Contraception the Best Kept Secret in HIV Prevention

1
Contraception the Best Kept Secret in HIV
Prevention

• May 24, 2008
• CCIH Annual Conference
• Ed Scholl
• Family Health International

2
Protect Womens Health

• Family planning
• Delays first births
• Lengthens birth intervals
• Reduces the total number of children born to
  one woman
• Prevents high-risk and unintended pregnancies
• Reduces the need for unsafe abortion

Source USAID
3
Protect Womens Rights

• All women have the right
• To decide freely and responsibly on the number
  and spacing of their children and to have access
  to the information, education and means to enable
  them to exercise these rights.

Source Convention on the Elimination of All
Discrimination against Women
4
FP Use in PEPFAR Focus Countries
Source Population Reference Bureau
5
Pregnancies are Often Unintended or Unwanted
100
90
80
70
60
50
40
30
20
10
0
Haiti
Kenya
Nigeria
Zambia
Vietnam
Ethiopia
Uganda
Namibia
Rwanda
Tanzania
Botswana
Côte d'Ivoire
South Africa
Mozambique
births unintended
births unwanted
Source DHS and other surveys
6
Women with HIV Also Have Unintended Pregnancies

• 84 unintended pregnancies among PMTCT clients in
  South Africa
• 51 unintended pregnancies among women with HIV
  in Cote dIvoire
• 74 unintended pregnancies among women in HIV
  care in Rwanda

Sources Rochat et al., JAMA 20062951376-8
Desgrées-du-Loû et al., Int J STD AIDS
200213462-468 Bangendanye, 3rd Peds CLS 2007.
7
WHO Four Element PMTCT Strategy
PMTCT-Plus
PMTCT
FP
SRH
Prevention of HIV in uninfected women, especially
young women
Prevention of unintended pregnancies in
HIV-infected women
Prevention of transmission from an HIV-infected
woman to her infant
Support for mother and family
Element 1
Element 2
Element 3
Element 4
General Population
FP Postnatal Clinics
ANC Clinics
HIV Care/ Treatment
8
Contraception as HIV Prevention Compared to ART
(15 PEPFAR countries)
9
Traditional Family Planning Programs Prevent MTCT
Source Reynolds et al, Sexually Transmitted
Diseases, 200633(6)350-356.
10
Contraception the best kept secret in HIV
prevention

• Effective contraception for HIV-infected women
  who do not wish pregnancy
• Prevents more infants becoming infected than
  ART
• Decreases the number of future orphans
• Preventing unintended pregnancy among women with
  HIV
• Is cost-effective
• Has a number of other benefits

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Types of FP/HIV Integration
FP?HIV or HIV?FP
FP? PMTCT or ANC
FP? VCT
FP?HIV Prevention (ABC)
FP?ART
FP? STI
12
FP/HIV Integration Opportunities and Challenges

• International level policies and funding trends
• Country level Ministry of Health structures and
  other coordinating bodies
• Service delivery level operationalizing FP and
  HIV linkages

13
International Level Opportunities

• FP/HIV integration supports the reproductive
  rights of HIV women
• Increasing international policy support for
  stronger RH/HIV linkages
• Glion Call to Action
• New York Call to Commitment
• Maputo Plan of Action

14
Appropriations for Global HIV/AIDS and Family
Planning, 2004-07
Appropriated in (000)
15
International Level Challenges

• International donor funding lacks FP indicators
• PMTCT has focused exclusively on antiretrovirals
• Resources for evaluating different FP integration
  approaches insufficient to build evidence base

16
Country Level Opportunities

• Emerging policy support
• Strategy for the Integration of FP and VCT
  Services (Kenya)
• High priority FP strategies (Mozambique, Rwanda)
• Country-specific technical working groups on
  RH/HIV integration
• Increasing number of integrated RH/HIV bilateral
  programs
• Kenya and Rwanda

17
Country Level Challenges

• Parallel RH and HIV departments and funding
  within Ministries of Health
• Lack of policies, guidelines, and training
  programs for integrated RH and HIV services
• Limited coordination between departments
• Turf issues

18
Service Delivery Opportunities

• Unmet need for FP and high levels of unintended
  pregnancy among clients of HIV services is well
  documented
• Integrated services are acceptable to HIV
  providers and clients
• Integrated services do not appear to negatively
  affect the quality of the basic service whether
  VCT, PMTCT, etc.

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Service Delivery Challenges

• Several potential models
• FP into VCT
• FP into PMTCT
• FP into ART
• FP into HBC
• FP into OVC
• Many pilot projects few rigorously evaluated

20
Service Delivery Challenges

• Various operational considerations
• Commodities/logistics
• Provider time
• Supervision
• Reporting
• Referral systems
• FP provider biases against and preparedness to
  serve HIV clients

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The Sexual Health TriadDivided We Fail
Unintended Pregnancies
STD
HIV