HIV/AIDS and Sexual and Reproductive Health Integration: Quarterly Highlights Newsletter (January 2010)
Contents
Hillary Rodham Clinton at the 15th Anniversary of the International Conference on Population and Development
On January 8, 2010, Hillary Rodham Clinton gave a speech to commemorate the 1994 Cairo Conference, celebrate the accomplishments in reproductive health and the advancement of women and girls in the last 15 years, and renew commitment to meeting the Millennium Development Goals. She highlighted the integration of women and gender issues into the foreign policy agenda of the Obama Administration, as well as the launch of the Global Health Initiative, which supports the integration of HIV/AIDS and reproductive health services. Clinton defined reproductive health as a human rights issue that demands the attention of leaders around the world. Read the transcript of her speech at http://www.state.gov/secretary/rm/2010/01/135001.htm.
Educational Materials
Global Health eLearning Course: FP/RH for People Living with HIV
Authors: Kim YM; Rinehart W; Mazzeo C.
Source: Global Health Learning, USAID.
The Global Health eLearning Center offers a menu of courses that learners can use to expand their knowledge in key public health areas and to access important up-to-date technical information. Each course is authored by a subject matter expert or a team of experts, is highly focused, and can be completed in about one to two hours. Although courses are designed to be taken online, a printer-friendly format allows you to download course materials for further study. The FP/RH for People Living with HIV course will help you consider the benefits of integrating family planning (FP) services and counseling with HIV/AIDS services – and how that can be done. The course also covers contraceptive methods for people with HIV and discusses how HIV care providers can help their clients make family planning choices. To access the course, go to www.globalhealthlearning.org and register to the site. Then you will be able to access 33 courses, and even more will be coming soon.
Policy and Practice
Family planning and HIV: Strange bedfellows no longer
Authors: Wilcher R; Cates W Jr; Gregson S.
Source: AIDS. 2009; 23(Suppl 1): S1-S6.
This supplement originated from the belief that more evidence is needed to compel funders, policymakers, program planners and implementers to act on the synergies between family planning and HIV/AIDS fields and enhance the public health impact of reproductive health and HIV programs. The contents of this supplement represent research being conducted within three broad areas: behavioral research examining contraceptive practices and fertility desires of HIV-positive women and couples; biomedical research addressing the safety and effectiveness of contraceptive methods for HIV-positive women; and programmatic research evaluating service delivery approaches to integrating family planning and HIV services. Taken together, the studies published in this supplement expand the evidence base regarding how the family planning and HIV fields are related and how they can be better integrated in practice.
Progress on scaling up integrated services for sexual and reproductive health services and HIV
Authors: Dickinson C; Attawell K; Druce N.
Source: Bulletin of the World Health Organization, 2009; 87: 846–851.
This paper considers new developments to strengthen sexual and reproductive health and HIV linkages and discusses factors that continue to impede progress. It is based on a previous review undertaken for the United Kingdom Department for International Development in 2006 that examined the constraints and opportunities to scaling up these linkages. We argue that, despite growing evidence that linking sexual and reproductive health and HIV is feasible and beneficial, few countries have achieved significant scale-up of integrated service provision. A lack of common understanding of terminology and clear technical operational guidance, and separate policy, institutional and financing processes continue to represent significant constraints. We draw on experience with tuberculosis and HIV integration to highlight some lessons. The paper concludes that there is little evidence to determine whether funding for health systems is strengthening linkages, and we make several recommendations to maximize opportunities represented by recent developments.
Young people, sexual and reproductive health and HIV
Author: Santos RF.
Source: Bulletin of the World Health Organization 2009; 87: 877–879.
Despite their vulnerability to HIV infection, young people’s needs are often overlooked when national AIDS strategies are designed and implemented. It is important to actively involve youth in finding solutions and provide them with the information and tools they need to make safe and healthy choices.
HIV/AIDS belongs with sexual and reproductive health
Author: Germain A; Dixon-Mueller R; Sen G.
Source: Bulletin of the World Health Organization 2009; 87: 840–845.
