1. Global SRH/HIV Integration National HIV Prevention Conference “Integration of Services: National and International Perspectives” Atlanta, GA August 24, 2009

2. The Three Cultures FP STD HIV

3. Access to HIV Prevention Tools – Low Resource Countries, 2004-2006/7 Sources: UNAIDS, 2004; UNICEF, 2008; UNGASS, 2008 0% 20% 40%60%80%100% HIV testing Antiretrovirals for PMTCT Condom Use Contraception for PMTCT 2004 9%32% 9% 14% 2006/7 Male Circumcision 20% 80% 85% 10% 90% 68% Unmet HIV Prevention Need 85% Estimates of CoverageUnmet Need for HIV Prevention 5% 15%

4. Dual Protection - Key Concepts Risks of pregnancy and infection Effectiveness of contraceptionEffectiveness of contraception – ideal use – typical use Effectiveness of HIV preventionEffectiveness of HIV prevention – ideal use – typical use

5. Risk of HIV Acquisition, By Consistency of Condom Use, Discordant Couples 0.9 5.1 6.5 0 1 3 5 7 AlwaysSometimesNever Source: Davis and Weller (1999) HIV Incidence/ 100 PY “Consistent” “Nonuse”“Inconsistent”

6. WHO - Four Phases of PMTCT 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 Phase 1Phase 2Phase 3Phase 4 4 Phase Approach to Perinatal HIV Prevention

7. 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 an ART program in Rwanda Sources: Rochat et al., JAMA2006:295:1376-8; Desgrées-du-Loû et al., Int J STD AIDS 2002;13:462-468; Bangendanye, et al., Presented November 2007.

8. 800 700 600 500 400 300 200 100 0 Contraception as HIV Prevention – Compared to ARVs # unintended births prevented ARVs (over 1 year) # infants spared HIV infection 50 Effective Contraception (over 1 year) 735 # of infants/births, in 1000s 220 Sources: PEPFAR (2009), Reynolds (2008)

9. 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 NVP –Decreases the number of future orphans Key Question – how best to promote the SRH/HIV linkages?

10. 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 and HIV: Key Linkages SRH Family Planning Maternal & infant care Management of sexually transmitted infections Management of other SRH problems Source: WHO/UNAIDS, IPPF/UNFPA (2005)

11. FP/HIV Integration Challenges Operational modelsOperational models Data inadequaciesData inadequacies Existing infrastructuresExisting infrastructures

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

13. Service Delivery Opportunities: FP Added to HIV 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.

14. Starting point … Hospital Ward Laboratory

17. FP/HIV Integration Catalysts Rationale for FP/HIV integration well- establishedRationale for FP/HIV integration well- established Strong international FP/HIV policy supportStrong international FP/HIV policy support Global Fund/World Bank/ PEPFAR/Foundation resourcesGlobal Fund/World Bank/ PEPFAR/Foundation resources Emerging focus on Health Services StrengtheningEmerging focus on Health Services Strengthening

18. The Sexual Health Triad “Divided We Fail” FP STD HIV