HIV Testing at Family Planning Clinics in Mombasa County, Kenya: A Cluster-Randomized Trial Comparing the Systems Analysis and Improvement Approach (SAIA) to Usual Procedures

Integration of HIV treatment and prevention with family planning (FP) services is a promising approach for optimizing delivery of comprehensive healthcare for HIV-positive women, as well as prevention services for those who are negative. The need for integration of services is evident in Africa, which bears a disproportionate burden of HIV, high birth rates, and maternal mortality. A high and increasing proportion of African women use FP services, making this a potentially efficient venue for reaching them.

Testing for HIV is the gateway to care and prevention. Integrating HIV testing into FP clinics could open this essential gateway, decreasing stigma associated with seeking HIV testing while reducing costs. The antenatal setting provides a useful example. In many African countries, testing for HIV in antenatal clinics (ANCs) has become routine. Diagnosis of HIV during pregnancy has paved the way to substantial reductions in mother-to-child transmission of HIV and AIDS-related deaths in women of reproductive age. These achievements demonstrate the feasibility and impact of wide-scale HIV testing through existing reproductive health services. In contrast to ANCs, integration of HIV testing into FP services remains at a formative stage in much of Africa. Recent reviews support the feasibility of integrating these services, but invariably conclude that additional research is needed.

In Kenya, the National AIDS and STD Control Program (NASCOP) states that the FP clinic is a setting in which, "Failure to offer HIV testing and counseling is unacceptable, and will be considered negligent." However, there has been almost no operational assessment of HIV testing in Kenyan FP clinics. In Mombasa County, the USAID-supported AIDS Population and Health Integrated Assistance II Program revised the FP Clinic Register to capture HIV testing in 2008. However, the rate of HIV testing in FP clinics remains low, and the County has requested our assistance in addressing this prevention gap. Colleagues at the University of Washington Department of Global Health have developed a systems analysis and performance enhancement approach, using industrial and systems engineering techniques, that the investigators believe will be useful in this setting. The overarching objective is to assess the effectiveness, costs, and budget impact of implementing this systems analysis and improvement approach (SAIA) to increase HIV testing in FP clinics in Mombasa County. The investigators specific aims are as follows:

AIM 1: To conduct a cluster-randomized trial comparing the effect of the SAIA approach versus usual procedures on rates of HIV testing in first-time attendees at 12 intervention versus 12 control FP clinics in Mombasa County, Kenya.

HYP 1: After one year of study team support implementing SAIA vs. usual procedures, a higher proportion of first-time FP clinic attendees will be tested for HIV at intervention compared to control facilities