In 2020, 36.0 million adults aged 15 years and older were living with HIV, with women and adolescent girls accounting for 53% of all HIV infections (Joint United Nations Programme on HIV and AIDS (UNAIDS), 2021). Approximately 72% of women and girls living with HIV (WLHIV) were on anti-retroviral treatment (ART) and about 64% had achieved viral suppression (UNAIDS, 2020). In 2019, 30% of Zambian women aged 15–49 years reported having an unmet need for family planning (defined as the percentage of women of reproductive age who want to stop or delay childbearing but are not using any method of contraception; Population Reference Bureau, 2012) resulting in an estimated 410,000 unplanned pregnancies (Family Planning, 2030, 2020). Unplanned pregnancies are common among WLHIV in sub-Saharan Africa (Mekie et al., 2021; Sutton et al., 2018) and present significant health risks for both the woman and her infant including a higher risk for maternal and infant mortality (Calvert & Ronsmans, 2013; Kassebaum et al., 2014; Matthews et al., 2013; Prendergast & Evans, 2023), and babies born pre-term, stillborn or at low birth weight (Duerr et al., 2005; Wedi et al., 2016).

Access to sexual and reproductive health (SRH) services is a key strategy for reducing mother-to-child transmission (World Health Organization (WHO), 2010; Hladik et al., 2009) and HIV-related mortality and morbidity (Ford et al., 2021). WHO guidance states that WLHIV should have the ability to make independent and informed decisions about their own reproduction, including the right to freely choose whether to have children, how many children to have and what age to have them (Kumar et al., 2015; WHO, 2017). In recognition of the importance of SRH services for WLHIV, UNAIDS has set a new goal that 95% of women and girls of reproductive age will have their HIV and SRH needs met by 2030 (United Nations General Assembly, 2021; WHO, 2022).

Integration of family planning (FP) services into HIV treatment programs has been shown to be an effective (Haberlen et al., 2017; O’Reilly et al., 2013) and cost saving (Reynolds et al., 2008; Shade et al., 2013; Wall et al., 2020) strategy to increase WLHIV’s access to SRH services and to reduce their unmet need for FP. Integrated services are supported by the Zambia Consolidated Guidelines for Treatment and Prevention of HIV Infection, which also allow task shifting of some HIV services to community-based distributors (CBDs) to support WLHIV who are stable on ART (Zambia Ministry of Health, 2020). This includes offering contraceptives in addition to HIV medication refills, to ensure continuity of both HIV treatment and FP services as part of differentiated service delivery models.

Despite this, integrating FP and HIV services in Zambia has faced several challenges. Resource constraints, including limited funding and a shortage of HIV care providers trained to offer comprehensive FP services, have made it difficult to implement and sustain integrated services across the country (Lince-Deroche et al., 2020; Warren et al., 2017). Furthermore, HIV and FP services have traditionally been delivered and funded as vertical and siloed services, creating barriers to coordination and integration (Kachale et al., 2022). Cultural and social barriers also contribute to the lack of integration. Stigma surrounding both HIV and contraceptive use, especially among young women, can prevent women from seeking out FP services from HIV care providers (Nattabi et al., 2011). Gender dynamics, which often discourage women from making autonomous reproductive health decisions, further complicate the uptake of FP services among WLHIV (Nattabi et al., 2011).

Thus, while international and national guidelines recommend integration of FP and HIV services, these barriers help explain why Zambia has struggled to fully implement this model. Moreover, limited research has been done to explore how HIV healthcare providers (HCPs) perceive the feasibility and utility of integrated services. This mixed methods study used both standardized questionnaires and in-depth interviews to obtain the perspectives of HCPs on the perceived benefits and barriers of implementing an enhanced model of FP/HIV service integration at six health facilities in Lusaka, Zambia based on their own experiences.

Data presented are from a larger study examining the impact of an enhanced model of FP/HIV integrated service delivery on contraceptive uptake and dual method use among WLHIV attending six health facilities in Lusaka, Zambia (Medley et al., 2023). The model, which was implemented from August 2018 to April 2019, had three main components: (1) improving documentation and monitoring of FP services in patient monitoring tools (paper-based and electronic); (2) strengthening integration of FP and HIV services by training six HIV care providers per facility – including two nurses, two lay counselors (LCs) and two CBDs – in FP service delivery and offering a full range of FP methods within the HIV clinic (e.g., oral contraceptive pills (OCPs), injectables, implants and intra-uterine devices (IUDs)) and (3) facilitating referrals to CBDs and other health facilities for FP services, as needed. FP services were offered in a private space within the HIV clinic and each facility was provided with specula and other necessary equipment (e.g., cotton wool, gloves, forceps, etc.) to safely offer a wider range of FP services. All contraceptive methods were provided by the Zambia Ministry of Health.

