Integration of family planning and HIV services: An evaluation of patient and provider preferences
Awarded 2013
Complex Family Planning Fellowship Research
Antoinette Danvers, MD
University of North Carolina at Chapel Hill

Background and purpose: HIV positive women in the United States use less effective contraceptive methods than HIV negative women and continue to rely primarily on condoms. Integration or linking of HIV and family planning services could improve contraception use. Integration strategies should be based on the needs and preferences of the target population. We embarked on a study to inform us about the way in which women with HIV would want the services to be provided to them.  We also wanted to learn what the providers who care for women with HIV think about integrating family planning in their clinic, whether they see it as a need for their patients and whether they would be receptive to adding the service. 
Methodology: We conducted a mixed methods study using both quantitative and qualitative methods.  The quantitative methods were used first using surveys. We used an interviewer-administered survey to ask HIV positive women, ages 18-45 attending the Infectious Disease clinics at the University of North Carolina Memorial Hospital (UNC) and the Wake County Health Department (WCHD) about their preferences. Women who desired pregnancy, history of sterilization, infertility or menopausal status were excluded from the study. Our sample size of 80 participants was based on the number of patients seen in the two clinics that met our inclusion criteria. The survey was used to obtain information about their contraception preferences, preferred time of initiation and preferences for integration. The survey was followed by in-depth interviews that were aimed at getting a deeper understanding about their experiences with contraception, factors that influenced their decision making about contraception and how they receive their care. 
Providers from the same sites completed an anonymous web-based survey consisting of both closed and open-ended questions to learn more about their current practice and receptiveness to integration of family planning services in the HIV clinic.
Findings: Eighty patient surveys were completed between 06/2013 and 09/2013. Thirty participants were recruited from UNC and 50 from WCHD. Thirty percent of the 80 women surveyed were using effective contraception. HIV positive women preferred to receive family planning services in the HIV clinic (44%) compared to the gynecology clinic (12.5%). Forty-nine preferred contraceptive counseling by an HIV specialist and 16% by a gynecologist. In depth interviews are being conducted to identify reasons for the low contraceptive use and preferences for receiving contraceptive services in the HIV clinic and by the HIV provider. Patients were more likely to be using the best methods if they discussed contraception with their HIV providers. 
We planned on enrolling 20 participants for the patient interviews.  However, due to challenges with recruitment, we set an a priori stop date of May 31st, 2014.  By that date, we completed 11 interviews.  The interviews have been transcribed and are currently being coded for analysis. 
Providers completed web-based surveys between 10/2013 and 01/2014. The response rate for the provider survey was 54% (15/28). Providers felt comfortable providing contraceptive counseling to their patients (14/15; 93%) but identified time and complexity of the HIV visit as a barrier for them to provide these services. Providers were receptive to integration (14/15; 93%) but identified space limitations, funding, and time constraints as barriers to integrating the services.
Conclusion: The HIV positive women receiving care in the infectious disease clinics preferred the HIV care setting and provider for receiving contraceptive services. The HIV providers may be most likely to have a better impact on contraceptive use but explained their clinics are already so busy that it would be difficult for them to provide the services. HIV providers are receptive to integrating services but identify time, space and complexity of the HIV visit as barriers.