SRH/HIV Linkages:What’s The Rationale?

Ward Cates, MD, MPHFamily Health International

World BankWashington, DC

November 19, 2008

Protect Women’s Health

• Family planning:

– Delays first births

– Lengthens birth intervals

– Reduces the total number of children born to one woman

– Prevents high-risk and unintended pregnancies

– Reduces the need for unsafe abortion

Source: USAID

Protect Women’s Rights

• All women have the right:

– “To decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.”

Source: Convention on the Elimination of All Discrimination against Women

Contraception is HIV Prevention

• Contraception as HIV prevention: evidence of individual-level efficacy and effectiveness

• Family planning/HIV integration: evidence of population-level effectiveness

• Considerations for scale-up

Contraceptive Pregnancy RatesContraceptive Pregnancy Rates

Oral Contraceptives

Source: Trussell (2004); NCHS (2005)

Percent of Women Pregnant in First Year of Use

Rate during typical use

Rate during perfect use

Female/male sterilization

Norplant/Depo-Provera

Spermicides

Diaphragm w/spermicides

Male condom

IUD (TCu-380A)

0 10 15 20 255

Female condom

Four-component Strategy for Perinatal HIV Prevention

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

Component 1 Component 2 Component 3 Component 4

Pregnancies are Often Unintended or Unwanted

Source: DHS and other surveys

0%10%20%30%40%50%60%70%80%90%

100%

Niger

ia

Moza

mbiq

ue

Tanza

nia

Vietn

am

Côte d

'Ivoire

Rwanda

Ethio

pia

Uganda

Zambia

Kenya

Namib

ia

South A

frica

Haiti

Botswan

a

% births unintended % births unwanted

28%

13%

Women with HIV Also Have Unintended Pregnancies

• 84% unintended pregnancies among PMTCT clients in South Africa

• 74% unintended pregnancies among women in an ART program in Rwanda

• 85% of women in Malawi who learned their HIV+ status reported desiring no more children

Sources: Rochat et al., JAMA 2006:295:1376-8; Bangendanye, et al., presented November 2007; Hoffman, et al. JAIDS 2008;47:477-83

• DHS surveys – basis for estimates

• 15% of women in SSA using effective contraception

• 7.8 M unintended births averted by contraception

• Average HIV prevalence in SSA women 7.4%

Effect of Current Contraceptive Use by HIV+ Women – Assumptions

800

700

600

500

400

300

200

1000

Contraception as HIV Prevention –Compared to ARVs

# unintended births prevented

ARVs(cumulative over 3 years)

# infants spared HIV infection

157

Effective Contraception(over 1 year)

735

# o

f in

fan

ts/b

irth

s, i

n 1

000s

220

Sources: PEPFAR (2008), Reynolds (in press)

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 ART

• Decreases the number of future orphans

From Contraception Efficacy to Family Planning/HIV Effectiveness

• FP/HIV integration – the key strategy to reducing unintended pregnancies among HIV+ women

• Crucial questions – what are the opportunities and challenges to translating efficacy into effectiveness?

FP/HIV Integration: Opportunities and Challenges

• International level – policies and funding trends

• Country level – Ministry of Health structures and other coordinating bodies

• Service delivery level – operationalizing SRH and HIV linkages

International Level Opportunities

• FP/HIV integration supports the reproductive rights of HIV+ women

• Increasing international policy support for stronger RH/HIV linkages– Glion Call to Action – New York Call to Commitment– Maputo Plan of Action

Appropriations for the Global HIV/AIDS Initiative and International

Family Planning 2004 - 2009

0500

100015002000250030003500400045005000

2004 2005 2006 2007 2008 2009

GHAI

Fam Pln

$ A

pp

rop

ria

ted

in (

X0

00)

Country Level Opportunities

• Emerging policy support– Strategy for the Integration of FP and VCT Services

(Kenya)– High priority FP strategies (Mozambique, Rwanda)

• Country-specific technical working groups on RH/HIV integration

• Increasing number of integrated RH/HIV bilateral programs– Kenya and Rwanda

Service Delivery Opportunities

• 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.

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

Inadequacies OpportunitiesIntegrated 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].”

Starting point …

Hospitalization wardsLabs

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 LinkagesSRH 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)

Conclusions

• Comprehensive MCH programs are needed to reach UNGASS goals for perinatal HIV

• Decreases in unintended pregnancies to HIV+ women will prevent a similar number of HIV+ births as current ARV programs

• Contraception is the “best-kept secret” in HIV prevention

• We have a unique opportunity to leverage HIV resources

The Sexual Health Triad“Divided We Fail”

Unintended Pregnancies

STD

HIV