Integration of Family Planning Services With HIV Treatment for Women of Reproductive Age Living With HIV Attending ART in Special Zone of Oromia Regional State, Ethiopia


 Background: In settings where HIV prevalence is high, management of sexual and reproductive health is critical to reducing HIV transmission and maternal mortality. Integration of family planning with HIV services is appropriate model for HIV therapy, HIV prevention and care with family planning services in a resource limiting area like Ethiopia. The aims of the study were to determine the status of integration of family planning services with HIV treatment for women of reproductive age in Oromia, Ethiopia Methods: A Health facility based cross-sectional study design was conducted with quantitative data collection approach was used to collect data from women living with HIV attending ART clinics in special zone of surrounding Finfinne, Oromia Region in five health centres. Simple random sampling computer-generated sample was used to select 654 respondents. The returned questionnaires were checked for completeness, cleaned manually, coded and entered into EPI INFO 7.1.6 version. These were then transferred to statistical Package for Social Sciences 23.0 for further analysis. Bivariate and multivariable logistic regressions analysis was used to identify factors associated with integration family planning with HIV services with the significant association at adjusted odds ratio (AOR) with 95% confidence interval (CI) to controlled effects of possible confounders from final model. Result: After discarded16 spoiled questionnaires, the completed response rate of this study was 97.6% (654/670). There were 654 respondents whose ages ranged between 18 and 49 years. The mean age of the respondents was 31.86 years with a SD of ±6.0 years. Most of the respondents in the sample were in the age group 26-35 (n=374, 57%), and only 96 (14.7%) were in the age group 18-25. This study determined the overall integration FP-HIV services were 55.8% among reproductive age women living with HIV in Oromia regional state of special zone health centres. Almost all respondents (n=635, 97.1%) preferred integrated sexual reproductive health and HIV services at the same facility, from the same providers, and 622 (95%) were very or mostly satisfied with the utilisation of integrated family planning/HIV services.Conclusion: The identified factors that affected the integration of family planning with HIV services were educational and occupational status, residence, discussion of family planning with healthcare providers, fertility desire and CD4 counts. Therefore, Ministry of health should engage women in the planning, implementation and evaluation of the integrated family planning/HIV services.


Introduction
The integration of 'family planning with human immune-de ciency virus'(HIV) services to promote contraceptive use among "women living with HIV" has emerged as a rich ground for research. Integrating family planning and HIV is a process that occurs at different levels of the health care system such as national, regional and at the health facility in relation to key healthcare functions such as governance, nancing, planning, service delivery, monitoring, evaluation and demand generation (Atun, Lazarus, Van Damme & Coker 2010:i1-i3).
According to Sustainable Development Goals (SDGs) recommendations, member countries should ensure universal access to sexual and reproductive healthcare services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes by the end of 2030 (SDGs 2015:9-10). According to a study by Kendall and Danel (2014:48060), integration of health service delivery is key to addressing improvements in MNCH services and HIV care and treatment in sub-Saharan African countries. Public health programmes emphasise that the integration of family planning services with HIV treatment to increases dual contraceptive methods' utilisation will ensure protection from both unintended pregnancy and STIs, including HIV/AIDS (Pack, Stanton & Cottrell 2011:2) Statements of the problems In 2012 it was estimated that in sub-Saharan Africa, 53 million women who wanted to avoid pregnancy were not using any family planning method (Darroch & Singh 2013:1756. Thus, the unmet need for contraception among women living with HIV in sub-Saharan Africa is high, with 66-92% of women reporting not wanting another child (now or ever), but only 20-43% of them using contraception (Sarnquist,  Meeting the unmet needs for family planning in sub-Saharan Africa could make an important contribution to improving maternal health through early studies or initiatives. In 2008, the estimated maternal mortality ratio in sub-Saharan Africa was 596 per 100,000 live births, the contraceptive prevalence was 22%, and the proportion of maternal deaths averted by contraceptive use was estimated at 32%. In contrast, among low-and-middle-income countries as a group, the maternal mortality ratio was 273, the contraceptive prevalence was 63%, and 44% of maternal deaths were estimated to be averted by family planning use (Ahmed, Li, Liu & Tsui 2012:111-125).
Programmes that have succeeded in promoting condom use and providing HIV prevention and treatment services in this region have largely missed the opportunity to address the contraceptive needs of the key populations they serve. Therefore, the research statement for this study is "What is status of family planning services with HIV treatment integration for women of reproductive age living with HIV attending healthcare facilities in Oromia Region, Ethiopia?"