The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV/AIDS, and for advancing other development goals. The United Nations Millennium Development Goals now incorporate a target of universal access to sexual and reproductive health within the goal of improving maternal health, but combating HIV remains a separate project with malaria and tuberculosis. We present a brief history of key decisions made by WHO, other United Nations’ agencies, the United Nations Millennium Project and major donors that have led to the separation of HIV/AIDS from its logical programmatic base in sexual and reproductive health and rights. This fragmentation does a disservice to the achievement of both sets of goals and objectives. In urging a return to the original ICPD construct as a framework for action, we call for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV/AIDS prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model to maximize their effectiveness and efficiency and to strengthen the capacity of health systems to deliver universally accessible sexual and reproductive health information and services.
Reproductive choices for women with HIV
Author: Wilcher R; Cates W.
Source: Bulletin of the World Health Organization 2009; 87: 833–839.
Access to reproductive health services for women with HIV is critical to ensuring their reproductive needs are addressed and their reproductive rights are protected. In addition, preventing unintended pregnancies in women with HIV is an essential component of a comprehensive prevention of mother-to-child transmission (PMTCT) programme. As a result, a call for stronger linkages between sexual and reproductive health and HIV policies, programmes and services has been issued by several international organizations. However, implementers of PMTCT and other HIV programmes have been constrained in translating these goals into practice. The obstacles include: (i) the narrow focus of current PMTCT programmes on treating HIV-positive women who are already pregnant; (ii) separate, parallel funding mechanisms for sexual and reproductive health and HIV programmes; (iii) political resistance from major HIV funders and policy-makers to include sexual and reproductive health as an important HIV programme component; and (iv) gaps in the evidence base regarding effective approaches for integrating sexual and reproductive health and HIV services. However, we now have a new opportunity to address these essential linkages. More supportive political views in the United States of America and the emergence of health systems strengthening as a priority global health initiative provide important springboards for advancing the agenda on linkages between sexual and reproductive health and HIV. By tapping into these platforms for advocating and by continuing to invest in research to identify integrated service delivery best practices, we have an opportunity to strengthen ties between the two synergistic fields.
Author: Wilcher R; Cates W.
Source: AIDS Support and Technical Assistance Resources (AIDSTAR-One), USAID.
Many HIV-positive women wish to control childbirth, but are unable to do so. Contraception is a powerful HIV-prevention strategy that could reach many HIV-positive women if it were a core component of HIV prevention, care, and treatment initiatives.
Supporting the integration of family planning and HIV services
Author: Ringheim K; Yeakey M; Gribble J; Sines E; Stepahin S.
Source: Washington, D.C., Population Reference Bureau [PRB], 2009 Sep. 6 p.
The rationale for integrating family planning/reproductive health (FP/RH) and HIV services, especially in high HIV prevalence settings, has long been apparent: Sexually active individuals are at risk of both unintended pregnancies and HIV. The integration of these two sets of services share the key intended health outcomes of prevention of new HIV infections and prevention of unintended pregnancies. Years of experience in reproductive health settings demonstrate that individuals make greater use of services if they are easy to access. Visits to a health facility represent costs to clients and health systems, and making the most of these visits can have enormous benefits in the uptake of services and efficient program operations. One of the biggest challenges to integrating FP and HIV services is generating the political will to bring together programs that have been physically, financially, and managerially separate. When policymakers understand the savings and benefits of integrating FP and HIV services, they are more likely to support it. This policy brief highlights why service integration makes political and program sense, and describes the lessons learned from successful integration strategies in Ethiopia, Kenya, Lesotho, and Uganda. This brief also urges policymakers and program managers to make integrated services routinely and widely available.
Author: Steen R; Wi TE; Kamali A; Ndowa F.
Source: Bulletin of the World Health Organization 2009; 87: 858–865.
Control of sexually transmitted infections (STIs) is feasible, leads to improved sexual and reproductive health and contributes to preventing HIV transmission. The most advanced HIV epidemics have developed under conditions of poor STI control, particularly where ulcerative STIs were prevalent. Several countries that have successfully controlled STIs have documented stabilization or reversal of their HIV epidemics. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.
Author: Lusti-Narasimhan M; Collin C; Mbizvo M.
Source: Bulletin of the World Health Organization 2009; 87: 816–823.
