Contraception – the Best Contraception – the Best Kept Secret in HIV Kept Secret in HIV

PreventionPreventionMay 24, 2008

CCIH Annual Conference

Ed Scholl

Family Health International

Protect Women’s HealthProtect Women’s 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

Protect Women’s RightsProtect Women’s 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

FP Use in PEPFAR Focus CountriesFP Use in PEPFAR Focus CountriesFP use (%) TFR

Cote d’Ivoire 7 5.0

Nigeria 8 5.9

Rwanda 10 6.1

Mozambique 12 5.2

Ethiopia 14 5.4

Uganda 18 6.7

Tanzania 20 5.4

Zambia 23 5.5

Haiti 25 4.0

Kenya 32 4.9

Source: Population Reference Bureau

Pregnancies are Often Unintended Pregnancies are Often Unintended or Unwantedor Unwanted

Source: DHS and other surveys

0%10%20%30%40%50%60%70%80%90%

100%

Niger

ia

Moza

mbiq

ue

Tanza

nia

Vietn

am

Côte d

'Ivoire

Rwanda

Ethio

pia

Uganda

Zambia

Kenya

Namib

ia

South A

frica

Haiti

Botswan

a

% births unintended % births unwanted

Women with HIV Also Have Women with HIV Also Have Unintended PregnanciesUnintended Pregnancies

• 84% unintended pregnancies among PMTCT clients in South Africa

• 51% unintended pregnancies among women with HIV in Cote d’Ivoire

• 74% unintended pregnancies among women in HIV care in Rwanda

Sources: Rochat et al., JAMA 2006:295:1376-8; Desgrées-du-Loû et al., Int J STD AIDS 2002;13:462-468;

Bangendanye, 3rd Peds CLS 2007.

WHO Four Element PMTCT StrategyWHO Four Element PMTCT Strategy

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

PMTCT PMTCT-PlusSRH FP

Contraception as HIV Prevention –Contraception as HIV Prevention –Compared to ART (15 PEPFAR Compared to ART (15 PEPFAR

countries)countries)

# unintended births prevented# infants spared HIV infection

600

500

400

300

200

100

0ART

(cumulative over 3 years)Source: http://www.pepfar.gov/about/c19785.htm

157

Effective Contraception(over 1 year)

Source: Reynolds et al., Sex Transm Infect, forthcoming

220

735

# o

f in

fan

ts/b

irth

s, i

n 1

000s

700

Traditional Family Planning Traditional Family Planning Programs Prevent MTCTPrograms Prevent MTCT

Source: Reynolds et al, Sexually Transmitted Diseases, 2006;33(6):350-356.

Number of HIV-positive births averted in an hypothetical SSA population of 100,000 women, given US$20,000

program cost (1 year)

30.123.3

0

5

10

15

20

25

30

35

Family planning services and outreach

HIV testing & nevirapine In ANC

Ad

dit

ion

al n

um

ber

of

HIV

+ b

irth

s av

erte

d

Contraception – the best kept Contraception – the best kept secret in HIV preventionsecret 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

Types of FP/HIV IntegrationTypes of FP/HIV Integration

FP→HIV orHIV→FP

FP→ART

FP→VCT

FP→HIV Prevention (ABC)

FP→PMTCT or ANC

FP→STI

FP/HIV Integration:FP/HIV Integration: Opportunities and Challenges 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

International Level OpportunitiesInternational 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

Appropriations for Global HIV/AIDS and Appropriations for Global HIV/AIDS and Family Planning, 2004-07Family Planning, 2004-07

0

500

1000

1500

2000

2500

3000

2004 2005 2006 2007

GHAI

Fam Pln

$ A

pp

rop

riat

ed in

(00

0)

International Level ChallengesInternational 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

Country Level OpportunitiesCountry 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

Country Level ChallengesCountry 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

Service Delivery OpportunitiesService 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.

Service Delivery ChallengesService 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

Service Delivery ChallengesService Delivery Challenges

• Various operational considerations• Commodities/logistics • Provider time• Supervision• Reporting• Referral systems

• FP provider biases against and preparedness to serve HIV+ clients

The Sexual Health TriadThe Sexual Health Triad“Divided We Fail”“Divided We Fail”

Unintended Pregnancies

STD

HIV