which include family planning and HIV and AIDS. The strategy addresses social norms and conditions that influence health behaviors across life stages and presents communications strategies through a multilevel approach: individual, interpersonal, sociocultural. Intended to guide national- and district-level strategic plans, the strategy can be used by the MOH and other stakeholders. FP The strategy shares a list of key FP messages that should be distributed to the public while being reflective of the differential needs of women, men, and couples at different life stages. Some of the key Family Planning and HIV Integration in Malawi: A Policy Analysis 22 messages focus on the safety of FP methods, the wide range of methods available, making informed choices on when to have children, and communicating with one’s partner about contraception and birth spacing. HIV The strategy outlines key HIV-related messages that the public should be exposed to. These include the importance of knowing one’s status, seeking early treatment for STIs, using condoms to protect oneself, staying faithful, PMTCT, and discussing HIV and options for prevention and protection with a partner. FP-HIV integration The strategy does not mention FP-HIV integration. National Health Information System Strategic Plan 2011–2016 (2013), Ministry of Health, Lilongwe, Malawi Overview The National Health Information System Strategic Plan guides the development of a sustainable integrated national health information system that is able to generate and manage available health information to support evidence-based decision making and planning within the health system. The plan and corresponding system were developed by MOH as a response to address inadequacies in the health management information system. The strategy serves to improve availability and use of health-related information for M&E of policies, plans, and programs, thus ensuring availability and use of information for decision making. It defines ways to strengthen the M&E system generally, thus indirectly benefitting the integration process. For instance, it facilitates the review of indicators and data collection/reporting tools to promote harmonization. The review of indicator requirements is in support of the National Health Sector Strategic Plan and associated programs. FP The plan does not explicitly mention family planning. HIV The plan does not explicitly mention HIV and AIDS. FP-HIV Integration The plan does not explicitly mention FP-HIV integration. National Standards for Youth Friendly Health Services (2007), Ministry of Health, Lilongwe, Malawi Overview The National Standards for Youth Friendly Health Services are intended to develop a supportive environment for youth-friendly health service delivery. The purpose of these standards is to provide guidance toward the implementation of various youth health activities including youth-friendly health services. The standards strive to increase youth participation in provision of health services, thus increasing accessibility and meeting the needs of young people. It also strives to provide information to youth on their health and their rights to health services. The standards are in line with the minimum health package, which combines clinical services and health promotion interventions to improve acceptability and use of health services by young people. Annex A 23 FP Family planning is listed as a key component of health promotion and counseling during service delivery at the community level. At the health center and hospital levels, the clinical service delivery package includes contraceptive services, including condoms. HIV HIV/ and AIDS are identified as a key component of health promotion and counseling during service delivery at the community, health center, and hospital levels. PMTCT is listed as a key component at the health center and hospital levels. FP-HIV integration The standards do not explicitly mention FP-HIV integration but outline types of health services provided at various levels, including family planning, PMTCT, and HIV testing and counseling while promoting referrals. 24 REFERENCES African Institute for Development Policy. 2014. “Rapid Assessment of MNCH, FP and HIV Service Delivery Integration in Malawi.” PowerPoint presentation at validation meeting for the Bill and Melinda Gates Foundation Integration Study, Lilongwe, Malawi. EngenderHealth. 2014. Integrating Family Planning and Antiretroviral Therapy: A Client-Oriented Service Model. New York: EngenderHealth. Farrell, B. L. 2007. Family Planning–Integrated HIV Services: A Framework for Integrating Family Planning and Antiretroviral Therapy Services. New York: EngenderHealth/The AQUIRE Project. FHI 360. 2010. Integrating Family Planning into HIV Programs: Evidence-Based Practices. Washington, DC: FHI 360. Ghana Health Service. 2005. 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For more information, contact: Health Policy Project Futures Group 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 Tel: (202) 775-9680 Fax: (202) 775-9694 Email: policyinfo@futuresgroup.com www.healthpolicyproject.com Contents Acknowledgments Abbreviations Introduction Background Rationale Methodology Search Strategy Search Results Types of Documents Retrieved Findings List of Policies, Guidelines, and Strategies Reviewed HIV and AIDS policies, strategies, and guidelines reviewed FP/SRH policies, strategies, and guidelines reviewed General health policies, strategies, and guidelines addressing FP and HIV integration General health policies, strategies, and guidelines not addressing FP and HIV integration Summary of Key Findings from the Policy Analysis Interventions for integrating FP services into HIV services Integration of HIV services into FP services Integration of FP services into other non-HIV services Integration of HIV services into other non-FP services PMTCT Youth-friendly health services Integration at the subnational level Discussion and Next Steps Annex A. Summary of Key Findings from Policies, Strategies, Guidelines Reviewed HIV and AIDS Policies, Strategies, Guidelines National HIV and AIDS Policy, June 2011–June 2016 (2011), Office of the President and Cabinet, Department of Nutrition, HIV and AIDS, Lilongwe, Malawi Overview FP HIV FP-HIV Integration Malawi National HIV and AIDS Strategic Plan 2011–2016 (2011), National AIDS Commission, Lilongwe, Malawi Overview FP HIV FP-HIV integration Malawi National Plan for the Elimination of Mother to Child Transmission 2012–2015 (2012), Ministry of Health, Lilongwe, Malawi. Overview FP HIV FP-HIV integration National HIV Prevention Strategy 2009–2013 (2009). National AIDS Commission, Lilongwe, Malawi Overview FP HIV FP-HIV integration Clinical Management of HIV in Children and Adults (2014), Ministry of Health, Lilongwe, Malawi Overview FP HIV FP-HIV integration FP/SRH Policies, Strategies, Guidelines National Sexual and Reproductive Health and Rights Policy 2009–2014 (2009), Ministry of Health, Lilongwe, Malawi Overview FP HIV FP-HIV integration National Sexual and Reproductive Health and Rights Strategy 2011–2016 (2012), Ministry of Health, Lilongwe, Malawi Overview FP HIV FP-HIV integration Road Map for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Malawi (2007), Ministry of Health, Lilongwe, Malawi Overview FP HIV FP-HIV integration Community Based Injectable Contraceptive Services Guidelines (2008), Ministry of Health, Lilongwe, Malawi Overview FP HIV FP-HIV integration Malawi Guidelines for Family Planning Communication (2011), Ministry of Health, Health Education Unit, Lilongwe, Malawi. 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