The objective of this study was to assess the sexual and reproductive health interventions included by countries in HIV-related proposals approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). At least 70% of the HIV-related proposals included one or more of the four broad elements: sexual and reproductive health information, education and communication; condom promotion/distribution; diagnosis and treatment of sexually transmitted infections; and prevention of mother-to-child transmission of HIV. Between 20% and 30% included sexual health counselling, gender-based violence, and the linking of voluntary counselling and testing for HIV with sexual and reproductive health services. Less than 20% focused on adolescent sexual and reproductive health, the rights and needs of people living with HIV, or safe abortion services. All these elements were rarely featured, if at all, in the grant agreements reviewed. Overall, however, sexual and reproductive health indicators did appear in most HIV-related proposals and in more than 80% of the grant agreements. Country coordinating mechanisms and national-level stakeholders see in funding for sexual and reproductive health a means to address the problem of HIV infection in their respective national settings. However, we highlight some missed opportunities for linking HIV and sexual and reproductive health services.
Literature Reviews
Authors: Church K; Mayhew SH.
Source: Studies in Family Planning. 2009 Sep;40(3):171-186.
The last comprehensive literature review to examine the effectiveness of family planning (FP) services in delivering STI and HIV prevention and care was published in 2000. This review updates that report by examining evidence of the impact of integrating any components of STI or HIV prevention, care, and treatment into a family planning setting in developing countries. Forty-four reports were identified from a comprehensive search of published databases and ‘grey literature.’ The weight of evidence demonstrates that integrated services can have a positive impact on client satisfaction, are cost-effective. Evidence of FP services reaching men and adolescents and of their impact on health outcomes is inconclusive. Several studies found that providers frequently miss opportunities to integrate care and that the capacity to maintain the quality of care is also influenced by many programmatic challenges. The range of experiences indicates that managers need to determine appropriate health-care service-delivery models based on a consideration of epidemiological, structural, and health-systems factors.
Linking family planning with HIV/AIDS interventions: A systematic review of the evidence
Authors: Spaulding AB; Brickley DB; Kennedy C; Almers L; Packel L.
Source: AIDS. 2009;23(Suppl 1):S79-S88.
The objective of this study was to conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Researchers used a systematic review of peer-reviewed articles and unpublished program reports ('promising practices') evaluating interventions linking family planning and HIV services. Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.
Evaluation of Integration Programs
Author: Ngure K; Heffron R; Mugo N; Irungu E; Celum F; Baeten JM.
Source: AIDS. 23():S89-S95, November 2009.
The objective of this study was to evaluate a multipronged approach to promote dual contraceptive use by women within heterosexual HIV-1-serodiscordant partnerships. Nonbarrier contraceptive use increased after implementation of the intervention. Self-reported condom use remained high during follow-up, and pregnancy incidence decreased. A multipronged family planning intervention can lead to high nonbarrier contraceptive uptake and reduced pregnancy incidence among women in HIV-1-serodiscordant partnerships.
Author: Liambila W; Askew I; Mwangi J; Ayisi R; Kibaru J.
Source: AIDS. 2009;23(Suppl 1):S115-S121.
The objective of this study was to assess an intervention for increasing access to and use of HIV testing among family planning clients through provider-initiated testing and counselling for HIV. Following the intervention, the proportion of consultations in which HIV prevention counselling was provided and HIV testing offered increased significantly. The proportion of clients requesting an HIV test increased from 1 to 26%; approximately one third of these had never been tested previously. Provider-initiated testing and counselling is feasible and acceptable in family planning services, does not adversely affect the quality of the family planning consultation and increases access to and use of HIV testing in a population who would benefit from knowing their status.
Author: Chabikuli NO; Awi DD; Chukwujekwu O; Abubakar Z; Gwarzo U.
Source: AIDS. 2009;23(Suppl 1):S97-S103.
The objective of this study was to measure changes in service utilization of a model integrating family planning with HIV counselling and testing (HCT), antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in the Nigerian public health facilities. Researchers found that family planning-HIV integration using the referral model improved family planning service utilization by clients accessing HIV services, but further improvement is possible. Male utilization of family planning services also improved. The government of Nigeria should review the family planning user fee policy and scale up the integration in primary healthcare facilities.
Authors: Bradley H; Gillespie D; Kidanu A; Bonnenfant YT; Karklins S.
Source: AIDS. 2009;23(Suppl 1):S105-S114.
