I. Definition of the Prevention Area
Family planning (FP) is a strategy to prevent vertical transmission of HIV from mother to child. Reducing the number of unplanned pregnancies in HIV-positive women reduces the number of infants exposed to HIV. Helping women with HIV meet their own family size and child spacing goals is one of four elements of a comprehensive approach to prevent mother-to-child transmission (PMTCT) of HIV. While this is still valid, in April, 2012, the World Health Organization (WHO) released a programmatic update on “Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants.” In the executive summary, the WHO said: "Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life.
Despite the approaches countries may undertake, there are several key factors to consider when planning and implementing programs to meet the family planning needs of women living with HIV:
- The social behavioral communication strategy being employed by the program should reinforce and complement approaches for meeting the family planning needs of HIV women and should extend between the community outreach efforts and the messages given at the health facility.
- Discuss and plan the family planning commodities (modern, traditional, and hormonal) that will be provided, the training of health providers and the health information system needed to document the challenges and successes.
- Promote the importance of using a condom for dual protection regardless of the other methods of family planning that may be used should be promoted. Condoms can prevent both an unplanned pregnancy and HIV transmission. Male and female condoms are effective at preventing HIV transmission among serodiscordant couples.
II. Epidemiologic Justification
During the PEPFAR expansion period, USAID funded several modeling studies showing that lowering the number of unplanned pregnancies among women with HIV can be as effective in reducing infant HIV infections as giving antiretrovirals (ARVs) to HIV-positive pregnant women. It is estimated that each year, contraceptive use prevents an estimated 577,200 unplanned pregnancies among HIV-positive women in sub-Saharan Africa, resulting in an estimated 173,000 HIV-positive births averted. Although many countries are planning to implement the new WHO policies, family planning is still a critical component for meeting the needs of all HIV positive women.
III. Core Programmatic Components
Contraception as an HIV prevention intervention is 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, ministries of health and collaborating programs should make FP services available to all women to maximize their HIV-prevention impact as well as their impact on maternal-child health.
Women living with HIV should have access to high-quality information and services so they can make informed decisions about future pregnancies. These include information about the effectiveness, side effects, and interaction of contraceptive drugs with ARVs, and about the advantages of dual protection, delivered as part of measures to prevent vertical transmission of HIV. Discussing pregnancy intentions and providing access to contraceptives is an important service in HIV care and treatment settings because certain ARVs possess toxicities that can affect the fetus. Trained counselors who can provide comprehensive information geared to the needs of HIV-positive women are critical for high-quality FP and providing information about all available methods of family planning.
Women with HIV, including those taking ARVs, can use almost all contraceptive methods safely and effectively, In 2012, the World Health Organization (WHO) held a technical consultation to review studies of the use of hormonal contraception and whether it increases risk of HIV acquisition and transmission. A thorough review of the evidence and study designs led the WHO to retain its position that women with HIV can safely use hormonal contraception, with the new recommendation that women at high risk of HIV who choose progestin-only injectable contraceptives should also use condoms and other HIV-preventive measures.
IV. Current Status of Implementation Experience
Although integrated FP/HIV services are scaling up globally, 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 publication by the WHO, USAID, and FHI 360 provides program planners, implementers, and managers with strategic considerations for implementing or strengthening integrated FP/HIV services.
The global health community, including the U.S. Government’s Global Health Initiative, encourages investigation and expansion of promising approaches to service integration and delivery. The Country Operational Plan guidance issued by the President’s Emergency Plan for AIDS Relief (PEPFAR) encourages country teams to consider co-locating FP and HIV services, 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 FP, for women living with HIV.