PRB

(March 2010) There is an urgent need for stronger links between family planning/reproductive health and HIV policies, programs, and services. Voluntary use of contraception has been an undervalued and little-used intervention in the fight against HIV. Preventing unintended pregnancies in women with HIV can prevent mother-to-child transmission of HIV and reduce the number of children needing HIV treatment. Moreover, women with HIV need access to reproductive health services to ensure their needs are addressed and their reproductive rights are protected. Integrating reproductive health and HIV programs has proved difficult for a variety of reasons, but new opportunities are emerging to strengthen these essential linkages.

During a PRB Discuss Online, Rose Wilcher, Family Health International (FHI), and Susan Adamchak, FHI and Kansas State University, answered participants’ questions about the advantages of and the barriers to improving family planning/HIV integration. 

March 11, 2010 1 PM EST

Transcript of Questions and Answers

Joshua Munguia: “Moreover, women with HIV need access to reproductive health services to ensure their needs are addressed and their reproductive rights are protected.” When I hear people discussing about HIV, or when I see ads on TV about HIV awareness, I never see or hear anything about protecting women with this virus who are trying to have a baby. When I read this sentence, it dawned on me that if in the case of younger women who has become a carrier of this virus, and was tested to become aware. Should this young lady who wishes to have a full family of her own someday soon, should she be encouraged to do other wise? My question is that if there was a young lady who has HIV, and she meets a man how does not, and they wanted to start a family. What medical needs must they abide by to assure a healthy family?
Susan Adamchak: Too often social groups and medical providers assume that women who are HIV-positive should not become pregnant. However, all women, regardless of their HIV status, have the right to determine the number, timing and spacing of their children. Increasingly, it is possible for women living with HIV to have healthy children and to protect the health of their uninfected partner. First, it is essential that both partners be tested and be aware of their HIV status. They should also be tested for other sexually transmitted infections that may complicate a pregnancy, and be treated for any that are diagnosed. Having a low viral load (that is, the amount of the HIV virus that is present in the body) reduces the risk of transmission to both the uninfected partner and the baby. If possible, women who wish to become pregnant should consult a health care provider and begin taking antiretroviral drugs before attempting to conceive. Viral loads and CD4 counts can be monitored through regular visits to the health care facility where they receive treatment. Once viral loads are so low as to be undetectable, the woman should begin to track the most fertile period of her menstrual cycle by using fertility awareness methods such as the standard days method, or checking the consistency of her cervical mucus. She and her partner should only have unprotected intercourse during these most fertile days; at all other times they should use condoms to protect against transmission. Once the woman becomes pregnant, she should follow the same guidelines applied to women who do not have HIV: eat well, rest, take iron tablets and folic acid, and be vaccinated against tetanus. At delivery, the baby should be given antiretroviral therapy according to the local guidelines, and mothers should be counseled on safe feeding practices, including exclusive breastfeeding for six months or use of formula if it is available, affordable and acceptable. She should also consider using an effective contraceptive method in order to appropriately time any subsequent pregnancies. Following these steps will help the entire family stay healthy.

