Annals of Clinical Case Reports Research Article

Published: 11 Jul, 2022

Strategies to Integrate Family Planning with Antiretroviral

Therapy Services for Women Living with Human
Immunodeficiency Virus in Oromia, Ethiopia
Dereje Bayissa Demissie1,2* and Rose Mmusi-Phetoe3
1
Department of Health Studies, College of Human Science, University of South Africa, South Africa
2
St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
3
Department of Public Health, College of Human Science, University of South Africa, Pretoria, South Africa

Abstract
The purpose of the study was to develop strategies for the integration of family planning services
with HIV treatment for women of reproductive age for better health outcomes and facilitate clinical
practice through the implementation of feasible strategies.
Self-administered structured questionnaires were used to collect data from focal persons, health
managers, and healthcare providers working in the ART/Prevention of Mother-To-Child
Transmission (PMTCT) clinics in the Oromia Region. Simple random sampling computer-
generated sample was used to select 670 respondents. The study findings were provided and the
research findings were interpreted in the outcome summary. The integration of family planning
with HIV services is key to this study, as it includes counseling and provision on available family
planning methods in the ART room, as well as providing referrals for long-acting and permanent
methods such as condoms and implants [1].
OPEN ACCESS
HIV-positive women of reproductive age need better access to family planning and HIV treatment
*Correspondence:
based on identified factors. The study found significant gaps between the availability of family
Dereje Bayissa Demissie, Department
planning/HIV services and the actual delivery of fully integrated sexual reproductive health services
of Health Studies, College of Human
[1].
Science, University of South Africa,
Pretoria, South Africa, St. Paul’s This study revealed that HIV-infected reproductive age women have a significant need for family
Hospital Millennium Medical College, planning services with identified factor-like attending ART/PMTC and discussions with healthcare
Addis Ababa, Ethiopia, practitioners are two factors that enhance demand. It should be a priority in high HIV seroprevalence
E-mail: [email protected] nations to ensure that family planning service providers are aware of the special family planning
Received Date: 11 May 2022
requirements of HIV-positive women [2].
Accepted Date: 05 Jul 2022 Existing family planning use was greater than the national contraceptive prevalence rate among
Published Date: 11 Jul 2022 women of reproductive age. This number is similar to the proportion of service providers that report
Citation: providing both HIV- and family planning-related services that are heavily reliant on training in
Demissie DB, Mmusi-Phetoe R. integrated family planning and HIV services [1,2].
Strategies to Integrate Family Planning The study found strong favor for women of reproductive age living with HIV-centered integrated
with Antiretroviral Therapy Services Family Planning services. The strategies were developed based on the findings of the study. The
for Women Living with Human Ministry of Health and the health bureaus should incorporate the strategic plan into its policy and
Immunodeficiency Virus in Oromia, establish documents to further ensure the provision of quality services.
Ethiopia. Ann Clin Case Rep. 2022; 7:
Keywords: Family planning; HIV services; integration; HIV-positive women strategy
2245.
ISSN: 2474-1655 Abbreviations
Copyright © 2022 Dereje Bayissa
Demissie. This is an open access AIDS: Acquired Immune Deficiency Syndrome; ART: Antiretroviral Therapy; AOR: Adjusted
article distributed under the Creative Odd Ratio; CSA: Central Statistical Agency; CI: Confidence Interval; COR: Crude Odd Ratio; EDHS:
Commons Attribution License, which Ethiopian Demographic Health Survey; FHI: Family Health International; FMOH: Federal Ministry
permits unrestricted use, distribution, of Health; HIV: Human Immunodeficiency Virus; IUDs: Intra-Uterine Devices; OR: Odds Ratio;
and reproduction in any medium, ORHB: Oromia Regional Health Bureau; PMTCT: Prevention of Mother-to-Child Transmission;
provided the original work is properly SDGs: Sustainable Development Goals; STIs: Sexually Transmitted Infections; UNAIDS: United
cited. Nations Program on HIV/AIDS; UNICEF: United Nations International Children's Emergency