Methods And Materials
Research Setting and design This study was conducted in the Oromia Region surroundings of Fin nne Oromia, Ethiopia. Currently, the health system of the zone consists of two hospitals under construction, and 27 health centres with 98% potential health service coverage. There were different governmental and non-governmental organisations working on HIV/AIDS in the zone. There were 13 health centres which have been providing ART and family planning services in the zone, of which ve were randomly selected as the study setting. The total number of people living with HIV enrolled at ART clinics in the zone was 9421, of which 2380 were women of reproductive age, and of these, 1557 were from ve randomly selected health centres (O ce Fin nne Special Zone 2018:6). The target population was HIV-positive women of reproductive age who had attended ART follow-up services for at least six months from randomly selected healthcare facilities in Oromia Region, Ethiopia. The accessible sample was 1557 eligible women of reproductive age living with HIV attending ART clinics in public health centres.
A Health facility based cross-sectional study design was conducted with quantitative data collection approach was used to collect data from women living with HIV attending ART clinics Sample size determination The sample size was determined through a single population proportion formula by using a case study found in integrated sites in Ethiopia, where 40% of women were family planning users (P) (Scholl & Cothran 2011:9). By considering the design effect of 2, with correction formula since the total population was less than 10 000 (2380) and with a 5% non-response rate considered, the nal sample size was 670 women living with HIV.
Sampling procedure All hospitals and health centres found in the Special Zone of Oromia Region that provide ART services were identi ed and randomly selected by computer-generated methods to be included in the study. A list of all women living with HIV from each facility, aged between 18 years and 49 years of age, was randomly created. Study sites were prepared and entered into SPSS version 23 by using their pre-ART registration numbers from the health management information system (HMIS) database. A simple random sampling technique by computer-generated samples was utilised at each health centre to select 670 study respondents. The number of study respondents was allocated proportionally for the ve health centres, based on their total number of ART clients.

Data collection
The questionnaire used for data collection was initially prepared in English, and translated to Afan Oromo, and back to English for language experts to con rm its consistency. Finally, the corrected Afan Oromo version was used to collect the data from women living with HIV attending ART clinics. The questions included in the questionnaire were adapted and prepared by reviewing different related literature and variables identi ed to be measured. Training was given for data collectors and supervisors by the primary researcher for two days. Data collectors cross-checked the pre-ART card numbers of women living with HIV who came to the ART clinic with sampled card numbers daily. Five trained data collectors collected data from women of reproductive age. The completed questionnaires were collected and checked daily for consistency and completeness by supervisors and the primary researcher. Data were collected using a pre-tested structured Afan Oromo version of the questionnaire. A pre-test of the questionnaire was done on 5% of the women living with HIV at Ambo health centre, to identify any ambiguity, to con rm consistency in the questionnaire, to determine acceptability, and to make necessary corrections one week before the actual data collection process. The respondents were guided through a questionnaire and chart abstraction conducted at their health facility by trained data collectors.

Data management and analysis
The returned questionnaires were checked for completeness, cleaned manually, coded and entered into EPI INFO 7.1.6 version and then transferred to SPSS version 23 for further analysis. Frequencies, percentages, mean and standard deviation (SD) were used to summarise descriptive statistics of the data and text. Moreover, tables and graphs will be used for data presentation. Bivariate analysis was used primarily to check which variables have an individual association with the dependent variable. Variables which were found to have an association with the dependent variables were then entered into multiple logistic regressions to control the possible effect of confounders. Finally, the variables which have signi cant association were identi ed on the basis of AOR, with a 95% CI and p-value to t into the nal regression model.