Providers were highly supportive of the enhanced model of FP/HIV integration and suggested that it be continued and expanded to other health facilities throughout Zambia. The provision of several contraceptive methods increased significantly following the intervention including OCPs, injectables, implants and IUDs, and the number of women referred to FP services outside the HIV clinic declined. During in-depth interviews, providers described several improvements that likely contributed to the success of the integrated model including improved provider training in FP service delivery, enhanced client education and increased provider comfort in delivering FP services within HIV clinics.

Despite the training offered as part of this intervention, FP knowledge about certain contraceptive methods remained low among some of the HIV care providers. This finding raises real concerns about the feasibility of fully integrating FP and HIV services and underscores the need for sustained educational efforts to ensure providers are both knowledgeable and confident in offering a range of contraceptive options to WLHIV. Moreover, at the time of this study, concerns had been raised that dolutegravir-based regimens may be associated with an increased risk of birth defects (Zash et al., 2018) and as a result nurses described switching women who desired a pregnancy to a less effective regimen as part of safer conception counseling. Further investigation has found no association between dolutegravir and congenital abnormalities (Hill et al., 2018; Zash et al., 2019). Ongoing refresher training is therefore needed to keep providers abreast of the rapidly changing knowledge around drug–drug interactions and to ensure additional providers are trained in FP service delivery to address human resource constraints (Nkhoma et al., 2022). These trainings should be offered annually to address staff turnover and include practical demonstrations and mentorship. Trainings can be provided in-person or through telehealth platforms such as Project ECHO (Wood et al., 2022; Bikinesi et al., 2020).

As in previous studies, providers described several myths and misconceptions that acted as barriers to women’s uptake of FP methods, despite their availability within the HIV clinic (Newmann et al., 2013; Wall et al., 2018). Providers emphasized the need to provide FP education and counseling, both within health facilities and out in the community, to help dispel these myths. As differentiated service delivery models for WLHIV who are stable on ART continue to expand, CBDs are well-positioned to support health facilities by dispelling FP myths, encouraging ART and contraceptive adherence, and supporting FP service delivery within the community (Brunie et al., 2016; Chin-Quee et al., 2013; Grimsrud et al., 2017; Hagey et al., 2018; Okegbe et al., 2019). Further operational research is needed on how best to engage CBDs to support integrated FP/HIV services, including provision of adequate compensation and supportive supervision to prevent CBD burn-out and attrition (Wall et al., 2020).

Providers also identified the need to offer FP counseling to male partners to improve FP uptake. A study in Kenya found that men living with HIV were supportive of FP and preferred obtaining FP services at their HIV clinics (Patel et al., 2014). Other studies have suggested that integrated FP/HIV services normalized FP for both men and women and helped foster male involvement in FP services (Newmann et al., 2013; Tao et al., 2015). Future programs offering integrated FP services to men and couples within HIV clinics could help facilitate shared decision making around fertility and contraception. Careful attention will be needed to balance men’s involvement in FP programs with the right of women to make informed decisions about their own health care (Tao et al., 2015).

Similar to findings from other studies, structural barriers include frequent stockouts and lack of space and equipment (Adamchak et al., 2010; Chen et al., 2020; Mutemwa et al., 2013; Newmann et al., 2013). Providers described limited options for coping with stockouts and generally advised women to either purchase the contraceptive directly or to temporarily switch methods until the preferred contraceptive came back into stock. In this study, providers were not systemically tracking contraceptives distributed nor using information from medical records to forecast the number of contraceptive methods needed to meet demand. Training providers to use routine program data for forecasting and establishing proper stock management systems may help prevent stockouts (Rasmussen et al., 2018; Zuniga et al., 2022). Collaboration across various health sectors to integrate funding streams and supply chain systems for contraceptives and HIV medications will also be needed to limit stockouts (Bravo et al., 2020).

This analysis has several limitations. First, health facilities were purposefully selected, and the number of providers interviewed was relatively small. Thus the views expressed may not be generalizable to other HCPs from Lusaka or from non-urban facilities in Zambia. Interviews were conducted by staff employed by the implementing partner which may have led to a social desirability bias in some of the responses. This study did not include a control group. Therefore, we cannot rule out the possibility that external factors, beyond the enhanced model of FP/HIV service integration, contributed to the observed changes in service provision and provider attitudes. Future studies could benefit from a more robust study design to strengthen evidence on the impact of integration. Finally, nuances of language and nonverbal communication may have been lost during the transcription process.

Nevertheless, this study has shown that HIV providers are willing and able to provide FP services as part of routine HIV care, adding to the growing evidence base supporting the integration of these services (Nkhoma et al., 2022). Key steps to address the challenges identified by HIV care providers include the need for continuous training on both family planning and HIV drug–drug interactions, addressing commodity stockouts, combatting common FP myths through community education, and offering FP services to men and couples. A phased approach, starting with well-supported facilities, followed by national scale-up, could facilitate the expansion of this model throughout Zambia. Improving WLHIV’s access to FP services will not only contribute to improvements in their health and the health of their children (Khosla et al., 2015; Narasimhan et al., 2015) but will also respect their right to make informed decisions about their own reproductive health (Kumar et al., 2015).