Voices from the Field: Rwanda's Pharmacy Integration—Increasing Family Planning and Decreasing Stigma among HIV-Infected Patients in Rural Rwanda

“Before integration, there was a lot of discrimination because there was only one HIV office, and patients had to wait in line outside and everyone knew you had HIV. Now with integration, you can go to any office and receive the services you need.” – HIV-positive client in rural Rwanda

Having worked with Rwandans for twenty years to improve the health care system, IntraHealth International is leading the HIV/AIDS Clinical Services Program (HCSP) in four districts to integrate family planning with HIV-related and other health services. Integration allows clients to have greater exposure to and greater likelihood of adopting family planning methods. Family planning integration is one component of HCSP Rwanda’s work to reinforce national- and district-level health systems and expand access to comprehensive HIV/AIDS services in the districts of Gasabo, Gicumbi, Nyagatare and Rulindo.

In 2007, the HCSP-supported Munyinya Health Center in Gicumbi District began a process of integrating family planning with all its services. Previously, the center housed a separate ward for HIV/AIDS care and treatment. Because services were segregated, HIV-infected clients were easily identified and thus targets for discrimination. Family planning services for HIV-infected clients were dispensed from a specific pharmacy window in the HIV/AIDS ward, outside of which clients had to wait in queues. Clients were simply handed their medication through the window—there was no opportunity for consultation or questions concerning treatment, and maintaining confidentiality was difficult. Some HIV-infected clients preferred not to present at all rather than face HIV-associated stigma, so very few used family planning methods. Unplanned pregnancies within HIV-infected couples risked not only transmitting HIV to the infant but also maternal mortality.

In October 2008, existing pharmacies at the Munyinya Health Center combined to create a single, integrated pharmacy in the main facility that includes antiretroviral treatment (ART) and family planning methods alongside all other medication, as well as the option for counseling with a qualified staff member in the privacy of a closed room. The hope was that the integration would increase family planning method use among HIV-infected clients, reduce stigma toward HIV-infected clients, and improve provider and client satisfaction.

That hope has come to fruition; the integration impact at the center has been very positive. The Ministry of Health has even named it as the Integration Model Site of the Northern Province.

Family planning method use has definitely increased: in October 2007, 26% of the estimated male and female adult population in the Munyinya coverage area used family planning methods (1,056 of 4,055). By October 2008, this rate had jumped to 34% (1,643 of 4,864), and by April 2009, it was up to 41% (2,007 of 4,864). Furthermore, between October and December 2008, only 12% of male and female ART clients at the center used family planning methods; by April 2009, this number had increased to 94%.

As hoped, service providers and HIV-infected clients alike declare that discrimination, once rife, no longer exists at the integrated pharmacy. “There is no more stigmatization here now,” says the Munyinya Health Center director. “All patients take their medicines in the same place, and no one outside knows what is being taken.”

Integration has also increased the number of providers skilled in family planning counseling and HIV treatment. Before integration, only one provider was trained in family planning counseling; now there are five. While only two providers were trained in overall care and treatment of HIV-infected clients before integration; now there are four.

Both clients and health center staff are enthusiastic about family planning/ART integration in their primary health care package. Health providers find that family planning service integration allows them to be more efficient in service delivery. Integration makes better use of existing infrastructure and personnel, delivers a greater number of services per visit and is more cost-effective. “This has lessened my workload,” notes the center director. “Now I can provide several services at the same time to a patient. In my view, this has been very good.”

Launched in June 2007, HCSP Rwanda significantly contributes to the country’s national goals and US President’s Emergency Plan for AIDS Relief (PEPFAR) targets. HCSP collaborates with Rwanda’s Ministry of Health to expand HIV/AIDS clinical service activities and capacity in: prevention of mother-to-child transmission; counseling and testing; antiretroviral therapy services; palliative care; TB/HIV integration; family planning integration; gender-sensitive care; and other prevention services including abstinence, be faithful and condom-based preventions and prevention of medical transmission. The five-year, $27 million dollar program is funded by the U.S. Agency for International Development (USAID).

Photos are not indicitive of the subjects' health status.