Reproductive Health into Reproductive Health into HIV Care IntegrationHIV Care Integration

Diane CooperWomen’s Health Research Unit, School of Public Health & Family Medicine, UCT

Background and SignificanceBackground and Significance

South Africa has one of the highest rates of HIV infection in the world

-29.3% prevalence among pregnant women attending antenatal clinics in 2008 (NDOH, 2009)

-In 2002, 53% of pregnancies were unplanned (36%) or unwanted (17%), even though 64% of sexually active 15-49 year-old SA women currently use contraception. (NDOH, 2007)

South African women experience high rates of unintended pregnancy despite the availability and use of family planning services

Background & SignificanceBackground & Significance (contin)(contin)

Relatively little is known about the impact of an HIV diagnosis on contraceptive practices and fertility intentions of HIV+ men and women in developing countries– 11% of women attending HIV Care in Cape Town had been

pregnant since knowing dx, and 2/3 pregnancies were unintended (Cooper et al 2009)

– Nearly 50% of recently diagnosed HIV+ women and men who enter the HIV care system are seeking or are open to the possibility of having children; this was confirmed in larger study (Cooper et al. 2009)

Linkages between SRH and HIVLinkages between SRH and HIV

(Source: WHO 2005)

HIV+ conception and fertility intentions

Why integration? Why integration?

Health service integration involves some form of combining interdependent health programs or service elements

Integration can occur both at the level of direct service provision to clients as well as at the level of the structure of management and organisational support of services

By providing joint services, integration hopes : to avoid duplication of program structures and services maximize use of scarce resources Allow greater program cost efficiency &effectiveness allowing clients greater convenience of being able to receive a

range of services simultaneously - promotes better client access to health services, with potentially positive consequences for client health

Integration of HIV & other Integration of HIV & other servicesservices

Sexually transmitted infection servicesContraceptive servicesTBSRH into HIV care & treatment

Integration of SRH into HIV Integration of SRH into HIV care & treatmentcare & treatment

Most people living with HIV (PLWH) are in the reproductive & productive years

Important to: Prevent unintended pregnancies Prevent horizontal (to partners) & vertical

(to infant) transmission Ensure safer conception & pregnancy

Overview of intervention study Overview of intervention study integrating SRH into HIV care integrating SRH into HIV care

4.5-year, multi-level structural intervention targeting HIV+ persons accessing public sector HIV Care Clinics in Cape Town, South Africa

Addresses poor access to contraceptive services and at same time introduces enhanced counseling approaches that maximize sexual risk-reduction based on clients’ individual situations

Combines quantitative and qualitative methodologies to address both clinic- and client-level factors

Consists of three phasesNIMH R01 MH078770-01NIMH R01 MH078770-01

Enhanced Intervention vs. Enhanced Intervention vs. Standard of CareStandard of Care

ENHANCEDENHANCED On site non-barrier

contraception available from HIV care nurses

On-site free male and female condoms

SRH training, counseling and contraception

Posters of HIV+ persons’ reproductive rights in waiting rooms/IEC

Systematic, ongoing technical support

STANDARD OF CARESTANDARD OF CARE No non-barrier contraception available On-site free male & female condoms No specific SRH training, counseling & contraceptionNo systematic IEC promotion No systematic, ongoing technical support

Preventing pregnancyPreventing pregnancy

Methods available & dual method or dual protection

Methods best for WLWH – ARV treatmentEmergency contraception (‘morning after

pill’)Termination of pregnancyInvolvement of men

Components of SRH-HIV Components of SRH-HIV integrationintegration

Safer conceptionSafer conceptionSeroconcordant Male & female

HIV-infected

Serodiscordant Male HIV-

infected

Serodiscordant Female HIV-

infectedResource limited

- Ensure viral load in both woman and man are as low as possible (preferably on HAART)

- Can try having unprotected sex only during the woman’s most fertile period

-Explain the risks of contracting another viral strain of HIV.

- PMTC - Encourage them to attend ANC once pregnant to ensure that they receive the best possible advice to minimize MTCT risk and to attend regularly.

-The only very risk reduced method is through the HIV-infected man having his sperm washing to remove the HIV in a laboratory. This reduces the risk but is not risk-free

-Can try manual self-insemination with a partner’s sperm

- There are no risks of the man becoming infected in this way

-Explain the risks of mother-to-child transmission and what can be done about this through PMTC

- Encourage them to attend ANC once pregnant to ensure that they receive the best possible advice to minimize MTCT risk and to attend regularly.

Other SRH needsOther SRH needs

Sexual desire & functioning: women & menErectile dysfunction & ageing: menWomen: Cancer of the cervix & ageing:

womenSTI & cross infection of HIV strains

Young people living with HIV Young people living with HIV (1)(1)

Growing concern - high number of HIV infected young people, in particular young women

HIV cases among the young people - those were vertically infected (VIY), whose life expectancy has been increased through use of HAART) & those behaviourally infected (BIY)

Behavioural infections among the youth account for large portion of new infections globally (45% of new HIV infections world wide in 2007 among young people 15-24 years)

In S.A in particular, estimated that 38% of school learners have had sexual intercourse

Of those that have begun sexual activity 13% initiated sexual activity before the age of 14

Young people living with HIV Young people living with HIV (2)(2)

Early age sexual debut - youth at > risk for HIV/AIDS & unintended pregnancies, other STIs & forces them to deal with SRH needs & rights at early age

Adolescence: period of rapid change -children become adults & r ability to negotiate numerous physiological & social transitions smoothly largely dependant on health

With changes in sexual activity young people often lack confidence & knowledge to assert reproductive needs & rights

In countries with a high HIV prevalence - need to improve quality of SRH services available to the young people is urgent

In many settings current SRH services offered do not adequately meet needs of young people

Proposed Study among young Proposed Study among young people living with HIVpeople living with HIV

Understanding SRH needs of young people living with HIV in particular - critical to ensure health services adequately resourced & programs appropriately designed to meet diverse, common & specific needs

Without this knowledge - difficult to advocate for program devt addressing SRH needs of young people living with HIV during critical stage of development & change in their lives

Study will provide unique information on SRH needs of both vertically and behaviourally infected HIV positive youth in Cape Town.

This formative research will be small collaborative project providing information on SRH needs of HIV positive youth -will be used to guide further counselling interventions - funding being sought

Agenda & needs: integrating Agenda & needs: integrating SRH into HIV care:SRH into HIV care:

Assessment of SRH needs of WLWH & MLWH Provide knowledge of SRH for women living with

HIV (WLWH) and men (MLWH) – esp. how fertility works

Preventing conception in people living with HIV (PLWH): Contraception

Safer conception and PMTCT for PLWH Other SRH needs SRH needs of young people living with HIVThese models & agenda can be used in business

sector too