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

Fund; UNISA: University of South Africa; USAID: United States on ART/PMTCT for better health outcomes. Such integration should
Agency for International Development; VCT: Voluntary HIV also facilitate clinical practice through the implementation of feasible
Counseling and Testing; WHO: World Health Organization strategies within the context of Ethiopian healthcare facilities.
Key Concepts Vision
What do we already know about this topic? The long-term vision of integrated family planning with HIV care
for women living with HIV in Ethiopia encompasses the long-term
The integration of family planning services with HIV treatment
vision of women of reproductive age living with HIV being free of
is an increasingly recognized strategy worldwide aimed at the
the threat of HIV and sexual reproductive health concerns by 2030.
prevention of unwanted pregnancy among women of reproductive
age living with HIV and new pediatric HIV infection. The results Mission
from this study were used to improve the availability of integrated Ethiopia is committed to rapidly and inclusively integrating
family planning/HIV services and address certain knowledge family planning with HIV services. To build and reinforce linkages
gaps. Therefore, the integration of family planning services with between family planning programs and HIV/AIDS prevention
HIV treatment is the cornerstone of reproductive healthcare for and care by fast-tracking multi-sectoral responses and scaling up
seropositive clients to ensure their reproductive health and quality prioritized actions to sexual reproductive health and HIV service
of life. needs in Ethiopia.
How does your research contribute to the field? Overall goal, objectives of the strategies
The integration of family planning with HIV services is an
The overall goals of these strategies are for the women living with
increasingly recognized strategy worldwide aimed at the prevention
HIV to receive integrated health services that strive to achieve the 90
of unwanted pregnancy among women of reproductive age living
90 90. These include providing integrated sexual reproductive health
with HIV and new pediatric HIV infection. The results from this study
services, such as family planning, as well as HIV prevention, therapy,
were used to improve the availability of integrated family planning/
and care, to end the AIDS pandemic by 2030. The purpose is also
HIV services and address certain knowledge gaps. The researcher
to improve the well-being of people infected with and impacted by
highlighted the need to strengthen the capacity of health centers to
HIV/AIDS by ensuring that no one is left behind. The goals of these
provide quality service for women living with HIV.
strategies are to prevent unintended pregnancy and HIV infections,
What are your research’s implications for theory, practice, reduce vulnerability to HIV, improve the provision of family planning
or policy? services, and offer dual contraceptive methods, treatment, care, and
The study's findings included ramifications for clinical practice support for women of reproductive age living with HIV. The aim is
and provided a foundation for future research. It is hoped that the also to mitigate the socioeconomic impact of unintended pregnancy
solutions proposed will be successfully adopted and used in health and HIV/AIDS on individuals, families, communities, and the nation.
facilities. The objective of these strategies is to describe the strategies
Introduction that would help the health system to overcome the problems and
challenges in offering quality integrated family planning/HIV
Strategies for integrating family planning and ART services for services. Preventing unintended pregnancy and HIV transmission
HIV-positive women in Ethiopia's Oromia region are described. Data can be achieved through dual protection which would improve the
were gathered from HIV-positive women of reproductive age and quality of life of women of reproductive age living with HIV and
healthcare practitioners that give ART/PMTC. It is aimed at outlining neonatal health.
the vision, mission, overall goal, objectives, and underlying principles
of the strategies. These will be followed by presenting strategies for Underlying principles of the development of strategies
strengthening the integration of family planning with HIV services The developed strategies put focus on addressing uncertainty
for women of reproductive age living with HIV. Integrated health and women’s unmet need for family planning. It creates awareness
services are defined as the management and delivery of health and knowledge among HIV-positive and sexually active women of
services such that people receive a continuum of health promotion, reproductive age about the importance of integrated family planning/
disease prevention, diagnosis, treatment, disease management, HIV services. The study assumes that awareness and knowledge
rehabilitation, and palliative care services. People are cared for at would, in turn, empower women to make choices about the use of
different levels and sites of the health system, and according to their family planning for better reproductive health outcomes.
needs throughout their life course [3]. Similarly, strategies defined
The following principles of WHO [5] were considered when
in Chapter 1 are concrete skills and activities for top managers and
developing these strategies to reflect the core values of integrated
their corporate advisers, where there are matters of policy that lead to
health and family planning strategies among women living with HIV
actions [4]. In the context of this thesis, the achievement of strategies
to establish better health outcomes.
leads to the achievement of a broader strategy.
Comprehensive offering care that is comprehensive and tailored
Accordingly, strategies are defined and described as a plan of
to the evolving health needs and aspirations of women.
action designed to achieve a long-term goal, a solution to a problem,
or a method chosen to bring about the desired future presented in Equitable-providing care accessible and available to all
Chapter 1. This study adopted a description of strategies to be activities
or actions that the healthcare providers and program managers would
• Sustainable: Delivering care that contributes to sustainable
engage in to enhance and facilitate the integration of family planning development.
services with HIV treatment for women of reproductive age that are • Empowering: Supporting women of reproductive age to

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manage and take responsibility for their health. The care is provided at different levels and sites within the health
system based on people’s needs throughout their life. The integrated
• Continuous: Providing care and services across the life
health services can cross sectors’ organizational structural, budgetary
course.
or administrative constraints, to reach efficient coordination and
• Co-produced through active partnerships with women of improved outcomes [10].
reproductive age living with HIV and peer educators, and mother-to-
The main goal of women living with HIV-centered care is to
mother support groups at an individual, organizational, and policy
achieve optimal experience and quality of care, quality of life, and
level.
positive health outcomes [11]. This care further requires that women
• Evidence-informed that policies and strategies are guided have the education and support to make decisions, participate in care
by the best available evidence. practices and goals, with their social determinants of health [5].
• Respectful: Being respectful of women living with HIV's Integrated strategies centered on women of reproductive age living
dignity, social circumstances, and cultural sensitivities. with HIV are organized around the health needs and expectations of
these women rather than diseases. Therefore, this study’s findings are
• Collaborative: Supporting relationship-building, team-
relevant in developing strategies to integrate family planning services
based work and collaborative practice across primary, secondary, and
with HIV treatment for women living with HIV to improve their
tertiary care, and with other sectors.
reproductive health needs based on the integrated model [12].
• Action within and between sectors that promote public
The researcher hypothesized that the root causes of failure to
health and health promotion should also be supported. Governed
provide integrated family planning/HIV care and treatment for
through shared accountability of care providers to local women of women of reproductive age living with HIV are lack of awareness
reproductive age living with HIV to improve the quality of care and about HIV care and preventative services through comprehensive
health outcomes. sexual reproductive health services in the context of family planning.
• Leading by whole-systems thinking that views the health The researcher has the view that integrated family planning and HIV
system as a whole and tries to understand how its parts interact with services will lead to improvements in such services. In turn, improved
each other. outcomes can be expected, such as demands for family planning
being met, untended pregnancy being prevented, and dual method/
• Ethical: By making sure that care optimizes the risk- family planning utilization among women of reproductive age living
benefit ratio in all interventions, respects the individual's right to with HIV.
make autonomous and informed decisions, safeguards privacy, and
protects the most vulnerable. Powers, Knapp, and Knapp [13] define deductive reasoning as a
method of reasoning in which the premises are viewed as supplying
• Leading by whole-systems thinking: That views the health strong evidence for the truth of the conclusions made, the way of
system as a whole and tries to understand how its parts interact with thinking, or logical mental processes which begin with premises
each other. about a phenomenon and systematically formulate a conclusion.
• Ethical: By making sure that care optimizes the risk- Based on this study’s design, a decision was taken to adopt the best
benefit ratio in all interventions, respects the individual's right to medical practice by developing strategies using deductive reasoning
make autonomous and informed decisions, safeguards privacy, and to empower both the women of reproductive age living with HIV,
protects the most vulnerable. their families, and the staff at the healthcare facilities as consumers
of the strategies.
Strategies for the Integration of Family
Planning with HIV Services for Women of The context of the development of the strategies
Reproductive Age Living with HIV Strategies for women living with HIV-centered integrated health
services are applied in the following contexts [3-5]:
Conceptual framework
Central to this study is the notion that contraceptives have been • Tackling sexual reproductive health service problems,
issued through family planning services in developing countries, including the unmet need for family planning, unwanted pregnancy,
primarily as a strategy to reduce fertility [6]. Revised laws on women’s and pediatrics' new HIV infections. Close collaboration between
reproductive health rights call for adopting a women-centered health health, social care, education, and the wider range of local services
perspective to improve access to reproductive healthcare [7]. A can all contribute to better health for women of reproductive age
woman-centered integrated health service conceptual framework living with HIV.
was developed by the World Health Organization (WHO) for future • Individual women living with HIV, families, and
health systems. The approach advocates for responding to the needs communities are at the center, placed within integrated family
and preferences of individuals, families, and communities humanely planning/HIV prevention, therapy, and care service delivery, to
and holistically. It includes integrated health services, managed and ensure universal and equitable health services.
delivered in a way that ensures people receive a continuum of care [5].
• Enabling policy environments that strengthen the
Future health systems describe the 'people-centered and integrated
implementation and promote the integration of family planning
health' service framework as a fundamental shift in the way health
programs with HIV prevention, treatment, and care, and paves the
services are funded, managed, and delivered. The approach advocates
way for universal health.
for responding to the needs and preferences of the individuals,
families, and communities humanely and holistically [8,9]. Integrated family planning with HIV prevention, treatment, and

