Moving in the Right Direction: PEPFAR Policy on HIV-Family Planning Integration Heather D. Boonstra XIX International AIDS Conference July 23, 2012

What are “Linkages” and “Integration?” Linkages refer to the “policy, programmatic, services and advocacy synergies between sexual and reproductive health and HIV/AIDS.” Integration refers to “different kinds of sexual and reproductive health and HIV/AIDS services or operational programmes that can be joined together to ensure collective outcomes,” including referrals from one service to another. From: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guide, prepared and published by IPPF, UNFPA, WHO, UNAIDS, GNP +, ICW and Young Positives, 2009.

What Reproductive Health Providers Can Do HIV prevention information and counseling, including information on dual protection and the importance of correct and consistent condom use; HIV testing and referral for HIV treatment as indicated; and Referral for PMTCT services for HIV-positive women who are already pregnant and intend to continue their pregnancies.

What HIV Service Providers Can Do Counseling on reproductive options; Voluntary contraceptive services; Prevention, diagnosis and treatment of sexually transmitted infections, other than HIV; Referral for prenatal care and high-quality obstetrical services; and Referral for safe, legal abortion services and for post-abortion care.

PEPFAR Policy

PEPFAR Encourages HIV → FP Services Endorses making HIV counseling and testing—as well as referrals for prevention of mother-to-child transmission and HIV care and treatment services—available in family planning programs. Endorses the use of PEPFAR funds for this purpose.

PEPFAR Encourages FP → HIV Services Encourages family planning counseling and referrals for contraceptives for women in HIV programs. Endorses the use of PEPFAR funds for that purpose. BUT prohibits the use of PEPFAR funds for contraceptives themselves.

Links with HIV Care, Treatment and Support Programs PEPFAR recognizes the significant contribution of unintended pregnancy prevention in averting new infant infections. PEPFAR recommends that “voluntary family planning should be part of comprehensive quality care for persons living with HIV.”

Links with PMTCT Programs Encourages increased access to family planning services, either directly or through referral, for postpartum women in PMTCT services. Based on WHO's 2002 recommended comprehensive strategy to prevent HIV transmission from mothers to their infants, which includes preventing unintended pregnancies among women living with HIV.

PEPFAR Funding Is Not a Two-Way Street PEPFAR encourages bidirectional linkages, but prohibits the use of its funds for contraceptives for women in HIV programs, even in settings where contraceptive services are not readily available elsewhere. Methods of family planning, other than male and female condoms, must be paid from non-HIV accounts.

Two Major Problems 1.USAID’s family planning program is underfunded and under attack. 2.There are places—both entire countries and within countries—where there is a PEPFAR treatment program, but not a corresponding U.S. family planning program.

Missing Links Four of the top 10 recipients of PEPFAR funding— including three with the world’s highest HIV-prevalence rates—receive no U.S. family planning assistance. CountryHIV Prevalence (%) Swaziland25.9 Botswana24.8 Lesotho23.6 South Africa17.8 Zimbabwe14.3 Zambia13.5 Namibia13.1 Mozambique11.5 Malawi11.0 Uganda6.5

Looking Ahead Much can be done under PEPFAR to advance linkages between HIV and family planning services. The United States should now go all the way to ensure that every woman has access to critical HIV services, including access to the contraceptive services she wants and needs.

Heather D. Boonstra Exhibit Hall Booth #142 Facebook.com/Guttmacher Twitter.com/Guttmacher Guttmacher Institute