Response rate
The response rate is the number of participants who completed a questionnaire, after discarded16 spoiled questionnaires the complete response rate of this study was 654/670 (97.6%) which re ects the quality of training provided to interviewers, their understanding and the daily supervision by the principal investigator.
There were 654 respondents whose ages ranged between 18 and 49 years. The mean age of the respondents was 31.86 years with a SD of ± 6.0 years. Most of the respondents in the sample were in the age group 26-35 (n = 374, 57%), and only 96 (14.7%) were in the age group 18-25. Of the 14.7%, 4 (0.6%) were younger than 20 years, as re ected in Table 1. Signi cant proportion of respondents (n = 577, 88.2%) were aged 20-39, and only 4 (0.6%) were younger than 20 years old (see described in Table 1). Of the 609 (93.1%) employed respondents, 256 (39.1%) were housewives. These were followed by 239 (36.5%) who were in the private or merchant sector, 55 (8.4%) were self-employed in agriculture on their farms, and only 59 (9.0%) were working for the public service sector. The family's monthly income distribution among the respondents was assessed, and it was found that on average, the income was 1398.18 Ethiopian Birr (50$), and ranged from 100 to 5000. More than 357 (54.6%) respondents were earning less than 1201 Ethiopian birr (1$= 27.84Birr).
With regard to the residential area, the majority of the respondents (n = 518, 79.2%), resided in urban areas, and 136 (20.8%) lived in the rural area. The socioeconomic characteristics of the respondents as summarised in Table 1 are not different from the socioeconomic pro le of Ethiopia. For example, in the general population of the same region, Christian denominations dominate and represent 65% of the population, and the largest ethnic group is Oromo, followed by Amhara which represent 64% of the population (CSA 2016:33). The results are also similar in terms of the proportion of women who are currently married or living together with a partner (65%) in the general population (CSA 2016:34).

Integrating family planning with HIV services
On assessing the level of integrated family planning with HIV services in the ART clinics, this study found that the ART providers provided a contraceptive method mix in ART clinics, of which 93.7% were condoms, 90.2% were injectable and 82.3% were oral contraceptives as chosen methods available during the study period. Therefore, the family planning/HIV services were integrated with the ART clinics of Oromia Region and speci cally focused on offering counselling on available family planning services to providing injectable contraceptive methods, pills, and condoms in the ART clinics. The integrated family planning/HIV services also referred women of reproductive age for consultation on available long-acting and permanent family planning methods within the same facility.  Of the respondents, 616 (94.2%) mentioned that service providers were knowledgeable and comfortable in providing integrated family planning/HIV counselling, and 537 (82.1%) stated that service providers were knowledgeable and comfortable providing integrated family planning/HIV services. Table 2 . The ten measurement variables related to integrate family planning/HIV services were analysed through SPSS under data transform count occurrence of value in terms of the respondents who answered "yes" to the integration of family planning/HIV services. Based on the analysis, the overall integration of family planning/HIV services were reported by 365 (55.8%) of 654 respondents, which ranges from 51.8-59.5% with 95%CI based on 1000 bootstrap samples (Fig. 1). Figure 2 reveals that as integrated family planning/HIV services increased, the number of modern contraceptive utilisers also increased. It was discovered that 325 (50%) current family planning users were using integrated family planning/HIV services versus 40 (6.1%) who were not using integrated services (Fig. 2).
This study determined that the integration of family planning with HIV services ranged from counselling on family planning in the ART room, to the provision of injectable contraceptive methods. Moreover, it also entailed patients being referred to a family planning unit in the same facility for long-acting and permanent contraceptive methods. An exit interview was conducted to determine the level of satisfaction on the utilisation of integrated services, as brie y exhibited in Fig. 3. The exit interview results revealed that more than 622 (95%) respondents are very or mostly satis ed with the utilisation of integrated family planning/HIV services.
In this study almost all respondents (n = 635, 97.1%) preferred integrated sexual reproductive health and HIV services at the same facility, from the same providers, and 622 (95%) were very or mostly satis ed with the utilisation of integrated family planning/HIV services.
Factors associated with the integration of family planning/HIV services Bivariate analysis was used primarily to check which variables had an individual association with the dependent variable. Variables which were found to have an association with the dependent variables were then entered into the multiple logistic regressions to control the possible effect of confounders. In this analysis, the outcome variables, integrated family planning/HIV services, were dichotomised with "1" being integrated and "0" not integrated. Two different models were employed to investigate the factors predicting integration of family planning/HIV services. Accordingly, the Hosmer-Lemeshow Test(HL) for the two models showed chi-square p-values > 0.05, which proved the goodness-of-t of the applied models for this study at p = 0.56 for the integrated family planning/HIV services model.
The estimates of the crude and adjusted odds ratio (AOR) were fairly similar and this showed that the variables used for adjustment were not confounding variables (Hamilton 2012:6). Variables which had signi cant association were identi ed on the basis of an AOR with 95%CI and p-value to t into the nal regression model as evidenced in Table 3. The table presents the outcomes of the bivariate analysis to determine factors associated with the integration of family planning/HIV services. Table 3 depicts variables associated with the integration of family planning/HIV services by multivariable logistic regression. The variables which had signi cant association were identi ed on the basis of AOR, with 95%CI and p-value to t into the nal regression model as evidenced in Table 3 which presents factors associated with the integration of family planning/HIV services.  9.36-23.07, p < 0.023) had a recent CD4cells/ml 3 of 501 and above (AOR 1.82, 95% CI; 1.087-3.047). These factors were independently associated with increased integration of family planning/HIV services.