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care is aligned to national reproductive health services including Strategy 1: Empowering and engaging women of
family planning per national health and development policies and reproductive age living with HIV
strategies. 'Empowering and engaging' women living with HIV is about
Approach to the development of the strategies providing opportunities, skills, and resources to these women as
users of health services. It is also about reaching the underserved and
Suggest [10] that the five interdependent strategic directions marginalized groups of the population to guarantee universal access
that underline the people-centered integrated health services can to services. Family and peer educators should also be roped into the
transform health systems to provide more comprehensive holistic input and co-produce their health through the integration of sexual
services for women of reproductive age living [5]. A systematic review reproductive health services, including family planning/HIV services
study conducted by [14] outlines salient lessons and challenges from and chronic care of ART [5]. This goal seeks to unlock community
five countries in sub-Saharan Africa which revealed that integrating and individual resources for action at all levels. It aims to enable
sexual reproductive health and HIV services is proposed as a means communities to become actively engaged in co-producing healthy
to improve service performance and reduce costs. The most common environments, providing care services, and contributing to healthy
challenges with integration are related to delayed or incomplete public policy.
integration of higher-level health system functions. There is a lack of
appropriate regulation and unified national policies and operational Women living with HIV need to be harnessed to achieve better
frameworks. It is being widely adopted as a national policy in sub- clinical outcomes through co-production of care, particularly for the
Saharan Africa, supported by international development partners integration of sexual reproductive health services (including family
[14]. planning/HIV) with chronic care of ART. 97.1% of respondent’s
preferred integrated sexual reproductive and HIV services at the
The five strategic directions include empowering and engaging same facility or site, and almost all (96.9%) preferred to receive HIV
these women, strengthening governance and accountability, and Sexual reproductive health services from the same provider. This
reorienting the model of care, coordinating services, and creating is fundamental because women of reproductive age living with HIV
an enabling environment. These directions are intended to influence themselves will spend the most time living with and responding to
different levels, from the way services are delivered to women living their own health needs. This is because they will be the ones making
with HIV, families, and communities. choices regarding healthy behaviors and their ability to self-care.
Reorienting the model of care that is tailored according to sexual It is also about the care that is delivered in an equal and reciprocal
reproductive health services and family planning. Coordinating relationship between clinical and non-clinical professionals and
the family planning services and HIV programs. These strategic individuals using care services, their families, and communities [5].
directions are intended to influence different levels, from the way Mother-to-mother support groups and peer educators should be
services are delivered to women of reproductive age living with HIV, empowered to voice their needs and influence how care is funded,
families, and communities, to changes in the way organizations, care planned, and provided. It helps build confidence, trust, mutual
systems, and policymakers operate. respect, and social networks because the women's physical and mental
well-being depends on strong and enduring relationships. Reaching
Creating an enabling environment: Policies, strategies, and
the underserved and marginalized is of paramount importance to
programs that strengthen the integration of family planning services
guarantee universal access to health services. It is essential for fulfilling
with HIV prevention, treatment and care.
broader societal goals such as equity, social justice, and solidarity. It
Figure 1 demonstrates the linkages between the strategic requires actions at all levels of the health sector, as well as intensive
initiatives for integrated family planning with HIV services centered action with other sectors and all segments of society. Urgent action is
on HIV-positive women of reproductive age. needed to improve access to sexual reproductive health services for

Figure 1: Developed strategies for women of reproductive age living with HIV centered integrated family planning with HIV services.

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women and girls in developing countries. It is essential for fulfilling HIV’s empowerment in terms of integrated family planning/HIV
broader societal goals such as equity, social justice, and solidarity. It prevention, treatment, and care.
requires actions at all levels of the health sector, as well as intensive
• Expanding integration of family planning/HIV services
action from other sectors and segments of society [5].
to the primary healthcare-based systems to increase availability and
Recommendations for empowering and engaging women accessibility.
of reproductive age living with HIV
• Advocating for the mitigation and reduction of harmful
Empowering and engaging women of reproductive age living with sexual reproductive health and family planning cultural practices.
HIV, family, and peer educators to co-produce their health through
the integration of sexual reproductive health services (including • Monitoring peer educators and mother-to-mother support
family planning with HIV services) with chronic care of ART is a groups’ engagement and support, and establishing a referral system.
responsibility of every sector. It can be implemented by adopting Strategy 2: Strengthening governance and accountability
integrated family planning/HIV indicators in an interconnected for integration of family planning with HIV services, and
sectoral approach. Program specifics include: HIV care
• Developing and distributing tailored IEC/BCC materials Good governance is essential for economic growth, social progress,
(posters, leaflets, flyers, brochures, magazines) related to integrated and general development. It is especially critical for healthcare
family planning and HIV services to the community by using the systems, where the poorest members of society appear to have the
local language. least power and are disproportionately harmed by corruption.
• Engaging women in planning, implementation, and Governance and accountability for universal, egalitarian,
evaluation of the integration of family planning-HIV services to integrated family planning/HIV services, as well as HIV care
empower them to decide on their choices regarding family planning/ interventions, entail policy discourse and appropriate governance
HIV. Utilizing health extension workers and mother-to-mother procedures [5]. Governance and accountability for the provision of
support groups to conduct intensive post-test counseling [15] aimed universal, equitable, integrated family planning/HIV services, and
at strengthening counseling on dual contraceptive methods for HIV care interventions involve policy dialogue, establishing good
effective protection of women and their partners. Moreover, partners governance mechanisms, accountability, and leadership. In this
are notified with permission. regard, all associated sectors are responsible but the Federal Ministry
• In line with the WHO [16], more HIV-positive people of Health has to be mandated in terms of overall governance,
should be identified and their early referral to care in some settings coordination, accountability, and resourcing.
should be promoted. Recommendations for strengthening governance and
• Encouraging partner or couple testing/male involvement. accountability for the integrated family planning/HIV
services and care
• Improving the integration of services such as the provision
of ART in antenatal care. • Establish standard operating procedures that guide the
implementation of policies and guidelines to facilitate integrated
• Co-producing healthy lifestyles and sexual reproductive family planning/HIV services, and revise the existing curriculum to
health. incorporate the integrated services. The ORHB, in collaboration with
• Advocating for and convincing leaders to strengthen the the Ministry of Health and Ministry of Education, should implement
integration of family planning/HIV services. the proposed strategic plan.