Governments and donors encourage the integration of family planning into voluntary HIV counseling and testing (VCT) services. Researchers aimed to determine whether VCT counselors could feasibly offer family planning and whether clients would accept such services. Clients demonstrated lower than expected immediate need for contraception, but, despite the relatively low risk this population had for unwanted pregnancy, family planning counseling in VCT increased from 2 to 41% for women and from 3 to 29% for men (P<0.01). Approximately, 6% of clients received contraceptive methods. However, sexually active men and women and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher client loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower client loads. Conclusion: Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted.
Cost-Benefit Analysis
Benefits and costs of expanding access to family planning programs to women living with HIV
Authors: Halperin DT; Stover J; Reynolds HW.
Source: AIDS. 23():S123-S130, November 2009.
This analysis models the potential benefits and costs of adding family planning to national strategies for achieving universal access to programs to prevent mother-to-child HIV transmission. Programs to prevent perinatal HIV transmission would, if accessed by all women in need with the most efficacious antiretroviral regimen available, prevent over 240 000 infant HIV infections in the top 14 countries (over 300 000 globally) at an estimated cost of over $131 million ($208 million globally). However, almost 72 000 infant HIV infections would still occur in the 14 countries (over 90 000 globally) that could have been averted by preventing unintended pregnancies at a cost of only about $26 million (over $33 million globally). If all unintended births (whether or not resulting in HIV-infected children) to HIV-positive women were prevented with family planning, the cost per birth averted would be $61 in the 14 countries ($63 globally). Conclusion: This analysis suggests that national strategies should adopt a comprehensive approach to preventing mother-to-child transmission and thus focus on preventing perinatal HIV transmission as well as unintended pregnancies. Family planning is cost effective for preventing HIV transmission and unintended pregnancies and will also reduce infant and maternal mortality and result in fewer orphans.
Fertility Preferences of Women Living with HIV/AIDS
Author: Johnson KB; Akwara P; Rutstein SO; Bernstein S.
Source: AIDS. 23():S7-S17, November 2009.
HIV-positive women have particular needs for contraception to avoid unwanted pregnancy, to protect their own health and to eliminate the risk of transmitting HIV to an infant. In 2004, the United Nations described a four-element strategy to preventing mother-to-child transmission of HIV; the second element is preventing unintended pregnancies among HIV-positive women. However, fertility preferences among HIV-positive women who know their status remain poorly understood. This study seeks to demonstrate the degree to which knowledge of one’s own serostatus is associated with fertility preferences and contraceptive demand and use. Knowledge of one’s own HIV-positive serostatus is significantly associated with a desire to limit childbearing with contraceptive use, but not necessarily with unmet need for contraception. HIV-positive women who know their status are more likely than other women to use condoms. Conclusion: HIV-positive women who know their serostatus exhibit fertility desires and contraceptive behaviors that are different from those of other women. These findings support the argument that efforts to scale up the second element of the strategy to prevent mother-to-child transmission of HIV should be accelerated: it is a cost-effective, rights-based approach to preventing incidence of mother-to-child transmission of HIV. Scaling up requires full commitment by both reproductive health/family planning and HIV constituencies to concerted integration at all levels of program planning, coordination and implementation.
Author: Elul B; Delvaux T; Munyana E; Lahuerta M; Horowitz D; Ndagije F; Roberfroid D; Mugisha V; Nash D; Asiimwe A.
Source: AIDS. 23():S19-S26, November 2009.
The objective of this study was to understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda. HIV-positive women were less likely to report wanting additional children than HIV-negative women, and although a majority of women reported discussing family planning with a health worker during their last pregnancy, modern family planning use remained low in both groups. Condoms were the most commonly used method among HIV-positive women, whereas withdrawal was most frequently reported among HIV-negative women. The results highlight success in provision of family planning counseling in PMTCT services in Rwanda. As family planning use was low among HIV-positive and negative women, further efforts are needed to improve uptake of modern methods, including dual protection, in Rwandan PMTCT settings.
Fertility desires and infection with the HIV: results from a survey in rural Uganda
Authors: Heys J; Kipp W; Jhangri GS; Alibhai A; Rubaale T.
Source: AIDS. 23():S37-S45, November 2009.