Discussion
Integration of family planning services with HIV treatment in As far as the integration of family planning and HIV services is concerned, the study revealed that the ART clinics provided both ART drugs and contraceptive methods in ART clinics, of which 93.7% were condoms, 90.2% were injectable, and 82.3% were oral contraceptives as chosen methods available during the study period. These ndings were supported by a systematic review by O'Reilly et al (2013:935), who claim that concerted efforts on the provision of information and support for family planning use, coupled with ready access to a wide range of contraceptive methods, seemed to be most effective in increasing family planning utilisation.
The proportion of contraceptive information that was provided and utilisation of the ART clinics was higher in this study, compared to a study conducted in Ghana. That study reported that 74% of women living with HIV had received information on contraception, 42.6% of participants and/or their partners were using a contraceptive method, and 79.6% used condoms (Laryea et al 2014:26 from the same providers. Another possible explanation may due to the fact that more than 95% of respondents were satis ed with the utilisation of integrated family planning/HIV services, which was con rmed during an exit interview at the time of the study.

Conclusion
This study established that, overall; the integration of family planning/HIV services was relatively moderate among women of reproductive age living with HIV. The identi ed factors that affected the integration of family planning with HIV services were educational and occupational status, residence, discussion of family planning with healthcare providers, fertility desire and CD4 counts. Therefore, this study identi ed factors affecting the integration of family planning and HIV services, from independent variables (sociodemographic, sexual reproductive, HIV therapy and chronic care, and health facility and services providers).

Recommendation
Engage women in the planning, implementation and evaluation of the integrated family planning/HIV services to empower them to decide on their choices regarding family planning/HIV services.
Promote the integrated family planning/HIV services using the mass media with local context in different languages.
Develop and distribute tailored IEC/BCC materials (posters, lea ets, yers, brochures, magazines) related to integrated family planning and HIV service to the community by using local languages for women of reproductive age and people living with HIV.
FMOH and other stakeholders should renovate and equip health facilities with trained, motivated, respectful, caring, and compassionate healthcare providers to offer integrated reproductive health services -including family planning/HIV services -at single visit based on their needs.
Healthcare providers (nurses, health o cers, midwives and physicians) should strengthen the provision of comprehensive health education throughout the sexual reproductive health servicesincluding family planning and chronic care for HIV -in the waiting room area to increase awareness on the integrated people-centred family planning/HIV services in Oromia Region health care facilities.
Provide quality counselling to improve the knowledge of reproductive-aged and empowered women by service providers on the integrated family planning/HIV services.