• Shared clinical decision-making between women of • Assign service providers to offer integrated family planning/
reproductive age, families, and providers. HIV services for long-term appointments in family planning or HIV
service provision.
• Self-management, including personal care assessment
of family planning/HIV service utilization and sexual reproductive • Ensure equipped health facilities with trained, motivated,
health service utilization plans with ART/PMTCT treatment plans. respectful, caring, and compassionate healthcare providers for the
provision of integrated sexual reproductive health services, including
• Developing and promoting peer educator and mother-to- family planning/HIV services like HIV prevention, therapy, and
mother support group-based integrated family planning/HIV service chronic care at a single visit based on their needs.
assessment, counseling, and support programs.
• Establish and implement continuous quality improvement
• Conducting annual patient satisfaction surveys to interventions based on integrated family planning/HIV care and
determine their level of satisfaction with integrated family planning/ experiences of the integrated model.
HIV services.
• Establish mechanisms for multidisciplinary collaboration
• Ensuring health equity goals in terms of integrating family service providers for the integration of family planning/HIV
planning/HIV services into health sector objectives. prevention, treatment, and care for reproductive-aged people living
• Conducting outreach services for the underserved, with HIV at public health facilities.
including mobile units with health extension workers to minimize
• Fund and support sectorial HIV programming that
transportation by providing one-stop comprehensive services fully
incorporates effective integration of family planning with HIV
integrated based on women’s needs.
services as a way of reducing vulnerability to HIV infection,
• Community engagement to facilitate women living with increasing resilience to AIDS, and addressing sexual reproductive

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health problems among people living with HIV. • Support new opportunities for inter-sectorial action at the
community level to address the family planning demands and needs
• Ensure the availability of essential equipment and supplies
of persons living with HIV by enhancing programs through referral.
for the integration of HIV prevention, treatment, and care at public
Screen and provide essential sexual reproductive services to HIV-
health facilities.
positive individuals using one-stop comprehensive, integrated health
• Define roles and distribute tasks among services providers. services to prevent unwanted pregnancy, re-infection with different
HIV viruses, STIs, pediatrics’ new HIV infection, and early mortality
• Create national health policies, strategies, and plans
while initiating ART and drug refilling during ART follow up.
promoting integrated family planning/HIV services and care.
• Life-cycle approach for sexual reproductive health service
• Harmonize and align donor programs with national
intervention targeting reproductive-aged pregnant women living
policies, strategies, and plans. The anticipated outcomes would be
with HIV and children.
sustainable financing for the integration of family planning/HIV
services, and ensuring the availability of essential equipment and • Assure the delivery of effective, efficient clinical care and
supplies for integrated family planning/HIV prevention, treatment, self-management support for women of reproductive age living with
and care. There would also likely be increased sustainability and HIV.
accessibility of integrated family planning/HIV services in universal
• Establish and strengthen community-based nationwide
health coverage.
strategic information management systems (tailored to the existing
• Establish good governance and accountability for the HMIS) to the strategies of integrating family planning with HIV
provision of integrated family planning/HIV services and care by services as interventions.
enhancing mutual accountability for financing and resourcing.
• Re-orient the health system to provide humanized and
Strategy 3: Reorienting the care paradigm to include women-centered integrated family planning/HIV services.
family planning and HIV services
• To allow integrated family planning with HIV services, new
'Reorienting the model of care means ensuring that efficient and
blocks/rooms are being built or the current infrastructure of public
effective healthcare services are purchased and provided through
health centers is being renovated.
models that prioritize primary and community care services.
• Propose policies that improve patient care.
In this case, it entails care that focuses on primary care; co-
production of health through sexual reproductive health services • In addition, the healthcare system should foster a culture,
especial family planning in the form of the holistic approach and organization, and mechanisms that encourage safe, high-quality care.
integrated with HIV prevention, treatment, and care, mainly within • Emphasize the patient's central involvement in health
the health sector [5]. management.
Integrated family planning/HIV service programs that center on • Encourage the use of effective improvement initiatives
women of reproductive age living with HIV encompass the shift from aimed at achieving comprehensive system transformation.
inpatient clinical HIV/AIDS and unwanted pregnancy by abortion
management. In this case, it entails care that focuses on primary care; • Utilize effective self-management support tools such as
co-production of health through sexual reproductive health services assessment, goal setting, and action planning, problem-solving, and
especially family planning in the form of the holistic approach. follow-up. Employ inter-professional teams to ensure the provision
of comprehensive services for all.
Integrated family planning/HIV service programs centered on
HIV-positive women of reproductive age include the transition from • Prioritize community and family-oriented models of care
inpatient clinical HIV/AIDS and undesired pregnancy by abortion as a mainstay of practice.
management. In this respect, it comprises primary care; co-production • Innovate and incorporate new information and
of health via sexual reproductive health services particularly family communication technologies to allow new types of information
planning as part of a holistic approach [11], such as: integration and sharing. This can assure continuity of information,
An integrated health service centered on women living with track quality, and reach geographically isolated communities.
HIV is one in which clients, carers, family, and the entire service- The anticipated outcomes would be improved service delivery,
delivery team work together to make care decisions. Care should be sectorial networks, facilities, and practitioners.
continuous across stages of care, levels, and types of service delivery,
including the community, primary clinic, hospital, primary and Strategy 4: Coordinating the family planning services with
specialty care, and life-cycle phases. HIV program interventions across sectors
Coordinating integrated family planning/HIV services
Recommendations for reorienting the model of care to
integrate family planning/HIV services centered on women living with HIV enhances and overcomes the
fragmentation of resources and care.
Ensuring the availability of sexual reproductive health services,
including family planning, assessment, counseling, and support It is about the coordination of sectoral and inter-sectoral
integration programs to improve treatment outcomes and quality of collaboration for sexual reproductive health services, specific and
life for women of reproductive age living with HIV based on mother- family planning sensitive interventions, as well as HIV programs.
to-mother support groups and patient-based service delivery and Recommendations for coordinating family planning services with
supplies. HIV program interventions across sectors.

