SRH/HIV Linkages: What’s The Rationale?

1. SRH/HIV Linkages:What’s The Rationale? Claudes Kamenga Family Health International Woodrow Wilson Center Washington, DC December 3, 2009

2. What do we mean by “integration”? • How different kinds of RH and HIV services or operational programs can be joined with the aim of maximizing collective outcomes. This includes referrals from one service to another, for example. It is based on the need to offer comprehensive services. Source: Rapid Assessment Tool for SRH Linkages: A Generic Guide (UNFPA, UNAIDS, WHO, IPPF, GNP+, ICW)

3. In practical terms it means… … Range of services that meet several needs simultaneously, where Providers screen clients for unmet needs (HIV or FP) Service provision offered only to clients who need services (e.g., VCT client not using FP but doesn’t want a pregnancy) Service organization options: Fully integrated, e.g., “one stop shop” Some services available (e.g., counseling) and others (e.g., method provision) available via referral

4. Why integrate? Clients Seeking HIV-related Services Share common needs: - Often both sexually active and fertile - Are at risk of HIV infection or might be infected - Need access to contraceptives - Need to know how HIV affects contraceptive options and vice versa AND Clients Seeking RH Services

5. 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

6. 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

7. Contraception is HIV Prevention • UNGASS goals cannot be met without increasing access to family planning • Even moderate decreases in unintended pregnancies to HIV+ women will reduce same number of HIV+ births as current PMTCT programs Source: Sweat et al, AIDS 2004; 18(12): 1661-71

8. WHO Four Element PMTCT Strategy PMTCT-Plus PMTCT FP SRH Prevention of HIV in uninfected 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 Element 1 Element 2 Element 3 Element 4 General Population FP & Postnatal Clinics HIV Care/ Treatment ANC Clinics VCT

9. Pregnancies are Often Unintended or Unwanted 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Haiti Kenya Nigeria Zambia Namibia Vietnam Ethiopia Uganda Rwanda Tanzania Botswana Côte d'Ivoire South Africa Mozambique % births unintended % births unwanted Source: DHS and other surveys

10. 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

11. Effect of Current Contraceptive Use by HIV+ Women–Assumptions • 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%

12. Contraception as HIV Prevention –Compared to ARVs 800 700 600 500 400 300 200 1000 735 # of infants/births, in 1000s 220 86 ARVs (over 1 year) Effective Contraception (over 1 year) # infants spared HIV infection # unintended births prevented Sources: WHO (2009), Reynolds (2008)

13. 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 NVP • Decreases the number of future orphans • Is a cost-effective HIV prevention intervention • Key Question – how best to achieve SRH/HIV integration?

14. SRH/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

15. International Level Opportunities • SRH/HIV integration supports the reproductive rights of HIV+ women • Increasing international policy support for stronger SRH/HIV linkages • Glion Call to Action • New York Call to Commitment • Maputo Plan of Action

16. International Level Opportunities • Global Fund • SRH components advocated • Can be used to purchase commodities • PEPFAR • Prevention with Positives • New COP guidance encourages integration

17. International Level Challenges • International donor funding lacks FP indicators – “what gets measured gets done” • PMTCT has focused mostly on antiretrovirals

18. 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 SRH/HIV integration • Increasing number of integrated SRH/HIV bilateral programs • Kenya, Nigeria, Zimbabwe

19. Country Level Challenges • Parallel RH and HIV departments and funding within Ministries of Health • Lack of policies, guidelines, and training programs for integrated RH and HIV services • Limited coordination between departments • Turf issues

20. 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.

21. Service Delivery Challenges • Various operational considerations • Commodities/logistics • Human resource capacity • Supervision • Reporting • Referral systems • Community involvement • Must address FP provider biases against and preparedness to serve HIV+ clients

22. Moving forward… • Evidence-base for SRH/HIV integration growing • Bulletin of the WHO (Nov 2009) • AIDS supplement on FP and HIV (Nov 2009) • New tools available to support integration programming