Introduction

Differentiated ART service delivery (DSD), previously referred to as ‘differentiated HIV care’, is a client-centered approach that simplifies and adapts HIV services in ways that not only meet the HIV clients’ needs but also reduce unnecessary burdens on the health care system [1]. Differentiated ART service delivery has been scaled up in many countries in recent years [2] with the goal of improving efficiencies in HIV care through reduced patients’ waiting time, reduced patients’ visits to the health facilities, and reduced health providers’ workload due to seeing patients less frequently through multi-month dispensing of ARV drugs [3]. As a result, most people living with HIV are now seen by clinicians or visit health facilities less frequently [4–6]. Concurrently, there is a renewed emphasis on ensuring that all women living with HIV (WLHIV) have access to other non-HIV services, including family planning (FP), as part of their HIV care and as an essential pillar in the prevention of mother-to-child transmission of HIV [7–9]. This renewed emphasis on FP as an essential part of HIV care follows closely on recent calls for more inclusive and patient-centered care for people living with HIV [10,11]. However, WLHIV who visit health facilities to collect their ART do not fully benefit from patient-centered care if they have to return to the same health facility more frequently to receive other non-HIV services, including FP. Clients in DSD models should be supported to use contraceptive methods of their choice and, where ongoing commodities are required, be able to obtain these through their differentiated ART service delivery models (DSDM) [1].

One way in which WLHIV can be supported to access the contraceptive methods that they need when they come for their ARV drug refills is to streamline the schedules for contraception and ART resupplies in such a way that the client can be provided with FP supplies of the same duration as their ART refills [12]. Under an ideal integrated FP and HIV service delivery mechanism, FP and ART care should be provided at the same time, in the same place and, where possible, by the same provider [13]. This can be achieved through different approaches, including use of multi-skilled HIV and FP providers and a one-stop service center within the ART clinic site (or at the community drug distribution point) offering HIV and FP services under one roof [14]. In Tanzania, for example, women in DSDM have access to a full range of contraception options; ART and FP are both offered within the same care and treatment centers [15]. This alignment ensures uninterrupted supply of contraceptives and ART while minimizing visits to the health facility [1]. Similar arrangements can be made for community-based ART delivery approaches, including sending out multi-skilled HIV and FP providers to manage ART refills and FP supplies at the community outreach service delivery points [16]. Similarly, for community group models, provision of FP can be aligned with the scheduled FP refill of the group member who goes to the health facility (or community drug distribution point) to pick ART for the other members [1].

In 2016, Uganda made DSDM a priority in the national HIV prevention, care and treatment guidelines so that HIV service delivery could be more client-centered and scarce resources could be refocused to those most in need [17]. In 2017, the Ugandan Ministry of Health developed the national policy guidelines and service standards for sexual and reproductive health services and rights (SRHR) [18] that called for integrating STI/HIV and AIDS within SRHR services. However, these guidelines did not include details on how STI/HIV and AIDS integration into SRHR services would be implemented. In tandem with this observation, the Ministry of Health, in 2017, developed DSDM implementation guidelines that were more aligned to HIV service delivery [19]. These guidelines were expected to provide guidance on the integration of FP into the differentiated ART service delivery models. However, until this assessment, there was no formal evaluation to determine if FP integration was well streamlined within the DSDM guidelines, and if so, whether integration of FP into the DSDM was being implemented based on these guidelines.

Differentiated ART service delivery is now the primary mode of providing ART refills to people living with HIV (PLHIV) in Uganda with the majority (65.6%) of the patients categorized as stable clients (or clients on less intensive models) while 34.4% are unstable patients/clients on more intensive models [20]. Stable patients are those with near-perfect ART adherence and who have achieved virological suppression while ‘unstable patients’ are those that still have ART adherence challenges and are still virally non-suppressed [19,20]. In Uganda, DSD models for stable patients include a) Fast-track drug refills (FTDR) in which HIV-positive stable patients in care for six or more months, who are TB-free, pick their drugs directly from the health facility’s dispensary or ART clinic once every three months; b) community drug distribution point (CDDP) in which healthcare providers provide ART services to stable patients in a given locality (e.g., at lower-level health centers, private pharmacy or other locations) in the community on a rotational basis, once every three months; and c) Community client-led ART delivery (CCLAD) in which stable patients (who have been on HIV treatment for six or more months) are arranged into groups of 3–6 patients, one of which goes to the facility of their ART registration to pick ARV drug refills on behalf of the other members on a rotational basis (once every three months). DSD models for unstable clients include: a) Facility-based individual management and b) Facility-based groups [19,20]. This paper focuses exclusively on DSD models for stable clients.