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To coordinate integrated and sectorial sexual reproductive different programs under one roof for people of reproductive age
health services and family planning interventions, the MOH has to living with HIV.
be responsible for overall program management, communication,
• Identify or revise the roles of different departments/actors
and coordinated evidence for shared decision-making across health
like PMTCT, ART, and family planning units under integrated family
sectors.
planning/HIV services.
• Ensure integrated vertical sexual reproductive health
• Coordinate the different departments/actors based on
services and family planning services across sectors, specifically
women’s sexual reproductive health needs and HIV therapy, care,
targeting reproductive-aged people living with HIV.
and prevention plans.
• Strengthen the capacity and sectorial coordination activities
• Provide timely reminders for providers and patients.
for sexual reproductive health services, including family planning
service interventions across the sectorial organization. • Share information with patients and providers to coordinate
care during single visits for multiple purposes.
• Promote and adopt targeted sectorial communication
for family planning-specific sexual reproductive health problems • Establish agreements that facilitate care coordination
sensitive interventions. within and across organizations.
• Establish an electronic family planning/HIV service • The anticipated outcomes would be inter-sectorial and
integration database for early warning, assessment, and program sectoral approaches.
monitoring of sexual reproductive health problems, including HIV/
Strategy 5: Creating an enabling environment for
AIDs. integrated family planning/HIV service interventions
According to [17], peer-to-peer programs improve self-efficacy centered on women living with HIV
and increase social support in PMTCT programs. Moreover, in Establishing an enabling environment for women living with
the mother-to-mother approach, mentor mothers are viewed as HIV, their families and peers promote and empower them to co-
approachable compared to ‘formal health workers’ by the beneficiaries produce their health through participation and inclusiveness. The
of the program and are better at communicating with women in the women-centered family planning and HIV service programs adhere
PMTCT program [18]. to the principles of holistic approaches serving all people living with
Recommendations are thus to: HIV equally in an environment that promotes the full potential
of women living with HIV to access or produce and utilize sexual
• Establish women living with HIV-centered cooperatives reproductive health services, including family planning and HIV care
and peer-to-peer organizations as entry points for sexual reproductive in a socially acceptable way.
health services including family planning utilization, resilience care,
and support interventions. Recommendations for creating an enabling environment
for integrated family planning/HIV service interventions
• Fund, recognize, coordinate and support initiatives tailored centered on women living with HIV
to the integration of sexual reproductive health services with HIV
The actions require that strategic approaches are adopted and
prevention, care, and therapy that can support, benefit women living
managed to facilitate the large-scale, transformational changes that
with HIV, and assist toward sexual reproductive health wellbeing and
support women-centered integrated health services.
reproductive health rights’ resilience.
Policy for gender dimensions of sexual reproductive health
• Establish mechanisms for multidisciplinary collaboration
services and family planning, such as addressing gender issues in
and teamwork among service providers to strengthen the integration
reproductive rights by improving women's access to finance and
of family planning with HIV prevention, treatment, and care for
decision-making.
reproductive-aged people living with HIV at public health facilities.
• Initiate and scale-up best practices for the integration of
• Fund and support sectorial HIV programming that
maternal health service utilization with HIV program interventions.
incorporates effective integration of family planning/HIV services as
an intervention to reduce vulnerability to HIV infection and increase • Establish a policy framework for promoting and integrating
resilience to AIDS and sexual reproductive health problems among sexual reproductive health services, family planning, and HIV focused
people living with HIV. on reproductive-aged people living with HIV.
• Provide training on program management to build the • The framework can be tailor-made across sectors with the
capacity of the family health team at the regional level and scale set goals of improving treatment outcomes and quality of life.
up for the nation. The provision of training for service providers is
• Establish regulatory directories for the overall management
one of the capacity-building processes that can improve the quality
of sexual reproductive health services, family planning, and HIV
of healthcare services and integrate family planning and HIV
interventions across sectors.
services [15]. Organize and conduct one-week rollout training on
integrated family planning/HIV for service providers, focusing on • Promote and create a Conducive environment for
the integration of family planning/HIV services, reporting, screening, innovative research in sexual reproductive health services, maternal
and monitoring program outcomes. health services, and HIV prevention, therapy, and chronic care.

• Revise the standard operating procedures to create an • Prepare adequate room/space at the public health centers
enabling environment at the public health center level to coordinate to provide integrated family planning/HIV services.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

Figure 2: Scheme implementing women living with HIV-centred integrated family planning with HIV prevention, treatment, and care.

