Priorities for Family Planning and HIV/AIDS Integration

Reducing HIV infant infection through family planning at PMTCT sites
A recent USAID-funded study demonstrated that adding voluntary family planning to services for prevention of mother-to-child transmission (PMTCT) of HIV can prevent an additional 55,000 child deaths and avert more than 150,000 unintended pregnancies in high HIV prevalence countries. 

A cost-effectiveness analysis by Family Health International demonstrated that any level of expenditure for provision of family planning as part of PMTCT would be more effective than providing Nevirapine (NVP) alone in reducing mother-to-child transmission1.

Effective linkages between Family Planning and VCT
VCT sites serve sexually active women and men, many of whom have need for contraception whether they are HIV-positive or HIV-negative. FP counseling always should be given, but ideally contraceptives are provided on site.

Operations research in Kenya demonstrated high interest among clients and providers in the provision of contraceptives during VCT2. When contraceptives were offered during VCT, over a quarter of the VCT clients were interested in avoiding pregnancy but were not currently using a family planning method. 

Caution is appropriate, however, about adding VCT to FP services where HIV prevalence is low and especially when FP clients are not those at highest risk for HIV. This may not be a productive investment of resources for VCT.

Women on ARVs and others who are HIV-positive should have access to FP
Women on ARV treatment will need to address their reproductive health needs as their health improves, so ARV sites should offer voluntary contraception to their clients. Unmet need for FP averages 19.4% in sub-Saharan Africa. A recent assessment of a home-based HIV care (HBC) project in Kenya found that over half of the HBC clients had been sexually active in the past year, 31% had an unmet need for FP, and 20% wanted to have children. Moreover, HIV and ARVs provide additional impetus to make voluntary family planning available:

• HIV-positive women have a right to equal access to reproductive health and family planning services.
• For HIV-positive women, pregnancy is associated with increased maternal mortality and a variety of adverse birth outcomes including low birth weight and infant death.
• ARVs (especially Efavirenz) have potential harmful effects on the developing fetus.
• The increased life stresses associated with HIV make provision of services compelling, including voluntary contraception.
• Preventing unwanted pregnancy among HIV-positive women can reduce mother-to-child transmission.

All methods of contraception can be appropriate choices for HIV-positive women
The table below displays current WHO medical eligibility guidance on contraception for HIV-positive women. (In most situations a category 1 or 2 means "yes" for eligibility.) Most HIV-positive women are eligible for IUDs. This includes HIV-positive women who do not have advanced disease and women on effective ARV treatment. NVP can lower the blood levels of contraceptive hormones, but not substantially and no studies with clinical outcomes have been completed. 

A range of contraceptives are appropriate for HIV-positive women

Programming for Integration

• Situation specific: Consider the scope and magnitude of the HIV epidemic, the strength of family planning efforts, and who is most at-risk for unintended pregnancy and HIV infection.
• Synergy: Strong FP service delivery can attract women in need of HIV services and vice versa, but assure added value. 
• Evidence-based: Base services on proven practices that maximize efficiency to achieve a broad health impact without sacrificing quality of services and care.
• Scale-up opportunities: Especially in focus countries, maximize opportunities by building family planning into emerging VCT, MTCT and ARV activities.

¹ Reynolds HW, Janowitz B, Homan R, Johnson L. Cost Effectiveness of Two Interventions to Prevent HIV Positive Births, XV International AIDS conference, Bangkok, Thailand. July 13, 2004

² Reynolds HW, Liku J, Maggwa BN, and the VCT & FP Study Integration Team. Assessment of Voluntary Counseling and Testing Centers in Kenya. Potential Demand, Acceptability, Readiness, and Feasibility of Integrating Family Planning Services into VCT. Family Health International, Research Triangle Park, NC, 2003

Where to get more information: www.maqweb.org

References:

Family Health International. Integrating Services. Network. 2004, Volume 23, Number 3. http://www.fhi.org/en/RH/Pubs/Network/v23_3/index.htm

Shelton, J. Contraception for Women on First-Line Antiretrovirals (ARVs). Global Health Technical Brief, March 25, 2005. http://www.maqweb.org/techbriefs/tb5arv.shtml

USAID. Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. September 2003. http://www.maqweb.org/maqtools/docs/fphiv.pdf

Last Revised: 5/13/05
Produced in association with The Maximizing Access and Quality Initiative

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