Given that the Uganda Government has prioritized self-care as part of its strategy to reach universal health care coverage [21], this study focused on three differentiated ART service delivery models for stable patients (fast-track drug refill, community drug distribution point, and community client-led ART delivery), hereafter referred to as ‘self-care-oriented DSDM’ (SC-DSDM), due to their potential increased efficiency within the HIV care system while enabling clients to receive self-care-oriented FP services. We defined self-care-oriented FP services as FP services that WLHIV, enrolled in SC-DSDM, can access and use with minimal or no provider interaction, and for which they can receive FP supplies or services of the same duration, if needed, as their ART refills. However, while integrating FP into the DSDM in general and the three SC-DSD models in particular would improve access to FP services and methods and reduce the frequency of client visits to the health facility, by the time of this assessment, no formal evaluation had been conducted to document the status of FP integration into the self-care-oriented DSD models. This assessment aimed to explore: a) the status of FP integration into the three SC-DSDM, b) client, health provider, implementing partner and policymaker perspectives about and barriers to integrating FP integration into the SC-DSDM, c) whether or not FP-HIV integration was clearly defined (in terms of how it should be done, when, and by whom) within the existing DSDM guidelines, and d) suggestions on how to improve FP-HIV integration within the DSDM framework in Uganda.

Methods

Results

Characteristics of the study participants

Table 1 shows the number and categories of participants included in this study. The distribution of WLHIV mimics the general distribution of the patients across the different DSDM, with the highest number of participants drawn from FTDR and the lowest number from CCLAD. Generally, there were few or no WLHIV enrolled in the CCLAD model across facilities.

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Table 1. Number and category of participants included in the study.

https://doi.org/10.1371/journal.pone.0324616.t001

Discussion

This study found that all the 18 facilities sampled offered FP information/ counseling through the three self-care-oriented DSDM but only four facilities provided FP methods in the same ART clinic or in the same community outreach visit. In general, we found that: a) most of the clients receiving their ARV drug refills through the facility-based DSD models have to access FP methods through referral to the MCH/FP clinic, located outside the ART service delivery point while b) most of the clients receiving their RV drug refills through the community-based DSD models have to make a separate physical visit to the MCH/FP clinic, usually on another day, to obtain their FP supplies.

The finding that only four out 18 health facilities had FP integrated into the SC-DSDM is frustrating given current efforts to support the integration of FP into non-HIV services in Uganda [27]. However, these findings are not unusual [28–30]. In an evaluation of FP integration into the DSDM in Kenya in 2020, the Elizabeth Glaser Pediatric Foundation found that FP services were not integrated into the comprehensive HIV care clinics in Kenya but required referral to the MCH unit. No FP services were integrated into ART refill visits, either in facility or community settings; as a result, all pre-packed ARVs for distribution in facility or community models did not include contraceptive commodities. Besides, ART and FP refills and visits were not formally aligned [30]. However, the successful integration of FP into services offered at HIV care clinics in other African settings has also been documented. In Tanzania, for example, contraceptive care was provided at the HIV care and treatment clinic, but in a different room and by a different healthcare provider as for ART refills. Contraceptive refills were aligned with ART refills (i.e., 3 months oral pills for those who receive 3-month ART refills) and could be collected along with ART (although women could queue for certain methods). Two lower-level sites offered a one-stop shop approach, while in higher level hospitals, FP services were offered by a different provider in a different room than ART [30]. The Tanzania example lends credence to the fact that integrating FP into the SC-DSDM is possible (only that it is not happening as expected) and that WLHIV can ably access FP services through these models. However, what is less documented is how the integration of FP into the SC-DSDM affects FP service uptake, including whether or not FP and ART supplies have been synchronized. Future research is needed to assess the dynamics of FP uptake in a FP-HIV integrated framework to inform the scale-up of FP-HIV integration across programs and countries.

