Table 1 Intervention elements as intended and related challenges during implementation

Provider training on reproductive health for HIV-positive women

• Capitalized on provincial-wide training being conducted through a PEPFAR-sponsored initiative, independent of the study.

• Some trainees were not actually responsible for counseling clients; they were sent because they were the lowest ranking in the clinic, and their time was perceived as most expendable.

• 5-day curriculum covered the sexual and reproductive rights of women; prevention of unintended pregnancy as a means of reducing maternal to child transmission of HIV; contraceptive methods that are safe and effective for HIV-positive women; and the promotion of dual protection.

• Participants lacked fundamental knowledge and skills for family planning service delivery. Instructors had to quickly supplement curriculum with basic family planning information before covering service adaptations for HIV-positive women.

• Participants include providers responsible for antenatal care, child health services, and family planning services.

• These training needs were not anticipated and accounted for in advance because district management lacked readily accessible records about providers’ completed in-service training.

IUD training

• Four days of theoretical classroom training led by a physician trainer.

• Managers recognized that higher ranking nurses would be most appropriate for the clinical training on IUD insertion, but they were reluctant to release them for the course given staff shortages.

• Immediately followed by clinical training and certification.

• Intervention was adjusted, dividing the 1-week training into two 2-day sessions to be held a few weeks apart.

• A municipal strike caused a 2-month delay between the first and second sessions, necessitating thorough review of the earlier material.

• To minimize providers’ time away from work, rather than offer the practical training to the group in a centralized location, it was conducted in the trainees’ home facilities with the support of a traveling trainer.

• Few providers completed the practical portion of the IUD insertion training. Trainees struggled to recruit clients desiring the method, and many clients who were interested in the IUD failed to keep their appointments for insertion.

Clinical supply management support

• Support for facilities in taking supply inventory and submitting orders to the sub-district health office.

• Facilities were slow in placing orders for IUD commodities and insertion equipment.

• Public sector health systems responsible for ensuring intervention sites adequately equipped to provide IUD services.

• Sub-district was not able to supply all insertion equipment requested.

• Study staff supported sub-district and facility managers to resolve these issues by contacting and follow-up with sub-district management, arranging for equipment to be transferred between facilities, and in some cases transporting equipment.

Strengthened referral system for female sterilization services

• Reinforced referral mechanisms between participating health centers and facilities offering sterilization services.

• Some providers reported that the required paperwork was burdensome.

• Both public sector reference facilities and those supported by the Association of Voluntary Sterilization South Africa (AVSSA), a non-governmental organization, serve as reference sites.

• Providers perceived the documentation as a requirement imposed by AVSSA, but in fact the documentation was consistent with provincial governmental policy.

• Breaches in communication occurred between the public sector facilities and AVSSA sterilization service managers.

• Some providers admitted that they did not make referrals because they lacked confidence in their ability to provide complete and accurate information about sterilization.

On-the-job coaching and mentoring

• A medical officer, hired by the study, makes periodic visits to the health care facilities to offer facility-based coaching to support providers in applying knowledge and skills acquired during HIV-FP training.

• The coach visited facilities once or twice per month over the intervention period to reinforce information and skills that trained providers had been taught in project-supported courses, and she facilitated spread of knowledge to other clinicians who had not attended trainings.

• She witnessed problems with provider morale, e.g., many providers complained that they felt overworked or that they were performing duties for which they had not been trained, including counseling on the IUD.

• An important role of the coach was thus to provide encouragement to build confidence in performing new tasks and to offer general moral support about coping under difficult work conditions.

IEC materials and job aids

• Facilities provided with the flipbook “Counseling Tool: Reproductive Choices for Clients with HIV,” adapted from Decision-Making Tool for Family Planning Clients and Providers and the Reproductive Choices and Family Planning for People Living with HIV: Counselling Tool.

• Providers used the flipbook inconsistently in delivering family planning counseling.

• Materials intended to be used by antenatal care, maternity, and child health service providers who serve PMTCT clients in the antenatal, peri-natal, and postpartum period.

• More time in training should have been dedicated to explaining purpose of educational materials, offering skill-building instruction on their use, and establishing the performance expectation that providers should use the flipbook routinely when counseling on family planning.

• Client pamphlets provided to present information on the full range of contraceptive options available in South Africa, including the IUD and sterilization.

• Clinics expressed a desire for additional material on the IUD. The study team produced and distributed copies of the “Balanced Counseling Strategy Plus” pamphlets developed by Population Council.