Sanjay Mishra: HIV/AIDS is no more a havock as there are many other diseases that are more serious than this pandemic but it can be felt that now it is in slept mode so we can not be careless or thnk that now it has been nomore a problems so it needs to be hooked up wiyh other programmes like reproductive health,family planning and STD/STI/RTI etc. … in many societies people are not agree to adopt any family planning methods unless they bear a son, so in waiting [a son] … they are multiplying the population and the other hand they are avoiding using any of the family planning methods, which is highly risky. This is equally responsible for the both partners but is is more inclined on male as they still enforce their women to have sex without using condom. … So now the problem perceived here is how to change that kind of mentality frm the masses, and how to make popular these methods among the less educated societies? Most of the programs run currently are inclined on advocacy but making inroads in the community still seems to be difficult.
Susan Adamchak: Sanjay, We agree that there are many serious diseases that have major impacts on the health of people across the globe, but it is premature to think that HIV/AIDS is “no more a problem”. According to the World Health Organization, AIDS-related illnesses continue to be a leading cause of death and a cause of premature mortality, and are projected to remain so for decades into the future. Due to both new infections, and people who have access to treatment living longer, the number of people living with HIV in 2008 was 20% higher than in 2000. The desire for children remains strong in most countries, and as you note there are many societies in which male children are valued more than females. These community norms affect the individual decisions made by couples about the number, timing and spacing of their children. It is true, advocacy and supportive polices alone are not sufficient to foster change regarding family planning use. Among the elements that need to be in place in order for programs to be successful are: effective communication to motivate users; client-centered care that is affordable and accessible; and strong management that uses evidence for decision making, supports staff, and ensures contraceptive security. Integrated services, either through providing multiple services or by offering referrals, can be an important way to meet client needs and to optimize the use of scarce financial and manpower resources. Also, there is ample evidence that supporting education, financial security, and decision making power of girls and women is frequently translated into the uptake of family planning services. A very useful resource for an overview of the global HIV/AIDS epidemic is published by UNAIDS and WHO: AIDS epidemic update December 2009. You can find it at: http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf. Another useful tool is a recent Population Report, “Elements of Success in Family Planning Programming” (September 2008), found at: http://info.k4health.org/pr/J57/J57.pdf  

Barbara Pillsbury: What is the latest wisdom for advising an HIV-positive woman who wants to have a child? (Assume she has a husband/partner but no children or only one and thus a “normal” desire to have a child. This is not about women who already have several children.)
Susan Adamchak: Hi, Barbara, We responded to a similar question earlier; please see if that addresses your concerns. Couples, particularly discordant couples, living in countries with greater medical resources have several additional options including in vitro fertilization (if the female partner is HIV-positive), or sperm washing (if the male partner is infected).

Barbara Pillsbury: What are the latest regulations on use of PEPFAR funds for family planning? What are additional ways in which the old (PEPFAR 1) regulations may be eased in order to achieve better integration of HIV and FP?
Rose Wilcher: Both the new five-year strategy for PEPFAR and the most recent PEPFAR Country Operational Plan (COP) guidance to the field include encouraging language with respect to family planning. In striking contrast to the COP guidance issued in FY2009, which explicitly forbade the use of PEPFAR resources for family planning activities, the current guidance states that “PEPFAR is a strong supporter of linkages between HIV/AIDS and voluntary family planning and reproductive health programs.” It also identifies family planning as an important component of preventive care for PLHIV. The five-year strategy outlines the contributions of PEPFAR to the Obama Administration’s Global Health Initiative. With integration and women-centered approaches as cross-cutting principles of the GHI, the new PEPFAR strategy also articulates support for these approaches, including through stronger linkages between PEPFAR-supported programs and family planning and reproductive health programs. While it remains unclear whether it will be allowable to use PEPFAR funds for the purchase of contraceptive commodities other than condoms, this new language suggests that there will be more flexibility regarding support for other FP/HIV-related activities. Two useful analyses of the FP content of these two PEPFAR documents were done by PAI and links to the summaries can be found here:

1) http://www.populationaction.org/Issues/U.S._Policies_and_Funding/Washington_Memo/Index.shtml   

2) http://www.populationaction.org/Issues/U.S._Policies_and_Funding/Washington_Memo/memo_120209.shtml   

