SRH/HIV Linkages: What’s The Rationale?

1. SRH/HIV Linkages:What’s The Rationale? Ward Cates, MD, MPH Family Health International World Bank Washington, DC November 19, 2008

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. Contraception is HIV Prevention • Contraception as HIV prevention: evidence of individual-level efficacy and effectiveness • Family planning/HIV integration: evidence of population-level effectiveness • Considerations for scale-up

5. Contraceptive Pregnancy Rates Spermicides Diaphragm w/spermicides Female condom Male condom Oral Contraceptives IUD (TCu-380A) Rate during perfect use Female/male sterilization Rate during typical use Norplant/Depo-Provera 0 10 20 25 5 15 Percent of Women Pregnant in First Year of Use Source: Trussell (2004); NCHS (2005)

6. Four-component Strategy for Perinatal HIV Prevention Prevention of HIV in 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 Component 1 Component 2 Component 3 Component 4

7. Pregnancies are Often Unintended or Unwanted 100% 90% 80% 70% 60% 50% 40% 28% 30% 20% 13% 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

8. Women with HIV Also Have Unintended Pregnancies • 84% unintended pregnancies among PMTCT clients in South Africa • 74% unintended pregnancies among women in an ART program in Rwanda • 85% of women in Malawi who learned their HIV+ status reported desiring no more children Sources: Rochat et al., JAMA 2006:295:1376-8; Bangendanye, et al., presented November 2007; Hoffman, et al. JAIDS 2008;47:477-83

9. Effect of Current Contraceptive Use by HIV+ Women–Assumptions • DHS surveys – basis for estimates • 15% of women in SSA using effective contraception • 7.8 M unintended births averted by contraception • Average HIV prevalence in SSA women 7.4%

10. Contraception as HIV Prevention –Compared to ARVs 800 700 600 500 400 300 200 1000 735 # of infants/births, in 1000s 220 157 ARVs (cumulative over 3 years) Effective Contraception (over 1 year) # infants spared HIV infection # unintended births prevented Sources: PEPFAR (2008), Reynolds (in press)

11. Contraception – The BEST KEPT SECRET in HIV Prevention Effective contraception for HIV-infected women who do not wish to become pregnant • Prevents more infants becoming infected than ART • Decreases the number of future orphans

12. From Contraception Efficacy to Family Planning/HIV Effectiveness • FP/HIV integration – the key strategy to reducing unintended pregnancies among HIV+ women • Crucial questions – what are the opportunities and challenges to translating efficacy into effectiveness?

13. 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 SRH and HIV linkages

14. 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

15. Appropriations for the Global HIV/AIDS Initiative and International Family Planning 2004 - 2009 $ Appropriated in (X000)

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. 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.

18. The Interface Between HIV Programs and Health Systems Long-standing inadequacies lead to new opportunities for improved health care An organizational culture of service fragmentation Inadequacies Opportunities Integrated services in concept and inpractice “The medicines[contraceptives]that we use are in this room. They can’t be put in another room[the HIV care and treatment room].”

19. Starting point … Hospitalization wards Labs

22. SRH and HIV: Key Linkages Key Linkages Learn HIV status Promote safer sex Optimize connection between HIV/AIDS and STI services Integrate HIV/AIDS with maternal and infant health • HIV/AIDS • Prevention • Treatment • Care • Support • SRH • Family Planning • Maternal & infant care • Management of sexually transmitted infections • Management of other SRH problems Source: WHO/UNAIDS, IPPF/UNFPA (2005)

23. Conclusions • Comprehensive MCH programs are needed to reach UNGASS goals for perinatal HIV • Decreases in unintended pregnancies to HIV+ women will prevent a similar number of HIV+ births as current ARV programs • Contraception is the “best-kept secret” in HIV prevention • We have a unique opportunity to leverage HIV resources

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