The Astonishing Neglect of an HIV-Prevention Strategy: The Value of Integrating Family Planning and HIV Services

This article examines the neglect of one strategy for reaching the United Nations General Assembly Special Sessions (UNGASS) target of reducing HIV-positive births by 50 percent by the year 2010.  The goal was to be achieved with the implementation of a four-part strategy to prevent mother-to-child transmission (PMTCT) of HIV. The strategies include:

1. Preventing primary HIV infections in women
   
2. Preventing unintended pregnancies in HIV-positive women
   
3. Preventing mother-to-child transmission with antiretroviral (ARV) prophylaxis
   
4. Providing care, treatment, and support for HIV-infected women, their infants, and their families
   

According to this United States Agency for International Development (USAID) AIDSTAR-One Spotlight on Prevention article: "The majority of the resources for PMTCT have been directed toward the provision of ARVs - such as the nevirapine regimen for HIV-positive pregnant women and their newborns. In contrast, preventing unintended pregnancies among HIV-positive women - by increasing the voluntary use of contraception - has been undervalued and little-used."

The document cites studies showing that between 84 and 90% of pregnancies among HIV positive women enrolled in PMTCT and antiretroviral programmes in South Africa and Uganda were unintended. It argues that "contraception is a powerful HIV-prevention strategy that could reach many of these women if it were a core component of HIV prevention, care, and treatment initiatives. It presents the positive benefits for contraception including mother and child health, among others. The funding gap for contraceptives and condoms will, according to The United Nations Fund for Population Activities (UNFPA) estimates, reach hundreds of millions of dollars annually by 2015. Further, "HIV funding to date has had only a limited impact on mitigating the shortfall in funding for family planning.... Neither PEPFAR [the President’s Emergency Plan for AIDS Relief (PEPFAR)] nor the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) includes contraceptive use as an indicator of programmatic success.... Strengthening traditional family planning programs, particularly in countries with a generalized epidemic, is one way to increase access to contraception, including for HIV-positive women. However, another more targeted approach is to integrate family planning and HIV services. The union of these services has the potential to draw on the strengths of both programs to address the client’s dual need for reproductive health and HIV-related services.... Both approaches to integration - with their emphasis on reducing organizational ‘silos’ to allow more comprehensive care - are central to the concept of health-systems strengthening, a rising global health priority, especially among HIV donors."

Because funding streams in reproductive health and HIV/AIDS have been separate, government structures in many countries have developed separately, with vertical policies, programmes, training, strategies, and service delivery. However, "in several countries specific individuals have been designated to provide liaison for - and support integrated activities among - the array of government programs with both reproductive health and HIV responsibilities. Coordination of multisectorial input to national public health strategies is essential. As they move forward, we must also continue to invest in research to build an evidence base of integrated service delivery best practices..... As in traditional family planning programs, informed-choice counseling must be the cornerstone of contraceptive services in HIV-service delivery settings. HIV-infected women, like all women, have the right to make reproductive choices for themselves - they should never be coerced into a particular reproductive decision. For those women who do not wish to become pregnant, providers must be able to discuss safe and effective contraceptive options."

The authors conclude that: "Reducing the unmet need for contraception will not only produce tangible gains against the HIV epidemic, it will also improve the overall health of mothers and their children. The current U.S. administration has included both HIV and family planning as two of its top four priorities in the President’s Global Health Initiative. In addition, the Secretary of State has identified Millennium Development Goal 3 - the empowerment of women and girls - as its ‘signature’ foreign policy goal. Now is the time for contraception to take its rightful place among HIV-prevention strategies."