The objective of this study was to determine how a positive HIV diagnosis influences fertility desires and reproductive decisions for women and men living in western Uganda. HIV-positive individuals in the Kabarole region have a much greater desire to stop childbearing than their HIV-negative counterparts. The barriers to utilizing family planning services, as evidenced through the very low use of highly effective contraceptive methods, have to be jointly addressed by HIV/AIDS care/prevention and family planning programs.
Family Planning for People Living with HIV/AIDS
Determinants of contraceptive choice among women with HIV
Author: Whiteman MK; Kissin DM; Samarina A; Curtis KM; Akatova N.
Source: AIDS. 2009;23(Suppl 1):S47-S54.
The objective of this study was to examine factors associated with contraceptive choice among HIV-infected women. The method chosen by most women was condoms alone (47%), followed by combined oral contraceptives (COCs) along with condoms (29%), depot medroxyprogesterone acetate DMPA along with condoms (20%) and IUD along with condoms (4%). In multivariable analyses, independent predictors of choosing a method highly effective during typical use (COCs, DMPA, or IUD) along with condoms included having at least two births, postpartum enrolment, desiring, or uncertainty about desiring a future pregnancy, prior oral contraceptive use, recent injection drug use, and never or sometimes using condoms in the last year. Conclusion: Among HIV-infected women, several characteristics that may place women at greater risk for unintended pregnancy and its adverse consequences were associated with choice of highly effective contraceptive methods. These findings may aid in the development of interventions to increase use of effective contraception among HIV-infected women.
Author: Curtis KM; Nanda K; Kapp N.
Source: AIDS. 23():S55-S67, November 2009.
The objective of this study was to determine from the literature whether HIV-infected women who use hormonal or intrauterine contraception are at increased risk of HIV disease progression, other adverse health outcomes, or HIV transmission to uninfected sexual partners. Evidence regarding the safety of hormonal and intrauterine contraceptive use among women with HIV remains limited, but generally reassuring regarding adverse health effects, disease transmission to uninfected partners, and disease progression; however, one randomized trial raised concerns about enhanced disease progression among women using hormonal contraception. Preventing unintended pregnancy among women with HIV remains a high priority in public health, both for the health of the woman as well as for the prevention of mother-to-child transmission of HIV.
Author: Stringer EM; Giganti M; Carter RJ; El-Sadr W; Abrams EJ; Stringer JSA.
Source: AIDS. 23():S69-S77, November 2009.
HIV-infected women need access to safe and effective contraception. Recent animal and human data suggest that hormonal contraception may accelerate HIV disease progression. Neither implants/injectables nor oral contraceptive were associated with disease progression. Treating contraceptive method as a time varying exposure did not change this negative finding. This multi-country cohort analysis provides some reassurance that hormonal contraception is not associated with HIV disease progression. Further research is needed to address the contraceptive needs of HIV-infected women.
This section lists upcoming public health conferences, meetings, or other events that include activities and information concerning HIV/AIDS and Sexual and Reproductive Health Integration. If you know of an upcoming event that may be of interest to HIV/SRH Integration professionals, please e-mail info@hivandsrh.org.
The Fourth Africa Conference on Sexual Health and Rights, Addis Ababa, Ethiopia, February 8-12, 2010
5th International Conference on Sexology, Chennai, India, February 13-14, 2010
2010 3rd Annual HIV/AIDS New & Innovative Approaches, Greenbelt, MD, March 29, 2010
RH2010: Reproductive Health Conference, Bellevue, WA, April 7-9, 2010
Second Joint Conference of British HIV Association with British Association for Sexual Health and HIV,
Manchester, UK, April 20-23, 2010
6th Annual AIDS Scenario Building Workshop: Planning for a Future with HIV and AIDS, London, UK, April 21-23, 2010
The 29th Annual Family Planning and Reproductive Health Conference, Honolulu, Hawaii, May 5-6, 2010
Global Health Council 2010 Conference, Washington, D.C., June 14-18, 2010
XVIII International AIDS Conference, Vienna, Austria, July 18-23, 2010
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HIV/AIDS and Sexual and Reproductive Health Integration: Quarterly Highlights is published by the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs. It is made possible through funding from the David and Lucile Packard Foundation and the William and Flora Hewlett Foundation.