Jann Anguish: Why are the policymakers not moving on the integration of family planning and HIV programs? It is obvious that it would save money to use one facility for both services.
Rose Wilcher: I wouldn’t say that policymakers are not moving on FP/HIV integration. In fact, at present, the policy environment is quite favorable for FP/HIV integration. At least eight international policy statements have been issued calling for stronger linkages between SRH and HIV policies and programs. Moreover, prevention of unintended pregnancies and prevention of HIV are two key priorities of the Global Health Initiative and integration is a cross-cutting principle. At country level, technical working groups on FP/HIV integration have been formed by the Ministries of Health in many countries, with co-leadership coming from policymakers in the Reproductive Health unit and the HIV/AIDS unit. The tide is even beginning to turn with donor policies. The Global Fund is not only supportive of SRH components within HIV proposals, but will even fund the procurement of contraceptive commodities. And, as indicated in an earlier response, PEPFAR is now encouraging better integration between HIV and FP programs. However, much work remains to translate these policy goals into practice. At this time, only limited data exist on effective models of integrated service delivery. More research is needed to expand the evidence base of best practices for FP/HIV service integration. Such data will not only enhance integration practice on the ground, but also bolster advocacy efforts with parties who remain unconvinced of the benefits of FP/HIV integration. Efforts in the field could also be strengthened if HIV donors who support linkages with FP programs required that implementers report on contraceptive use or other FP-related indicators as measures of programmatic success.

Diddie Schaaf: I would like to know what you recommend in the integration of FP and HIV programmes in low level concentrated HIV epidemics.
Rose Wilcher: One of the most important factors to consider with FP/HIV programming is the scale of the HIV epidemic. The integration of HIV services into FP services might not be appropriate if an epidemic is concentrated or at a low level. In this scenario, the majority of the FP clients will not be at risk of HIV or in need of most HIV services, so integrating HIV services into FP programs may not be cost-effective nor have much impact. However, integrating FP services into HIV prevention, care and treatment programs is of critical importance in concentrated or low-level epidemics. Because most HIV programs in these settings target PLHIV and most-at-risk populations (MARPs), such as female sex workers and injection drug users, they provide a platform for reaching these groups with FP information and services. And, indeed, studies are increasingly documenting that these groups have substantial unmet need for FP. For example, despite high levels of self-reported condom use by FSWs at last commercial sex, low levels of condom use with non-commercial partners or regular partners, as well as high levels of forced unprotected sex mean FSWs remain at high risk of unintended pregnancy. To the extent possible, efforts to integrate FP into HIV programs reaching MARPs should not only introduce strategies to increase dual contraceptive use, but also address broader sexual and reproductive health concerns of MARPs, including gender-based violence. That said, most of our documented FP/HIV integration program examples come from countries in sub-Saharan Africa with a generalized epidemic. As FP/HIV integration efforts expand in Asia and other areas with concentrated epidemics, strong monitoring and evaluation of these efforts is needed in order to build the evidence based of effective integration models for these settings.

Sanjay Mishra: Hi,Integrated family planning if properly implemented no doubt it may become a very useful in curving the HIV rates, but the problem is family planning resources are being drained and not properly utilised by the people who are targetted, I wanted to know is there any method to convince people to use integrated family planning methods? And other thing is that how to penetrate the population groups [which] are still rigid on not using it saying by using condom it does not give the real pleasure and may reduce the male potency. In many parts of the Bihar, India I have personally observed that these service centers are not much functional and active. Also [on] one hand we are advocating that circumcision may help in reducing the HIV then why people will become convinced to use condoms? This is a recent trend in Malawi and other southern parts of the Africa.
Rose Wilcher: Integrating family planning services into HIV service settings provides an opportunity for HIV providers to screen their clients for risk of unintended pregnancy and provide contraceptive information, methods and referrals as needed. However, screening clients for their need for FP services is a critical responsibility that providers must assume in order to target FP-related services (and resources) appropriately. Fortunately, implementing FP/HIV integration does not necessarily have to be supported solely by limited family planning resources. The Global Fund supports sexual and reproductive health components of HIV/AIDS proposals, including the procurement of contraceptive commodities, and new opportunities may be emerging under PEPFAR. Your concern that male circumcision interventions may reduce condom use is a legitimate one. Indeed, there is widespread concern that male circumcision will bring a false sense of protection and result in an increase in risky sexual behavior by men, including less condom use. Similar concerns apply to FP/HIV integration interventions. Will promoting methods of contraception in addition to condoms in HIV service settings negatively affect condom use by clients of HIV services? While limited data are available to answer this question, a recent study by Kenneth Ngure et al in the November 2009 supplement of AIDS reported the findings from an evaluation of an intervention to promote dual contraceptive use by women in HIV-serodiscordant partnerships. They found that not only did non-barrier contraceptive use increase significantly after the intervention, but self-reported condom use also remained high during follow-up. Your question raises the important point that “dual method use” counseling – that is, promoting use of condoms for HIV/STI prevention in combination with other non-barrier methods of contraception for added protection against unintended pregnancy – must be a central feature of FP/HIV integration efforts in order to achieve the desired reproductive health and HIV prevention outcomes.