• Endorse social protection policies and programs that can HIV services and address certain knowledge gaps which will facilitate
equitably serve all women living with HIV. clinical practice through the implementation of a feasible strategy.
This enables the policymakers, health managers, planners, and
• The anticipated outcomes would be universal, equitable,
healthcare providers to plan, implement and evaluate the integrated
integrated family planning/HIV services centered on women living
family planning/HIV treatment for women living with HIV as an
with HIV.
intervention for their healthcare facilities.
Framework • Provide a framework to address challenges associated with
The schematic arrangement of women living with HIV-centered the integrated family planning/HIV services; demands for family
integrated health service development, as it evolves, is illustrated in planning, unintended pregnancy, dual contraceptive methods, and
Figure 2. family planning utilization among women of reproductive age that
are on ART/PMTCT.
The purpose of developing strategies
The purpose of this study was to develop strategies that can be Implementation of integrated family planning and HIV strategies
applied to integrate family planning and HIV services for women of for women of reproductive age living with HIV. The activities for the
reproductive age living with HIV. These strategies will guide clinicians implementation of the strategies should be explicit and transparent.
in practice to integrate family planning services with HIV treatment. The proposed strategies are to be applied in the communities, primary
healthcare units, district health offices, ORHB, and FMOH. The
The developed strategies will contribute to the quality of activities were designed to support the planning, implementation,
integrated family planning/HIV service provision through the monitoring, and evaluation of quality integrated family planning/
following activities: HIV services.
• Enable policymakers and healthcare workers to identify Target groups for whom strategies are proposed in the healthcare
factors that affect the integration of family planning services with fields are generally public health policymakers, health program
HIV treatment for women of reproductive age living with HIV. managers, healthcare providers, patients, caregivers, the general
• Brief healthcare providers, focal persons, and healthcare public and other stakeholders [19]. However, in this study, they
were tailored for the primary and secondary groups as users of the
managers on the existing challenges associated with integrated family
strategies or beneficiaries, as evidenced in Figure 3.
planning/HIV services, demands for family planning, unintended
pregnancy, dual contraceptive methods, and family planning The strategies formulated in this study were primarily tailored and
utilization among women of reproductive age that are on ART/ directed to empower the reproductive-aged women living with HIV
PMTCT. who are participating in the integrated family planning/HIV service
program, as well as their partners, families, and caretakers. Secondary
• Foster appropriate use of established guidelines, standards,
recipients, on the other hand, included the healthcare providers, focal
policies, and protocols by the healthcare providers, supervisors, and
persons, supervisors, Ministry of Health (MOH), clinic managers,
healthcare managers to provide quality integrated family planning/
clinic coordinators, community healthcare workers, counselors and
HIV services.
peer educators, NGOs working in these areas, and other stakeholders
• Improve the availability of integrated family planning/ such as the health facility.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

Figure 3: Primary and secondary target groups.

Leading and managing integrated family planning/HIV • The number of women living with HIV counseled for
prevention, treatment, and care among women living with HIV. sexual reproductive health services including family planning at their
Delivering high-quality, integrated health services for women chronic care program.
living with HIV requires the creation and nurturing of collective
• The number of women living with HIV was assessed and
engagement, commonly held values, good communication, teamwork,
counseled on sexual reproductive health services, including family
and transparency [5]. Women’s living with HIV-centered integrated
planning by the peer educator.
sexual reproductive health services requires sectoral coordination
mechanisms to succeed. This study envisions a national coordinating • The number of women living with HIV identified as having
body as a health sector vested with appropriate executive power and an unmet need for family planning while attending chronic follow up
accountability. The Ministry of Health should take the responsibility at the health facility.
of leading multi-stakeholders in the integration of family planning/
• The number of women living with HIV identified as facing
HIV services [20].
repeated unwanted pregnancies while attending health facilities for
Achieving integrated health services for women living with HIV ART drug refills.
involves many national and international stakeholders. Stakeholders • The proportion of HIV-related service-delivery points with
should have to integrate their support for sexual reproductive health family planning/HIV integrated services.
services, including family planning with HIV, across their respective
targets and sectors. The Ministry of health could establish effective • The proportion of HIV-related service clients screened for
collaboration between all parties with its principal responsibilities family planning.
being leadership and coordination. • The proportion of HIV-related service-delivery point
Monitoring, evaluation, and learning clients who received a family planning method or referral after family
Monitoring integrated sexual reproductive health services planning counseling.
centered on women living with HIV, including family planning • The proportion of female clients of reproductive age
with HIV prevention, treatments, and care, are complex; hence, attending HIV-related service-delivery points with an unmet need
they should be monitored by several sectors (sectorial intervention). for family planning.
The WHO [5] suggests that people-centered and integrated health
• The proportion of repeat care and treatment clients
service monitoring should be conducted at several levels. Monitoring
reporting unintended pregnancy.
sexual reproductive health services centered on women living with
HIV, including family planning with HIV prevention, treatment, • The proportion of clients who report receiving more than
and care, is complex and should be monitored by several sectors. one service during their visit.
Data can be collected across sectors at the community, individual,
• The number of facilities with personnel trained in family
and facility levels [5]. Electronic sexual reproductive health services
planning/HIV service integration.
and information management systems that are central and tailor-
made with regular programs that capture family planning services, • The number of facilities with no stock-outs in the prior six
HIV programs, and treatment can be collected across sectors at the months of family planning methods, ARVs, HIV test kits, and drugs
community, individual, and facility levels. for opportunistic infections.
The number of women living with HIV who are assessed for • The number of people living with HIV who has been
sexual reproductive health services, including family planning in empowered and assisted in self-reliance in terms of sexual
their chronic care program, include reproductive health service needs and utilization.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

• The number of women living with HIV empowered on recommendations for further research are presented. In addition,
their sexual reproductive health services, including family planning the weaknesses, strengths, and contributions of the study are
and HIV self-reliance. discussed. The chapter commences by briefly presenting a summary
of the main findings of the study. To reiterate, the study explored
• Amount of capital utilized concerning the allocated budget
the integration of family planning services with HIV treatment for
for women living with HIV-centered integrated family planning/HIV
women of reproductive age living with HIV and attending services
prevention, treatment, and care resilience by an organization in a
given year. for the provision of ART. The findings informed the development
of strategies for better sexual reproductive health outcomes in the
Evaluation and learning Oromia Region, Ethiopia.
Evaluating and learning about women living with HIV-centered
Implications of the findings
integrated sexual reproductive health services. The FMOH and
sectorial organizations should understand the progress and impact Based on the findings, the researcher determined the following
of investments and interventions. Developing and strengthening implications for clinical practice, education, and training.
information systems that can deliver timely and reliable data about Implications for clinical practice
the nature of services being delivered. Family, peer educators, and
Many factors were identified that can contribute to the integration
mother-to-mother support groups should also be looked at.
of family planning with HIV services, demands for family planning,
Learning and evaluating women living with HIV-centered contraceptive, and dual method utilization in the study setting; these
integrated sexual reproductive health services, including family need further research. Such indisputable differences exist everywhere.
planning and HIV programs requires the execution of research. The The implication to be drawn from this research is for policymakers
endorsed strategies are chosen in light of what types of interventions and program planners to narrow the gaps in these programs based on
work in the selected area in the case of the integrated program. evidence in similar settings.
Learning and evaluation are increasingly recognized for their The FMOH and ORHB launched the integration of family
potential to enable interventions, including policies, programs, and planning services with ART/PMTCT services for women of
individual practices to work better, reach targeted populations, scale- reproductive age living with HIV attending ART/PMTCT in January
up coverage and impact, and be sustainable. As such, implementation 2017. The developed strategies serve as a strategic plan to guide
research is reported to be an important tool for identifying and healthcare providers and healthcare managers in offering women of
revising strategies to achieve women living with HIV-centered reproductive age living with HIV integrated family planning/HIV
integrated healthcare. services at the facilities. For the FMOH and ORHB, it is recommended
Experts’ Review of the Proposed Strategies that:

