9. Comprehensive health services are not the same as Integrated health services, but both are necessary to deliver good services to key populations, and to promote uptake of services. The PSI New Start facilities, in particular, describe their services as “integrated”, but this may be a misnomer. Whilst there is a logical flow to the sequence of services, from entry-point issues (HIV; family planning; cancer screening) to other programmes (ART; PREP; contact tracing; STI treatment), it may be more accurate instead to describe the package of diverse services as ‘comprehensive’. But why not convincingly “integrated”? Most notably at these facilities, the range of services are presently provided in compartmentalised ways, organised by ‘specialisation’ into departments between which clients are transferred. Clients may meet with an initial nurse or counsellor in a consulting or examination room. HIV counselling and HIV testing take place in a separate section of the facility, staffed by different nurses. Family Planning is a separate department. TB-screening is a separate department. area. Each area may have its own queue or waiting area. Given that “visibility equals vulnerability”, and the realities of a busy, congested, high-traffic facility, this is a less than ideal design for an integrated service, especially one that is intended to be KP-sensitive. Amongst other effects: i. It increases wait-time and through-time in the facility. ii. It increases the level of visibility and exposure for key populations to staff and other service-users; there is a higher chance of a KP-client leaving midway through the visit, or avoiding seeking services entirely. iii. It requires a client to repeat a history several times, depending on how many service providers he or she is required to see. More appropriately, an integrated service might mean that a client sees as few health workers as possible in a single visit, and that, ideally, one health worker is qualified to provide a range of services: to do HIV counselling and testing; to examine and treat STIs; to take TB samples; etc. For the service-user, integration means: • good systems for communication and handover between service- providers “We don’t want to have to keep explaining our situation over and over and over again to different people when we are referred between departments.” Whilst comprehensive services provide the scope of clinical and health-related services, integration facilitates the continuity of care where systems and services are organised, primarily, to meet the patient need. And, in the context of key populations especially, those needs are discretion, privacy, dignity, limited exposure, and efficient patient flow and facility throughput. Improving integration is a technical, systems and culture issue, and one of practical design. It requires a different way of thinking about how health workers are trained, how the health system operates within the environment of the facility, and how the physical layout of the clinic is organised to facilitate smooth and efficient movement of clients from entry to exit. It presents a programming opportunity for modelling thoughtful design of a KP-friendly health facility. 10. A health facility cannot claim to offer a “KP-friendly service” where STI care, treatment and management are not offered as a stand-alone programme or service. Two interrelated issues were prolific in conversation with the key populations focus groups in both Harare and Bulawayo: sex, and sexually transmitted infections. People are having sex – not infrequently and, by choice or circumstance, not always safely – and they are contracting infections. Infections other than HIV. In a public health landscape where sexual and reproductive health discourse is still dominated by HIV prevention and treatment targets, STIs receive relatively little profile. And yet, they constitute an equally voracious parallel epidemic of frequently atypical or asymptomatic presentation, with significant negative health consequences, and damaging psychosocial impacts that compound stigma. More, the presence of an STI multiplies the transmissibility of HIV and the risk of acquiring it. • an experience that is as seamless, smooth and easy to navigate as possible. • that services are coordinated and organised to reduce the stages in a visit (ideally a single point of care) and the number of separate visits required. PERCEPTIONS, PERSPECTIVES Access to facility-based health services for LGBT people in Harare & Bulawayo, Zimbabwe: A Situational Analysis 15