Milly Kayongo - USAID- GHB; Office o f HIV/AIDS Andrew Abutu -CDC Division of Global HIV & AIDS

1. Integration of Family Planning in PEPFAR-Supported PMTCT and Treatment Programs ART in Pregnancy, Breastfeeding and Beyond Workshop South Africa, June 18-20 Milly Kayongo - USAID- GHB; Office o f HIV/AIDS Andrew Abutu -CDC Division of Global HIV & AIDS

2. Presentation Outline USG Policy and Guidance for Integration Global Health Initiative PEPFAR Integration Guidelines 2011-2012 Global Plan towards Elimination of MTCT Research and Scientific Updates on FP/HIV Integration Models and Case Studies Program Considerations for FP/HIV integration

3. PMTCT: FP is Prevention Family planning and effective use of contraceptives

4. FP- HIV Linkages Bolster Prevention • Pregnant women are at an approximately 2-fold increased biological risk of acquiringHIV (Gray, Kigozi et al Lancet. 2005 Oct ). • Due to high total fertility rate in sub-Saharan Africa, a high proportion of new infections in women occur in pregnancy. • Partner discordance rates -documented to be high (up to 50%) among HIV infected persons. • Couple counseling and involving male partners in MNCH service delivery to reduce risk • Partner testing • Treatment of the Infected Partner and referral of the negative man to VMMC, • Counseling both partners on mutual fidelity • Other PLHIV/prevention with positives (PWP) interventions

5. FP- HIV Linkages cont’d • Women with HIV, like all women, have right to determine number and spacing of children • Women with HIV have unmet need for contraception. • Expand access to contraception • Prevent unintended pregnancy • Improves quality of life -PLWHA

6. Benefits and costs of expanding access to family planning programs to women living with HIV • FP is cost-effective in reducing number of HIV+ births • Cost is $61 per birth averted in 14 PEPFAR countries Halperin DT, Stover J, Reynolds HW. AIDS 2009, 23 (suppl 1):S123-S130 • Contribution of Family Planning towards Prevention of Vertical HIV Transmission in Uganda • Expanding FP services can substantially contribute towards PMTCT Hladik W, Stover J, Esiru G, Harper, M, Tappero J (2009) PLoS One 4(11): e7691. doi:10.1371/journal.pone.0007691 Research on FP and PMTCT

7. Global Plan towards Elimination of MTCT Overall Targets: Reduce the number of new paediatric HIV infections by 90% Reduce the number of AIDS-related maternal deaths by 50%. * Reduce population-level MTCT rate to <5% • PEPFAR support for Global Plans for Elimination of MTCT • 14 countries implementing PMTCT acceleration plans • Many acceleration countries have incorporated PMTCT Prong 2 to plan • * Ref: Countdown to zero. Global plan for the elimination of new HIV infections among children by 2015 and keeping their mothers alive. UNAIDS, 2011.

8. What will it take? A comprehensive approachMahy et al. Sex Transm Infect 2010

9. FY2011 PEPFAR Technical Considerations • Integration central to PEPFAR goals on Prevention, PMTCT ,Care and Treatment • Harmonize HIV/PMTCT with RH/FP and MNCH services • Specific Language :PMTCT/PwP section of Guidance • Minimizing unintended pregnancies (Prong 2) is a key component of strategy to eliminate new pediatric infections. • Efforts should support the availability of FP services to all women who desire them; includes training FP providers on integrated FP-HIV care • Programs should explicitly explore opportunities for- integration of FP and HIV services including PMTCT Treatment and Care • FP and safe pregnancy counseling key component of PLHIV package of care.