The accessibility and acceptability of the program were reviewed • The strategic plan is tested and adapted in different regional
by experts from ORHB, FMOH, and professionals. This was done states in Ethiopia under the leadership of the FMOH.
to assess whether the strategies could be acceptable as described, • The MOH, in collaboration with other stakeholders, should
acceptable but with recommendations, or not acceptable at all. A take the lead and responsibility for ensuring the implementation
matrix of convergence was developed to measure the experts' opinion of integrated sexual reproductive health services including family
of the developed people-centered and integrated strategies. The planning/HIV services with chronic care of ART. The involvement
process of expert review involved selecting the experts, designing a of stakeholders and partners is imperative to guarantee universal
matrix for data collection, and analyzing the responses. Eight experts access to integrated family planning/HIV services (HIV prevention,
were purposively selected in the areas of family planning, sexual
therapy, and chronic care) at primary healthcare units.
reproductive health; HIV services providers, and regional health care
design and development. • The FMOH and the ORHB should incorporate the strategic
plan into their policy and develop strategic documents to further
As expert reviewed results revealed, experts rating the proposed
ensure the provision of quality services.
strategies by relevance, adaptability, practicality, and usefulness,
rated each criterion at 100% and fully accepted. Only 25% of experts • The FMOH, the ORHB, and the researcher should organize
accepted the clarity and consistency of the proposed strategies with and facilitate a workshop on the developed strategic plans for all
recommended changes. service providers, focal persons, and healthcare managers to enhance
and scale-up integrated family planning/HIV services to different
The proposed strategies were reviewed by experts and fully
health facilities to ensure their accessibility and availability.
accepted for clinical practice, decision-making, monitoring, and
evaluation of integrated family planning/HIV services. This is the first • FMOH and ORHB should emphasize the integration of
in a series of articles on the integration of family planning services sexual reproductive health services including family planning/HIV
with HIV prevention, treatment, and care based on the principles services with chronic care of ART, and it should be included as a key
of women living with an HIV-centered integrated health service performance indicator. This will help to regularly follow up on the
approach. The next chapter will present the implications of the activities.
findings and recommendations for further research.
• Conduct regular self-assessment by service providers
Implications of the Findings, and supportive supervision by the ORHB to ensure the quality of
Recommendations, and Conclusions counseling according to the standard protocols.
Introduction • Develop standard operating procedures that guide the
In this final chapter, the implications of the findings and the implementation of policies and guidelines to facilitate the integration

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

of family planning and HIV services. cross-section study design. A recall bias among women, especially
concerning missed appointments and pills, is a potential limitation to
• Assign trained service providers to offer integrated family
the study. Internal validity may also be tampered with due to temporal
planning/HIV services for long-term appointments in family
effects like the premature exit of respondents or measurement effects.
planning or HIV services.
Strengths of the study
• Policymakers and health planners should revise the
existing curriculum of medical education and training to incorporate The strengths of this study were recorded in terms of the high
integrated sexual reproductive health services including family response rate of 97.61% (654/670). Moreover, the researcher pre-
planning/HIV services based on the needs of service utilizes to tested the instruments, as discussed in Chapter 3, to overcome any
improve the quality of sexual reproductive health services in Ethiopia. measurement limitations [21,22]. Quantitative studies prefer large
populations, and the population of this study was reasonably large;
• MOH and health bureaus should employ supervision, representative samples were selected by simple random sampling
mentoring, and monitoring mechanisms based on the identified computer-generated method. The research design included obtaining
indicators of integrated family planning/HIV services which will the views from different subgroups of women of reproductive
improve family planning, dual contraceptive method utilization, and age living with HIV, service providers, focal persons, and Health
prevent unwanted pregnancy, and new pediatric HIV infections. office/Bureau managers of family planning/ART/PMTCT, on the
• At the regional state and zonal health office level, the availability of integrated sexual reproductive health services.
researcher recommends training for services providers and focal The strengths of the study concerning its contribution to
persons on family planning/ART/PMTCT to further ensure the the level of health theory
provision of quality services. From the findings presented in [1], the study demonstrated that
Implications for practice for healthcare providers the integration of family planning services with HIV services ranged
from counseling on available family planning in the ART room to
Ethiopia's Ministry of Health (MoH) has released its final strategic
provisions of family planning methods such as condoms, pills, and
plan for the integration of family planning and HIV services in
the injectable methods. This included the provision of implants in
Oromia Region healthcare facilities. The plan aims to improve access
the ART rooms and referring women in need of long-acting and
to family planning, dual contraceptive methods, the need for family
permanent methods for consultation. The insertion of the IUD was
planning being met, prevent repeated unwanted pregnancy, and offer
not part of the family planning methods in this regard.
HIV services. Healthcare providers should be trained, equipped,
and encouraged to take ownership of the implementation of the This study assessed the existing integration of sexual reproductive
reproductive-aged women-centered integrated family planning/HIV health services with HIV treatment for women living with HIV and
strategic plan. This will ultimately improve the quality of the lives of attending ART in the Oromia Region, Ethiopia. Such integration
women, the community, and families at large. ranged from the provision of maternal and family planning, neonatal
health services, and health education on sexual reproductive health,
Recommendations for further research
combined with HIV services. Almost all women (97.1%) preferred
• Prospective studies can be conducted to gain a greater integrating sexual reproductive health with HIV services at the same
understanding of the impacts of integrated family planning/HIV facility. Also, most of the providers (95%) were in favor of integrated
services; on the uptake of MNCH and HIV services; satisfaction family planning/HIV services. The factors related to the integration
and retention among healthcare workers and service users; human of family planning services with HIV treatment for women of
resources needed to deliver integrated family planning/HIV services reproductive age living with HIV were identified as educational
(ratio and cadre of providers to service users, skill level); cost-benefit status, occupational status, residence, discussed family planning with
and cost-effectiveness. healthcare providers, fertility desire, counseled in family planning,
• Challenges and opportunities for the implementation of and CD4 count. The study assessed the magnitude of demand for
integrated family planning/HIV services in the private health sector family planning among HIV-infected women and established that
and public hospitals can also be considered. the demand for family planning among these women living with HIV
was 96.3%, of which 16% had unmet needs for family planning while
• Research is recommended on service providers’ workload attending the monthly ART drug refilling and follow-up program.
in terms of the implementation of integrated family planning/HIV
services in health Facilities in Oromia, Ethiopia. The study thus indicates that reproductive health continues
to be understudied as an integrated model. The study established
• Factors identified in integrated family planning/HIV that women of reproductive health status are not only affected by
services at all health facility levels in Ethiopia should be studied. biological factors but are also a product of sociodemographic and
• An assessment of the implementation and success of the cultural factors that are interrelated. This suggests the importance of
developed strategic plan for the integrated family planning/HIV the application of an integrated model analysis to address negative
services can be conducted. reproductive outcomes in the Oromia Region, Ethiopia.