Our finding that FP information and counseling were provided to all clients at the surveyed health facilities demonstrates a very important step to ensure WLHIV have the information needed to reach their reproductive goals. Previous research shows that WLHIV who receive any FP counseling are significantly more likely to report current use of modern contraception than those who do not [31,32]. These findings support the need to ensure that FP counseling provided to WLHIV is of good quality and to enhance FP counseling when quality standards are not met. We, however, did not assess the quality of the FP information and counseling provided. Future research should focus on assessing quality and new tools to facilitate efficient provision of information and counseling in the context of staff shortages and numerous clients.

We found that most WLHIV accessed FP services through non-coordinated intra-facility referral to the MCH/FP clinic. This means that when WLHIV are referred from the ART clinic to the MCH/FP clinic, they have to line up afresh for FP services since there is no prior arrangement (coordination) between the two clinics to offer timely FP services to the women referred from the ART clinic. The absence of FP supplies at the ART clinic is a historical challenge that emanates from the fact that, traditionally, FP services at health facility level are provided through the MCH/FP clinic. We think that the traditional alignment of FP with MCH services makes HIV providers to feel less compelled to stock FP services as part of HIV care. While this may be speculative (since we did not specifically collect data on HIV service providers’ attitudes towards providing FP services within the ART clinic), we believe that the long-standing availability of FP services at the MCH/FP clinic may call for a need to strengthen FP-HIV integration through coordinated intra-facility referral as an alternative model of integration, especially in situations where integration through the one-stop center may not be practically possible or achievable. Our findings already point to the fact that, in practice, there is more integration going on through collaboration than the one-stop center; thus, it may be helpful for the Ministry of Health and the donor community to explore the potential benefits of strengthening FP-HIV integration through referral to the MCH/FP clinic vis-à-vis promoting integration through the one-stop center that may be less feasible in some situations.

However, it is important to note that the women interviewed for this study indicated a preference for the one-stop center model of FP integration into the SC-DSDM. The acceptability of integration as one of the approaches necessary to improve health service delivery has been documented in other studies [33,34]. For instance, in a study conducted in Mayuge, Uganda, Mezei et al. [33] found that 99% of women and 100% of the surveyed community health workers felt that integrating community-based HIV testing with cervical cancer screening was acceptable. In this same study, women noted a preference for a combined service delivery model as it can save them time and eliminate additional trips to the health center, which have resource implications, in cases when services are not available on the same day. Women living with HIV face heightened vulnerability compared to their counterparts who do not live with HIV given that they have to manage a chronic condition for life. The importance of facilitating access to holistic health care that addresses their full needs has been highlighted as the HIV community moves towards more holistic care [35] and lends credence to the fact that offering FP methods and ART refills in the same place, at the same time, by the same or a different provider is not only acceptable but also possible. However, the one-stop shop model, usually dubbed as “combined service provision” in the case of integrating FP into immunization services [36], is likely harder to achieve than models that offer information/counseling plus referral given that it requires staff training and coordination such as the need to synchronize or integrate family planning and HIV commodity supply chains [37]. Studies also show that the implementation of the one-stop shop model can be hampered by patients’ fear of stigma and discrimination (especially in community-based ART models), patients’ and providers’ low literacy levels on the DSD model and supply chain inconsistencies [29,38]. Thus, efforts geared at strengthening the provision of FP services through coordinated intra-facility referral may be the game-changer needed to improve access to FP services in most resource-constrained settings including Uganda.

While the Ministry of Health has already developed a National Strategy for Integration of Sexual Reproductive Health (SRH), HIV/AIDS, TB, Nutrition and Gender Based Violence (GBV) [39], we believe that the need for the development of implementation guidelines to support the integration of FP into the SC-DSDM remains essential. It is important to note that the above-mentioned SRH-HIV-GBV strategy examines the aspect of integration from the point of view of sexual and reproductive health rather than from the HIV care point of view, offering limited guidance on how and when to integrate FP into the SC-DSDM. To support the integration of FP into the DSDM in general and SC-DSDM in particular, it will be essential that the Ministry of Health develops specific DSDM-focused, FP-HIV integration implementation guidelines that define how, when and for whom the integration should happen in each health facility. The Ministry of Health should put in place mechanisms to ensure a constant supply of contraceptive supplies as well as provide for adequate office space to improve space available for the implementation of the one-stop center integration approach. Combined reporting tools that capture data on the use of both FP and ARV drug refills may need to be developed to avoid the need for completing two different registers; one for the HIV care and the other for the FP supplies received. Finally, since we did not assess contraceptive uptake among WLHIV enrolled in the different SC-DSDM, we recommend further studies to assess differentials in FP uptake across the different SC-DSDM and document barriers/challenges and facilitators of contraceptive uptake under each DSD model within the FP-SC-DSDM integrated framework.

