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 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

3. Protect 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

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 Namibia Vietnam Ethiopia Uganda 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 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.

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 HIV Care/ Treatment ANC Clinics

8. 700 600 500 400 300 200 100 0 735 # of infants/births, in 1000s 220 157 Effective Contraception (over 1 year) Source: Reynolds et al., Sex Transm Infect, forthcoming ART (cumulative over 3 years) Source: http://www.pepfar.gov/about/c19785.htm # infants spared HIV infection # unintended births prevented Contraception as HIV Prevention –Compared to ART (15 PEPFAR countries)

9. Number of HIV-positive births averted in an hypothetical SSA population of 100,000 women, given US$20,000 program cost (1 year) 35 30.1 30 23.3 25 20 HIV+ births averted Additional number of 15 10 5 0 Family planning services HIV testing & nevirapine and outreach In ANC Traditional Family Planning Programs Prevent MTCT Source: Reynolds et al, Sexually Transmitted Diseases, 2006;33(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

11. Types of FP/HIV Integration FP→ PMTCT or ANC FP→HIV or HIV→FP 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.

19. 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

21. The Sexual Health Triad“Divided We Fail” Unintended Pregnancies STD HIV