Dr. Anima Sharma: Hi, I think it is absolutely essential to integrate the Family Planning and HIV programmes. But don’t you think that along with it awareness and empowerment of women is more necessary?
Rose Wilcher: Efforts to improve women’s reproductive health and protect them from HIV must consider how gender constraints such as women’s lack of decision-making power, limited mobility, and lack of control over financial resources affect their ability to access and use health care information and services. So, indeed, maximizing the impact of FP/HIV interventions requires that strategies to address common gender-related barriers to contraceptive use, HIV prevention behaviors, etc are part and parcel of these interventions.

Peterson Mwaniki: This is the best thing that will hapen in HIV/AIDS program.However, this shouls not be interpreted to mean that F/p is only meant to prevent couples from having children but also help those couples helplessly looking for children while in discordant relationships or in cocordant relationshps safeky have children since this too is a family planning issue. Many are engaging in risk behaviours since there are no standard procedures for these couples at the care centres.Are you planning to incoporate these issues?
Susan Adamchak: Hello, Peterson, This is indeed an important concern, raised by several people in this chat. Please see our responses to Sanjay and Barbara where we discuss the same topic.

Damtew G/Tsadik: In developing Countries like Ethiopia,most of the positive mothres will have pregnancy two or more in thier life after they knew thier status. what do you think the barries will be for this?
Susan Adamchak: Many women first learn their HIV status when they are tested as part of their antenatal care, or when a baby who is not born in a health facility is tested for HIV after failing to thrive in its first few months of life. Increasingly, women diagnosed with HIV are referred to care and treatment services, either facility based or offered through community and home based care programs. Integrating family planning with care and treatment services will reach women and men with the information and services they need to plan future pregnancies, either by timing them to maximize the chance for a healthy outcome, or by avoiding becoming pregnant.

Yinka Shokunbi: It would be interesting to know what other opportunities could be opened to women in conflict situations to access family planning services given the fact in war or conflict situations a lot of the affected, mostly women are displaced from their homes and they often turn up in refugee camps and how can these women sustainably use these services voluntarily to stem spread of HIV as well as prevent unwanted pregnmancis.
Susan Adamchak: The World Health Organization has published several useful resources that address your questions. These include: Reproductive Health during Conflict and Displacement, A guide for programme managers” (2000) and “Reproductive Health in Refugee Situations—An Inter-Agency Field Manual” (1999). While both of these were published prior to the focus on integrated services generated in recent years, the guidelines an integrated approach in which “reproductive health is treated as an integral component of primary health care.” The care package for RH interventions includes both making condoms freely available to reduce HIV transmission, and to meet pre-existing FP needs by having condoms and other contraceptives available for women and men.

Meskerem Bekele, Ethiopia: It is good [to] integrate HIV Program and FP. I have one question. I think most of contraceptive methods are not like condom …[in preventing HIV]. (Tell me if there are more) what do you think about that?
Rose Wilcher: True, only barrier methods, namely male and female condoms, offer dual protection against both unintended pregnancy and HIV/STI. Thus, as previously mentioned, promotion of dual method use – use of condoms for HIV/STI prevention in combination with other non-barrier methods of contraception for added protection against unintended pregnancy – should be a cornerstone of FP/HIV integration efforts.