Weaknesses, Strengths, and Contributions Despite the fact that family planning services have made
of the Study a significant contribution to the elimination of new pediatric
HIV infections, few PMTCT programs have extended access to
Weaknesses of the study contraception for HIV-infected women and couples who do not
This study used a cross-sectional study design, so the cause- intend to get pregnant. More widespread use of evidence-based
and-effect relationship is not assured because of the nature of the approaches to integrated family planning/HIV care can boost family

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

planning's contribution to the elimination of new pediatric HIV based input for policymakers and health planners.
infections. The strengths of the study concerning its contribution to
The integration of family planning with HIV services is an
the level of methodology.
increasingly recognized strategy worldwide aimed at the prevention
At a methodological level, the quantitative survey, explorative, of unwanted pregnancy among women of reproductive age living
descriptive, and contextual research design with multiple data with HIV and new pediatric HIV infection. The integration of sexual
collection approaches was used to collect data. The positivist paradigm and reproductive health/HIV policies and services delivered by the
was used to understand the underlying causes of sexual reproductive same provider is prioritized worldwide, especially in sub-Saharan
health problems among women living with HIV and HIV services Africa, where HIV prevalence is highest. Therefore, the integration
like therapy, prevention, and chronic care. This was achieved by of family planning services with HIV treatment is the cornerstone
using the integrated model on the service points of integrated of reproductive healthcare for seropositive clients to ensure their
family planning/HIV services that were obtained from literature as reproductive health and quality of life.
conceptual frameworks.
The results generated from this study helped to support the
Deductive reasoning allowed the researcher to explore experiences existing limited available knowledge regarding how to integrate
of sexual reproductive health that exposed repeated unplanned family planning services with HIV treatment and its implementation
pregnancy; the unmet need for family planning and other sexual among women living with HIV in the study area for evidence-based
reproductive problems like STIs and HIV infection with different interventions.
viral strains. In a survey research design, the procedures used to select
The study contributed to the existing body of evidence and
respondents are of utmost importance because the primary goal is to
knowledge about the integration of family planning services with
generalize the results from the respondents to the whole population
HIV treatment for women of reproductive age that are on ART for
of interest. The best procedure for obtaining a representative sample
better health outcomes. Implications for practice were established, as
occurs when the researcher randomly selects respondents from a list
well as recommendations for the MOH and the ORHB in Ethiopia.
of all members of the group [23,24].
The results from this study were used to improve the
The comprehensive quantitative research design further
availability of integrated family planning/HIV services and address
demonstrated its relevance and appropriateness for investigating
certain knowledge gaps to facilitate clinical practice through the
core issues relating to the need for a change in policy making from
implementation of a feasible strategy. This enabled the policymakers,
disease-centered organizations to women of reproductive age living
health managers, planners, and healthcare providers to plan
with HIV-centered integrated family planning/HIV services based on
implement and evaluate the integration of family planning services
their needs.
with HIV treatment for women living with HIV as interventions for
The strengths of the study to its contribution to the level their healthcare facilities.
of health policy
The study's findings emphasized the critical need to properly
The developed strategies for women of reproductive age living
implement integrated family planning/HIV services for HIV-positive
with HIV-centered integrated family planning/HIV services
women of reproductive age attending ART clinics. The researcher also
contribute to HIV programs of prevention, therapy, and sexual
emphasized the importance of strengthening health centers' capacity
reproductive health problems to tackle these interrelated problems
to provide quality family planning and HIV services. Based on the
under comprehensive one-stop services provision. The developed
findings, the researcher proposed that service providers’ capacity
strategies empower women of reproductive age in terms of their own
building be improved through training on the integration of sexual
healthcare needs. They embrace more coordinated, multi-sectoral,
reproductive services including family planning with HIV services for
and interdisciplinary as well as empowering policies and approaches.
people living with HIV. The main contribution of the study to the
Integrated reproductive healthcare with HIV services improves level of women of reproductive age living with HIV follows:
clients' well-being by meeting a broader variety of health requirements
• Make informed choices about their sexual and reproductive
and providing the ease of receiving various services in a single
health.
visit. They address both structural and intermediate elements that
contribute to women's vulnerability to sexual reproductive health • Represent an opportunity for women to pursue additional
issues. The following is the study's key contribution to the level of education and participate in public life, including paid employment
health policy: in non-family organizations.
Work to ensure universal access to sexual and reproductive • Prevent closely spaced and ill-timed pregnancies and
healthcare services, including family planning, information and births, which contribute to reducing infant and maternal mortality.
education, and the integration of reproductive health into national
• Reduce adolescent pregnancies. This has long-term
plans and programs, to meet the SDGs. Win over employees by
implications for them as individuals, their families, and their
demonstrating how integrated services benefit clients while also
communities.
being more engaging and gratifying for providers. The strengths of
the study with its contribution to the level of women of reproductive • Reduce the risk of unintended pregnancies among women
age living with HIV. living with HIV, resulting in a reduction in the need for unsafe
abortions and fewer infected babies and orphans.
This study aimed to explore and describe the integration of family
planning services with HIV treatment for women living with HIV, • In addition, male and female condoms provide dual
to contribute to the success of the above goal by supplying evidence- protection against unintended pregnancies and STIs, including HIV.

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Dereje Bayissa Demissie, et al., Annals of Clinical Case Reports - Palliative Care

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