Rose Wilcher FHI Global Business Coalition NGO Conference Call April 2011

1. Family Planning: The Best-kept Secret in HIV Prevention The Case for Integrating Family Planning and HIV/AIDS Services Rose Wilcher FHI Global Business Coalition NGO Conference Call April 2011

2. Women’s right to family planning • 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

3. Benefits of 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

4. Benefits of family planning • Women who use contraception are more likely to be employed than non-users • Use of long-acting or permanent contraceptive methods associated with greater likelihood of working for pay • Use of family planning prolongs education; girls often have to drop out of school due to unintended pregnancy

5. PMTCT: Family planning is HIV prevention Family planning and effective use of contraceptives Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV+ women Prevention of trans-mission from an HIV+ woman to her infant Support for mother and family

6. Impact of family planning on PMTCT 800 700 600 500 400 300 200 1000 735 # of infants/births, in 1000s 220 97 ARVs (over 1 year) Contraception (over 1 year) # infants spared HIV infection Sources: PEPFAR (2009), Reynolds (2008) # unintended births prevented

7. Impact of family planning on PMTCT – Uganda, 2007 Infants Spared HIV Infection 13,000 12,000 11,400 11,000 10,000 9,000 8,000 7,000 6,100 6,100 6,000 5,000 4,000 3,000 2,200 2,000 1,000 0 If All Unwanted Fertility Prevented Current FP Current ART Source: Hladik, 2009

8. Cost-effectiveness of family planning as an HIV prevention intervention 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 Source: Reynolds et al, Sexually Transmitted Diseases, 2006;33(6):350-356.

9. Women with HIV have unintended pregnancies • 84% unintended pregnancies among PMTCT clients in South Africa (2006) • 70% unintended repeat pregnancies among women with HIV in India (2008) • 74% unintended pregnancies among women in an ART program in Rwanda (2007) • 3 different studies by FHI found high levels of unintended pregnancies among PMTCT clients: 50% in Kenya, 60% in Rwanda, 70% in SA (2010) Sources: Rochat et al., JAMA 2006:295:1376-8; Suryavanshi et al., AIDS Care 2008;20:1111-1118;Bangendanye et al., 3rd Peds CLS 2007

10. How best to increase access to FP among PLHIV? • Strengthen traditional FP programs • Integrate FP and HIV services

11. What do we mean by “integration”? UNFPA-WHO-UNAIDS definition: • "Refers to how different kinds of reproductive health and HIV services or operational programs can be joined together to ensure and perhaps maximize collective outcomes. This would include referrals from one service to another. It is based on the need to offer comprehensive services."

12. Reduce missed opportunities Share common needs: • often both sexually active and fertile • are at risk of HIV infection or might be infected • need access to contraceptives • need to know how HIV affects contraceptive options and vice versa Clients Seeking HIV-related Services AND Clients Seeking FP Services

13. Obstacles to FP/HIV integration • “Siloed” service delivery platforms • Lack of infrastructure/capacity at facility level • Staff shortages, high turnover or inadequate training • Poor program management and supervision • Inadequate equipment and commodity supply • Gender-based barriers to service utilization, including lack of male partner involvement and lack of women’s empowerment to make SRH decisions Sources: Kennedy 2010; Petruney 2010; Wilcher 2008; Wilcher & Cates 2009;

14. Signs of progress • Broad international policy support • Expansion of field-based efforts • Programmatic tools/guidance available • Commitment from MOH leadership • Growth of behavioral, biomedical and programmatic evidence

15. Cochrane Review: FP/HIV integration • 16 studies • Several “models” of FP/HIV integration • Interventions generally considered feasible and effective • No negative results; positive or mixed results for key outcomes (HIV testing, condom use, contraceptive use, quality of services, cost) • Average study design rigor was low (3.25 out of 9) Source: Spaulding (2009)

16. Program examples: Nigeria • Referral-based model of integration implemented in 71 facilities • Training and job aides for VCT, ART, PMTCT, and FP providers • Integration coordinator identified at each facility • Referral system between FP and HIV clinics formalized • Clinic registers, monthly summary forms modified • Evaluation findings • Major improvements in FP clinic attendance, FP uptake • Proportion of men attending FP clinic significantly higher among referred clients • Routinely collected data can be used for evaluation Source: Chabikuli (2009)

17. Program examples: Coast and Rift Valley, Kenya • FP integration rolled out to 148 ART facilities • Sensitization meetings with facility staff • Training and job aides for ART providers on offering FP services • Supportive supervision • Some FP methods available on-site, depending on facility • Evaluation findings: • FP use among female clients increased from 36% to 52% • Providers more likely to report provision of non-condom modern methods post-intervention (38% to 59%); condom provision stayed constant

18. Program examples: Thika, Kenya • 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: • HIV-positive – from 32% to 65% • HIV-negative – from 29% to 47% • Other Kenyan sites – minimal change Source: Ngure (2009)

19. What have we learned? • Integrated services are acceptable to clients and providers • FP/HIV integration is feasible, and evidence of positive impact on health outcomes is growing • No “one-size-fits-all” approach • Different levels of integration depending on physical, human, financial, and technical capacity • Must address provider biases – condoms only contraceptive messaging for HIV+ women/couples • Various operational considerations

20. Corporate support for FP/HIV integration can… • Extend the benefits of FP to employees/community members accessing corporation supported HIV prevention, care and treatment programs • Enhance the HIV prevention impact of corporation supported HIV/AIDS programs • Improve the cost-effectiveness of corporation supported HIV prevention (PMTCT) programs • Provide opportunities to involve the male workforce in family planning • Expand the evidence base of FP/HIV integration best practices through research/M&E