1. Integration of Family Planning in PEPFAR-Supported PMTCT and Treatment Programs ART in Pregnancy, Breastfeeding and Beyond Workshop South Africa, June 18-20 Milly Kayongo - USAID- GHB; Office o f HIV/AIDS Andrew Abutu -CDC Division of Global HIV & AIDS

2. Presentation Outline  USG Policy and Guidance for Integration  Global Health Initiative  PEPFAR Integration Guidelines 2011-2012  Global Plan towards Elimination of MTCT  Research and Scientific Updates on FP/HIV  Integration Models and Case Studies  Program Considerations for FP/HIV integration

3. PMTCT: FP is Prevention Prevention of HIV in women of reproductive age Prevention of unintended pregnancies in HIV+ women Prevention of transmission from an HIV+ woman to her infant Treatment Care & Support for mother and family Family planning and effective use of contraceptives

4. FP- HIV Linkages Bolster Prevention Pregnant women are at an approximately 2-fold increased biological risk of acquiring HIV ( Gray, Kigozi et al Lancet. 2005 Oct ). Due to high total fertility rate in sub-Saharan Africa, a high proportion of new infections in women occur in pregnancy. Partner discordance rates -documented to be high (up to 50%) among HIV infected persons. Couple counseling and involving male partners in MNCH service delivery to reduce risk –Partner testing –Treatment of the Infected Partner and referral of the negative man to VMMC, –Counseling both partners on mutual fidelity –Other PLHIV/prevention with positives (PWP) interventions

5. FP- HIV Linkages cont’d  Women with HIV, like all women, have right to determine number and spacing of children  Women with HIV have unmet need for contraception.  Expand access to contraception  Prevent unintended pregnancy  Improves quality of life -PLWHA % of PMTCT clients reporting their most recent pregnancy was unintended Kenya: 50% Rwanda: 50-60% South Africa: 69%

6. Research on FP and PMTCT  Benefits and costs of expanding access to family planning programs to women living with HIV –FP is cost-effective in reducing number of HIV+ births –Cost is $61 per birth averted in 14 PEPFAR countries Halperin DT, Stover J, Reynolds HW. AIDS 2009, 23 (suppl 1):S123-S130  Contribution of Family Planning towards Prevention of Vertical HIV Transmission in Uganda –Expanding FP services can substantially contribute towards PMTCT Hladik W, Stover J, Esiru G, Harper, M, Tappero J (2009) PLoS One 4(11): e7691. doi:10.1371/journal.pone.0007691

7. Global Plan towards Elimination of MTCT PEPFAR support for Global Plans for Elimination of MTCT 14 countries implementing PMTCT acceleration plans Many acceleration countries have incorporated PMTCT Prong 2 to plan * Ref: Countdown to zero. Global plan for the elimination of new HIV infections among children by 2015 and keeping their mothers alive. UNAIDS, 2011. Overall Targets: 1.Reduce the number of new paediatric HIV infections by 90% 2.Reduce the number of AIDS-related maternal deaths by 50%. * 3.Reduce population-level MTCT rate to <5%

8. What will it take? A comprehensive approach Mahy et al. Sex Transm Infect 2010

9. FY2011 PEPFAR Technical Considerations  Integration central to PEPFAR goals on Prevention, PMTCT,Care and Treatment  Harmonize HIV/PMTCT with RH/FP and MNCH services  Specific Language :PMTCT/PwP section of Guidance o Minimizing unintended pregnancies (Prong 2) is a key component of strategy to eliminate new pediatric infections. o Efforts should support the availability of FP services to all women who desire them; includes training FP providers on integrated FP-HIV care o Programs should explicitly explore opportunities for- integration of FP and HIV services including PMTCT Treatment and Care  FP and safe pregnancy counseling key component of PLHIV package of care.

