Contraception – the Best Kept Secret in HIV Prevention May 24, 2008 CCIH Annual Conference Ed Scholl Family Health International

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

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

FP Use in PEPFAR Focus Countries FP use (%)TFR Cote d’Ivoire75.0 Nigeria85.9 Rwanda106.1 Mozambique125.2 Ethiopia145.4 Uganda186.7 Tanzania205.4 Zambia235.5 Haiti254.0 Kenya324.9 Source: Population Reference Bureau

Pregnancies are Often Unintended or Unwanted Source: DHS and other surveys 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Nigeria Mozambique Tanzania Vietnam Côte d'Ivoire Rwanda Ethiopia Uganda Zambia Kenya Namibia South Africa Haiti Botswana % births unintended% births unwanted

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: ; Bangendanye, 3rd Peds CLS 2007.

WHO 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 1Element 2Element 3Element 4 General Population FP & Postnatal Clinics ANC Clinics HIV Care/ Treatment PMTCT PMTCT-Plus SRH FP

Contraception as HIV Prevention – Compared to ART (15 PEPFAR countries) # unintended births prevented # infants spared HIV infection ART (cumulative over 3 years) Source: Effective Contraception (over 1 year) Source: Reynolds et al., Sex Transm Infect, forthcoming # of infants/births, in 1000s 700

Traditional Family Planning Programs Prevent MTCT Source: Reynolds et al, Sexually Transmitted Diseases, 2006;33(6):

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

Types of FP/HIV Integration FP→HIV or HIV→FP FP→ART FP→ VCT FP→HIV Prevention (ABC) FP→ PMTCT or ANC FP→ STI

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

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

Appropriations for Global HIV/AIDS and Family Planning, $ Appropriated in (000)

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

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

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

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.

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

Service 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 Triad “Divided We Fail” Unintended Pregnancies STD HIV