Contraception: The Best Kept Secret in HIV Prevention Global Health Mini-University October 27, 2006 Rose Wilcher & Heidi Reynolds

True or False? Preventing unintended pregnancies in HIV-infected women is one part of the WHO’s four-part strategy for preventing mother-to-child transmission of HIV.

For the same amount of money, which of the following strategies would prevent more HIV infections? a) Family planning services b) ARV prophylaxis in PMTCT programs

How many HIV infections in infants does current contraceptive use prevent in sub- Saharan Africa each year? a) 1,000 b) 14,000 c) 90,000 d) 173,000

In Kenya, how many infant HIV infections have been prevented through ARV prophylaxis since the beginning of the Emergency Plan? a) 500 b) 7,100 c) 10,000 d) 100,000

True or False? Family planning is included as an indicator for evaluating the programmatic success of HIV funding initiatives such as PEPFAR and GFATM.

Which of the following are international statements of support for strengthening the linkages between FP and HIV services? a) NY Call to Commitment b) Glion Call to Action c) African Union Ministers of Health SRH Plan of Action d) All of the above

True or False? We already have evidence-based models of integrated FP/HIV service delivery.

Contraception and HIV integration Findings and gaps post-Addis FP HIV

Presentation objectives To highlight messages the Linking Reproductive Health, Family Planning and HIV/AIDS in Africa conference To review the evidence and knowledge gaps –Integration of family planning services and HIV services –Safety and effectiveness of methods

Linking Reproductive Health, Family Planning and HIV/AIDS in Africa Addis Ababa, Ethiopia October 9-10, 2006 Acknowledgements –Amy Tsui, Gates Institute, JHU –Yemane Berhane, Addis Ababa University –Duff Gillespie, Gates Institute, JHU –Sabrina Karklins, Gates Institute, JHU –Heather Bradley, Gates Institute, JHU

Addis dissemination plans Publication of proceedings Summary piece to major journal Available in one month: –Conference presentations, any contributed papers and weblinks –Participant list with contact information –

Take home messages Strong rationale for integration Inconclusive evidence base: –Cross-sectional studies or have methodological shortcomings –Need more methodologically rigorous research –Outcomes measured varied widely –Few outcomes of interest to HIV researchers Many potential models of integration and populations

Take home messages (con’t.) Cross cutting health system constraints –Parallel MOH divisions and funding –Stronger guidelines and protocols needed –Lack of institutional leadership and technical capacity –Lack of adequate health infrastructure –Lack of resources for re-training & support –High staff turnover and high workload

Take home messages (con’t.) More evidence is needed to develop and inform policies and strategies for effective integration of reproductive health, family planning and HIV/AIDS programs

Findings and gaps: Integration of family planning services and HIV services

Integration of family planning services and HIV services (con’t.) HIV service clients (including youth and men) have unmet need for contraception FP services integrated into VCT and PMTCT are feasible and acceptable FP services integrated into VCT –Do not negatively affect VCT quality –Appear to increase satisfaction HIV in FP/RH newly emerging

Integration of family planning services and HIV services (con’t.) Gaps –“Micro” Provider messages –Assess client preferences –Translate fertility desire findings into messages –Counseling messages to inform childbearing decisions –Balance dual protection messages with messages about other methods –“Macro” Effective integrated models Innovations to address health system constraints

Integration of family planning services and HIV services (con’t.) Gaps –Continue to monitor feasibility of integration and service quality –Measures Contraceptive uptake Continuation Unintended pregnancies averted On HIV outcomes –Cost of achieved effect of integration Inform scale up

Findings and gaps: Safety and effectiveness of methods

Safety and effectiveness of methods All methods can be safely used by HIV+ women Hormonal contraception (HC) –No convincing evidence to suspect increased risk of HIV acquisition, transmission or progression –Unknown clinical significance of HC and ART Pills are category 2 Maybe less of a concern with Depo and implants IUDs –Can initiate and use if HIV status is unknown, if HIV+ in good health, or if on ARVs For more info:

Conclusions Clear, strong rationale for contraception as HIV prevention Evidence of potential demand, acceptability & feasibility for FP services in HIV programs More evidence is needed to develop and inform policies and strategies for effective integration of reproductive health, family planning and HIV/AIDS programs

Given the level of evidence, what is your recommendation for the future of FP-HIV integration? A) Abandon ship. It’s not worth pursuing B) Continue to conduct research C) Rationale is strong enough, put money into integrated programs D) Combo of B&C