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HIV Prevention Knowledge Base

A Collection of Research and Tools to Help You Find What Works in Prevention

Biomedical Interventions: Contraception to Prevent Unintended Pregnancies among Women with HIV

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Keywords: women,vertical transmission,pregnancy,integration,family planning (FP),contraception

I. Definition of the Prevention Area

Providing contraception to women with HIV who wish to postpone or avoid pregnancy can prevent vertical transmission of HIV from mother to child. Indeed, the prevention of unintended pregnancies among women living with HIV is one of four elements of a comprehensive approach to prevent mother-to-child transmission of HIV (PMTCT), as seen in the diagram below. Most PMTCT efforts to date have focused on HIV testing to identify and provide antiretroviral (ARV) prophylaxis to pregnant women who are HIV-infected (Element 3). The role of contraceptive use in preventing unintended pregnancies among women living with HIV (Element 2) has received relatively less attention, but is no less important.

 

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II. Epidemiological Justification for the Prevention Area

Each year, an estimated 577,200 unintended pregnancies among HIV-positive women in sub-Saharan Africa are prevented through the use of contraception, resulting in an estimated 173,000 HIV-positive births averted. An additional 160,000 HIV-positive births could be prevented by meeting the need for contraception among all women in the region who do not wish to become pregnant. A USAID study projected that adding family planning services to PMTCT programs could prevent almost twice the number of infections among children as PMTCT programs without family planning. Another analysis concluded that existing family planning use contributes as much or more than PMTCT to mitigating pediatric HIV in Uganda.

III. Core Programmatic Components

The integration of family planning and HIV services is a key strategy for preventing unintended pregnancies among women with HIV. Contraception as an HIV prevention intervention will be most cost-effective when implemented in settings with generalized HIV epidemics that disproportionately affect women of reproductive age. Given that most women do not know their HIV status, programs should make family planning services available to all women to maximize their HIV-prevention impact, as well as their impact on maternal-child health.

Men should also be part of a programmatic response to prevent unintended pregnancies among women with HIV. Men may prevent unintended pregnancies by using condoms or by getting a vasectomy. In addition, men often play decisive roles in either supporting or hindering the use of contraceptives by their spouses or partners.

Women with HIV, including those who are taking ARVs, can use almost all contraceptive methods safely and effectively, including intrauterine devices (IUDs), though only male and female condoms are effective at preventing transmission of HIV among serodiscordant couples. Nevertheless, many providers have misconceptions about contraceptive eligibility and unnecessarily restrict women with HIV from using certain methods.

Critical components of family planning service provision for HIV- positive women include:

  • Locating family planning (FP) and HIV services at the same site, or facilitating referrals, to ensure that women receiving HIV services can easily obtain contraceptives.
  • Training providers to screen for unmet FP needs and offering counseling on method selection and use.
  • Offering dual protection from both HIV (in the case of serodiscordant couples) and pregnancy.
  • Providing injectable contraceptives, pills, and condoms by trained community-based workers, including those who work in home-based HIV care and support programs.
  • Modifying registries and data collection forms to effectively monitor integrated service delivery.
  • Building the capacity of supervisors to support trained providers to offer integrated services.

IV. Current Status of Implementation Experience

A recent review of the literature found that bi-directional linkages between sexual and reproductive health and HIV-related policies and programs can lead to a number of important public health, socioeconomic, and individual benefits. To more fully reap the benefits of contraception as an HIV prevention strategy, greater integration of FP and HIV programs is needed, particularly in generalized epidemic settings where women of childbearing age are disproportionately affected by HIV.

Although many ministries of health and implementing partners are now scaling up integrated FP/HIV services, a number of obstacles continue to impede this process. These include separate funding streams for FP and HIV programming, the vertical organization of health ministries and service facilities, and a lack of evidence for the effectiveness of integrated service delivery models. A recent publication by the World Health Organization, the U.S. Agency for International Development, and Family Health International provides program planners, implementers, and managers with strategic considerations for implementing or strengthening integrated FP/HIV services.

The reauthorized PEPFAR (U.S. President's Emergency Plan for AIDS Relief) program puts increased emphasis on supporting linkages between HIV services and other health and development programs. Likewise, Country Operational Plan guidance encourages country teams to consider locating family planning and HIV services together, particularly at the primary health care level. PEPFAR encourages the programs it supports to train health workers to deliver an enhanced package of maternal, newborn, and child health services, including family planning, for women living with HIV. Providing HIV counseling and testing at family planning sites is also encouraged in areas of high HIV prevalence.

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