Study limitations and strengths

This study was limited by the purposive sampling approach. Strictly interpreted, the results are only applicable to WLHIV who were interviewed for this study and not to the general population of WLHIV in the study regions in particular or Uganda in general. Nonetheless, the four study regions were chosen to represent a variety of local characteristics and we feel that the results will be useful to policymakers in designing guidelines for integrating FP into the SC-DSDM in other similar contexts. The other limitation is that this study relied on the self-reports of the clients and health providers regarding FP-HIV integration and the health facilities were categorized as integrating or not integrating based on this information. Because most WLHIV indicated that they obtained their FP services from the MCH/FP clinic, we categorized most health facilities as not integrating FP into the SC-DSDM without verifying that they actually obtained their FP methods from the MCH/FP clinics. If we did, this should have helped to inform our decision regarding whether or not the health facilities were actually integrating or not integrating FP into the SC-DSDM. However, we believe that this is a minor limitation. Given that we triangulated data collection methods and data sources (i.e., data were collected using in-depth interviews and key informant interviews with a diversity of participants including WLHIV, program implementers, district health managers, and policymakers), we believe that we made an accurate estimate of the FP-HIV integration status at the health facilities that we visited. Lastly, while we documented challenges/barriers inherent in implementing FP integration in the SC-DSDM, we relied on self-reports but did not try to quantify the magnitude of each barrier/challenge. For instance, we did not collect data on stock-outs of FP supplies but relied on self-reports during the provider interviews. This was because this study was conducted as a landscaping, qualitative study to inform future FP integration into the SC-DSDM rather than as a survey to obtain quantitative measures of each of the challenges/barriers noted.

These limitations notwithstanding, our study had a number of strengths. First and foremost, this study is one among the few studies that have assessed FP-HIV integration from the perspective of SC-DSDM. Thus, while studies on integration of HIV with other services, including family planning, have been previously conducted, these studies did not assess FP integration from the perspective of SC-DSDM. We, therefore, believe that the study findings can help to inform the design of FP-HIV integration interventions in the context of SC-DSDM, including facility and community-based models. Secondly, our study involved a total of 83 qualitative interviews (including in-depth interviews and key informant interviews) with different categories of participants, including clients, healthcare providers, district health managers, implementing partner representatives, and policy-makers, thereby improving the credibility of the findings through triangulation by data source and data collection methods.

Conclusion

Our findings show that despite the potential benefits of integrating FP into the SC-DSDM, only four out of 18 health facilities offered FP services integrated into the SC-DSDM. Even in the few facilities that integrated FP into SC-DSDM, several challenges/barriers, including frequent stock-outs of short-term FP supplies, staff shortages, and lack of adequate office space continued to hamper effective integration. Unfortunately, while the integration of FP into the SC-DSDM is being spear-headed by the donor community, at the moment, there are no guidelines to inform the effective integration of FP into the SC-DSDM. These findings call for policy guidance from the Ministry of Health in integrating FP into the SC-DSDM in Uganda. This will not only help in ensuring that there is uniform implementation of FP integration into the SC-DSDM but also provide guidance on how to address the barriers that currently inhibit the effective integration of FP into SC-DSDM in Uganda.

Supporting information

Acknowledgments

We are greatly indebted to Rawlance Ndejjo, Sarah Nabukeera, and Noel Namuhani (Research Officers working with the Research for Scalable Solutions [R4S] Project) who supervised the data collection process and participated in the analysis of data. We thank the participants at all levels (policymakers at the Ministry of Health, implementing partner staff, district health officers, and women living with HIV, enrolled in the different DSD models) for agreeing to participate in the study. Finally, we are grateful for the support that we received from the Ugandan Ministry of Health, FHI360 Uganda office and the USAID/Uganda office during the conduct of this study.