Laurette Cucuzza: I’ve been thinking about indicators to measure integrated programs, and though I can come up with process and service delivery output and outcome indicators, I am struggling with how to measure the impact of integration itself. How would one capture the magnitude of difference, or the expected efficiencies of integration?
Susan Adamchak: Hi, Laurette, This is an excellent question, and one we’ve been grappling with ourselves. Short of undertaking a large scale matched sample comparing indicators such as contraceptive prevalence rates or pregnancy rates among clients attending integrated versus stand alone services, or the cost incurred in each type of service, it is challenging to attribute impact. To my knowledge, no such study has been reported yet. An alternative, though less robust, would be to collect good quality baseline data on the impact indicator of choice prior to introducing the integrated services, and then conduct post-intervention data collection at some reasonable time in the future to determine whether introducing integrated services resulted in FP or testing uptake, reduced pregnancies, or cost savings. A series of pilot tests of key integration indicators are planned by FHI and by the Inter-Agency Task Team on PMTCT M&E later this year; the experience gained in these efforts may help move our thinking forward on this topic.

Dr. Saye D. Baawo: What are some lessons learned from countries where vertical programs have worked together in achieving integration of RH/FP and HIV services? What were their challenges in achieving this? How [has] the situation changed for the better?
Rose Wilcher: In late 2009, FHI, USAID and WHO published a document entitled “Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs and Services” (available: http://www.fhi.org/en/RH/Pubs/booksReports/FP-HIV_Strategic_Considerations.htm). Drawing from the published literature, the recommendations of more than 100 experts in FP and HIV/AIDS, and lessons learned from field experience to date, the authors suggest that four key questions are central to systematically and strategically pursuing stronger linkages between the two fields:

• What type of service integration, if any, is needed?

• To what extent should services be integrated?

• What steps are needed to establish and sustain high-quality integrated services?

• What information is needed to measure program success and inform program/service delivery improvement, replication, and/or scale-up? The guidance indicates that no one-size-fits-all approach to FP/HIV integration exists. Different facilities will be able to implement different levels of integration, depending on factors such as physical, human, financial and technical capacity. The guidance also suggests that achieving and sustaining FP/HIV integration will likely require a range of interventions across different levels of the health system (e.g., policy, facility, provider, and community levels). Specific recommendations for actions that can be taken at each level are provided in the guidance. Many countries, primarily in sub-Saharan Africa, are making measurable progress in FP/HIV integration as evidenced by the formation of Ministry of Health-led national technical working groups on integration, the development of national integration strategies, the strengthening of the FP content in HIV policies, guidelines, and protocols, and the development of national FP/HIV training curricula and tools.

Hally Mahler: Hi Rose and Susan! Male circumcision programs, which are scaling up in most of East and Southern Africa, are reaching men with RH/HIV counseling – perhaps the most indepth couseling on these topics they will get in their lives. Many MC providers are hesitant to go beyond general education about RH for fear that clients will confuse MC with vacectomy. Yet if we miss this opportunity to address FP we may have missed a once-in-a-lifetime opportunity. How do you propose we can meaningfully address MC providers’ fears, and the logistical challenges of adding on to an already intense counseling package and clinica service, while still taking advantage of the opportunity that MC presents? Thanks, Hally
Rose Wilcher: Hi, Hally. Great question! Most FP/HIV integration efforts to date have focused on linking FP services with HIV programs such as counseling and testing, PMTCT, and care and treatment. However, the burgeoning male circumcision service delivery platform certainly holds promise as an opportunity to reach men with FP information and services. While I’m not aware of any data on the feasibility and effectiveness of FP/MC interventions, it seems like an important new area of research. Fears and concerns about adding a responsibility to an already full workload has been raised by other HIV service providers (e.g., VCT, PMTCT, ART providers), but several studies have shown that integrating FP counseling/services/referrals is both feasible and acceptable to these providers. Once the feasibility of FP/MC integration has been established, the key will be identifying and implementing a level of FP integration that can easily become part of the routinized care that MC providers offer. And, institutionalizing it as part of their routinized care will likely require not just training the MC providers on FP, but also modifying service delivery protocols and reporting forms, building capacity of supervisors in FP, formalizing referrals networks to FP providers, etc. In Kenya, FHI is currently conducting a formative study to determine how men who consider adult circumcision for HIV prevention can be targeted with counseling on dual protection and male involvement in family planning. Data analysis is underway, so stay tuned for results in the next couple of months.