10. Who funds what? U.S. funding through PEPFAR, and Reproductive Health and/or MNCH programs can pay for various components within context of appropriate legislative and policy guidelines and requirements.  Examples of integrated program models:  Pooled procurement instruments- APHIA Kenya  Program coordination to ensure service delivery in similar geographic sites; e.g. Malawi, Tanzania  Development of MoU between USAID-PRH and PEPFAR programs to coordinate and support RH/FP-e.g Uganda and MSI  PEPFAR Funds will not be used to purchase contraceptive commodities  Multilateral partners and donors; --Global Fund (GFATM) UNFPA, UNICEF, partner country governments, and the private sector

11. HC-HIV research update: Heffron Study

12. Prospective studies of injectables & HIV acquisition * Unadjusted estimate, May contain DMPA and Net-EN Mostly injectable, some OC 

13. Limitations Of Heffron 2011  Small sample sizes, few HC users, limited power  Exposure measurement  High and possibly differential attrition rates  Generalizability  Self-reported information on sensitive sexual behaviors  Self-selection into HC use affects risk of HIV exposure  HC users may have higher coital frequency and lower condom use; thus greater exposure to HIV due to behavioral differences  HC users often compared to “non-users”; definition of “non-users” varies, often includes condom-contraceptors  Unmeasured confounding  Condom use, HIV status of partners, differences in type/frequency of sexual activity

14. Conclusion of WHO HC-HIV consultation o All hormonal methods remain Medical Eligibility Criteria (MEC )Category 1 (no restrictions) o Clarification added for injectables for women at high risk of HIV (see statement for full text) o In part: “women using progestogen- only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures”

15. FP/HIV promising practices: Nigeria  Referral-based model of integration implemented in 71 facilities Training and job aides for HCT, 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

16. FP/HIV promising practice: Malawi Lighthouse clinic 2011  Center of Excellence in Integrated Continuum of HIV prevention, Treatment Care and Support  Integrated HIV and FP programs  ART in PMTCT settings and linkage to Treatment  Preliminary Results- Over 95% ART uptake in Pregnancy - Increased FP uptake across MCH & Treatment - Condoms routinely given to all women and men - 247 (57%) injectables - 144 (31%) IUCD - 59 (13%) Pills 17 (3%) Implants  Lessons learned: HIV/FP (Including LARC) can be integrated Clients are interested in integrated services

17. FP/HIV promising practices: 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( Excludes Condoms) : HIV-positive – from 32% to 65% HIV-negative – from 29% to 47%  Other Kenyan sites – minimal change

18. Service Delivery- Entry points for Integration Opportunities for FP integration at PMTCT sites –Opportunity for counseling in ANC, Immunization –High unmet need for FP in post partum period –Reach sero- discordant couples; increasing male participation –FP information to WRA that are sexually active, known HIV status Opportunities at HIV treatment and care/support sites –Reach HIV positive clients- prevent unintended pregnancies and contribute to PMTCT –Regular repeat visits for drugs and resupply - follow up on side effects/complications of ART and fertility intention/contraceptive need –Linkages with community support enhances adherence /nutritional counseling for ART and FP follow up –Less stigma and discrimination

19. Programmatic Considerations: Health Systems Framework Leadership and Governance Engage RH and HIV leadership of MOH Revise relevant policies and guidelines Service Delivery Clarify service procedures Strengthen referral systems Non-discriminatory services in stigma-free settings Health Workforce Build technical capacity of providers Address provider bias Engage managers who set performance expectations Medical Products Ensure availability of contraceptive commodities Information Track performance Modify data collection and reporting systems Financing Include FP for PMTCT in national HIV budget Incorporate FP/HIV into proposals to donors Community Engage organizations of people living with HIV Promote greater involvement of men

20. FP-HIV integration: Service Delivery considerations  What model suitable for your setting? no “one-size” fits all  To what extent should services be integrated? o Human resource capacity o Physical set-up of facility o Strength and organization of existing services o Client flow and volume; Availability of financial resources  What information is needed to measure progress ? o Indicators for routine monitoring and evaluation o M & E systems o Opportunities for rigorous operations research and special studies  Indicators related to FP (draft)- London MTG/ proposed with IATT o Proportion of PMTCT clients screened for FP, Proportion of PMTCT sites/ HIV service delivery points with FP services etc.. o Reducing Unmet Need; Proportion of Demand satisfied with contraceptive use

21. Discussion in Small groups on DAY 3 Q& A

22. Discussion: Policy –What are the policy/ funding support for integration in your country? –Do you have a national RH/HIV TWG? Who are the key stakeholders in your country for FP/RH support- do you have USAID PRH office, Other key partners? –What are key facilitating/ inhibiting factors for integration? Systems –What are key systems barriers/ constraints in your context for integration- Planning and administration, HRH, logistics, M & E, etc –What can PEPFAR do to address these barriers? What is required Service Delivery –What are some of the specific entry points along both the life cycle and service delivery points that present opportunities for integration –Where are the challenges? –How can Integration between PMTCT and ART – structure(program management and service delivery)be strengthened?