10. Who funds what? • U.S. funding through PEPFAR, and Reproductive Health and/or MNCH programs can pay for various components within context of appropriate legislative and policy guidelines and requirements. • Examples of integrated program models: • Pooled procurement instruments- APHIA Kenya • Program coordination to ensure service delivery in similar geographic sites; e.g. Malawi, Tanzania • Development of MoU between USAID-PRH and PEPFAR programs to coordinate and support RH/FP-e.g Uganda and MSI • PEPFAR Funds will not be used to purchase contraceptive commodities • Multilateral partners and donors; --Global Fund (GFATM) UNFPA, UNICEF, partner country governments, and the private sector

11. HC-HIV research update:Heffron Study

12. Prospective studies of injectables & HIV acquisition Mostly injectable, some OC Mostly injectable, some OC * Unadjusted estimate, ₴May contain DMPA and Net-EN

13. Limitations Of Heffron 2011 • Small sample sizes, few HC users, limited power • Exposure measurement • High and possibly differential attrition rates • Generalizability • Self-reported information on sensitive sexual behaviors • Self-selection into HC use affects risk of HIV exposure • HC users may have higher coital frequency and lower condom use; thus greater exposure to HIV due to behavioral differences • HC users often compared to “non-users”; definition of “non-users” varies, often includes condom-contraceptors • Unmeasured confounding • Condom use, HIV status of partners, differences in type/frequency of sexual activity

14. Conclusion of WHO HC-HIV consultation All hormonal methods remain Medical Eligibility Criteria (MEC )Category 1 (no restrictions) Clarification added for injectables for women at high risk of HIV (see statement for full text) In part: “women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures”

15. FP/HIV promising practice: Malawi Lighthouse clinic 2011 • Center of Excellence in Integrated Continuum of HIV prevention, Treatment Care and Support • Integrated HIV and FP programs • ART in PMTCT settings and linkage to Treatment • Preliminary Results- Over 95% ART uptake in Pregnancy - Increased FP uptake across MCH & Treatment - Condoms routinely given to all women and men - 247 (57%) injectables - 144 (31%) IUCD - 59 (13%) Pills 17 (3%) Implants • Lessons learned: • HIV/FP (Including LARC) can be integrated • Clients are interested in integrated services

16. Partners HSV/HIV Transmission Study • 213 HIV Discordant Couples • Multipronged contraceptive intervention • Staff training • Couples FP counseling • Free hormonal contraception on-site • Non-barrier contraception( Excludes Condoms): • HIV-positive – from 32% to 65% • HIV-negative – from 29% to 47% • Other Kenyan sites – minimal change FP/HIV promising practices: Kenya

17. Service Delivery- Entry points for Integration • Opportunities for FP integration at PMTCT sites • Opportunity for counseling in ANC, Immunization • High unmet need for FP in post partum period • Reach sero- discordant couples; increasing male participation • FP information to WRA that are sexually active, known HIV status • Opportunities at HIV treatment and care/support sites • Reach HIV positive clients- prevent unintended pregnancies and contribute to PMTCT • Regular repeat visits for drugs and resupply - follow up on side effects/complications of ART and fertility intention/contraceptive need • Linkages with community support enhances adherence /nutritional counseling for ART and FP follow up • Less stigma and discrimination

18. FP-HIV integration: Service Delivery considerations What model suitable for your setting? no “one-size” fits all To what extent should services be integrated? Human resource capacity Physical set-up of facility Strength and organization of existing services Client flow and volume; Availability of financial resources What information is needed to measure progress ? Indicators for routine monitoring and evaluation M & E systems Opportunities for rigorous operations research and special studies Indicators related to FP (draft)- London MTG/ proposed with IATT Proportion of PMTCT clients screened for FP, Proportion of PMTCT sites/ HIV service delivery points with FP services etc.. Reducing Unmet Need; Proportion of Demand satisfied with contraceptive use

19. Discussion in Small groups on DAY 3 Q& A

20. Discussion: • Policy • What are the policy/ funding support for integration in your country? • Do you have a national RH/HIV TWG? Who are the key stakeholders in your country for FP/RH support- do you have USAID PRH office, Other key partners? • What are key facilitating/ inhibiting factors for integration? • Systems • What are key systems barriers/ constraints in your context for integration- Planning and administration, HRH, logistics , M & E, etc • What can PEPFAR do to address these barriers? What is required • Service Delivery • What are some of the specific entry points along both the life cycle and service delivery points that present opportunities for integration • Where are the challenges? • How can Integration between PMTCT and ART – structure(program management and service delivery)be strengthened?