Dr Alex Hakuimana: We all agree that integrating FP and HIV programs has numerous advantages and benefits. Do we have supporting research evidence on the cost effectiveness at all levels, I mean programmatic and client levels?

Do we have tools to track the integrated interventions?
Susan Adamchak: As yet, evidence on the cost effectiveness of integrated services relative to stand along service is limited. The Population Council, reporting on integration of VCT with family planning in Kenya, found that the integrated services were able to be offered at one-third the cost of estimated costs of stand alone VCT (Liambila, et al. Feasibility and effectiveness of integrating provider-initiated testing and counseling within family planning services in Kenya. AIDS 2009, 23 (suppl 1): S115-S121).To our knowledge, there is no single document that summarizes methods and indicators to track integrated interventions, although several organizations are working to test indicators in local situations. One source prepared by Population Action International to review is http://www.populationaction.org/Publications/Reports/A_Practical_Guide_to_Integrating_Reproductive_Health_HIV-AIDS/Summary.shtml  

Andrew Cummings: Where are the highest rates of occurrence of pregnant women with HIV/AIDS? Again, is this an just education issue or should I stop assuming that people are intelligent enough to understand what HIV/AIDS is an how it passes, or do we need to hold their hands through the entire process? Family planning and HIV programs should undoubtedly be implemented the world over, but cynical and harsh as it may sound why not abstaining from reproduction if you have HIV/AIDS? Isn’t HIV/AIDS a pandemic? Shouldn’t we treat it as such, quaratines and etc? Or, have we lost sight of the greater good of the world population for the sake of the few that have more or less been given a death sentence anyway?
Susan Adamchak: The highest rates of seroprevalence among pregnanty women occurs in the countries of southern Africa, including Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. In many cases, people are aware of the means of transmission of HIV; however, people often do not have accurate assessments of their own risk of exposure to the disease. Poverty, social norms, lack of women’s autonomy all come to bear in influencing behaviors that expose people to the risk of contracting HIV/AIDS. There are several responses to your question about reproduction. First and foremost, all women and men have the right to decide the number, timing and spacing of their children, regardless of HIV status. Second, timely and appropriate treatment with antiretroviral drugs can reduce the risk of mother to child transmission of HIV to only 1-2%, allowing HIV-infected parents to bear healthy children (see responses to several other questions on means to achieve safe pregnancy). Third, of the estimated 33 million people living with HIV today worldwide, as many as 70% do not know their HIV status. Many women first learn they are HIV-positive when they are tested in antenatal care. Finally, the rapid roll out of ARV treatment in resource-constrained settings has dramatically changed the way people live with HIV/AIDS. Far from being a “death sentence,” HIV/AIDS can now be managed as a chronic condition, much like hypertension or diabetes. You might look at this documen, “Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV” http://www.gnpplus.net/content/view/1511/114/  

Dr. Satyajeet Nanda: Is there a chance that by interlinking HIV program with FP program, the latter may be hampered due to the stigma of general attached with HIV, and people will not prefer the instituions with linked programs. …in few developing countries … some people either donot prefer to go to govt. systems or any system due to HIV stigma.
Susan Adamchak: One ration