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Biomedical Interventions: Contraception to Prevent Unplanned Pregnancies among Women with HIV
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.
Impact of Integrated Family Planning and HIV Care Services on Contraceptive Use and Pregnancy Outcomes: A Retrospective Cohort Study
Kosgei, R. J., Lubano, K. M., Shen, C., et al. Journal of Acquired Immune Deficiency Syndromes (2011), Vol. 58 No. 5, pp. e121-126.
The United States Agency for International Development–Academic Model Providing Access to Healthcare (AMPATH) Partnership in Kenya assessed a pilot program intended to increase the use of family planning methods among HIV-positive women. The study sought to measure the differences between routine care (RC) and an integrated family planning services (IFP) model to determine the impact of the additional FP services in HIV care on the use of modern contraceptive methods and pregnancy rates. The AMPATH site was located in a hospital in Eldoret, Kenya, where more than 17,000 adult patients were receiving HIV care. In RC, two groups of patients, totaling 2578, received FP services that included condom counseling and condom availability as a means to reduce HIV transmission. In IFP, one group of patients, totaling 1453, were provided the RC in addition to visiting a reproductive health room staff by experienced nurses to obtain FP services. It was found that in the IFP group that the incidence of new condom use increased (16.7 percent; P < 0.001), the incidence of use of new FP methods including condoms increased (12.9 percent; P < 0.001), and the incidence of new FP use excluding condoms decreased (3.8 percent; P < 0.001). There was no statistical difference in the number of new pregnancies in the IFP group (0.1 percent; P = 0.9). The results of the attributable risk of the incidence rate per 100-person-years of IFP and RC followed similar trends. The study demonstrates how an IFP model can be successful in HIV care sites.
A Randomized Controlled Trial to Promote Long-term Contraceptive Use Among HIV Serodiscordant and Concordant Positive Couples in Zambia
Stephenson, R., Vwalika, B., Greenberg, L., et al. Journal of Women’s Health (2011), Vol. 20 No. 4, pp. 567-574.
The study aimed to increase the use of modern family planning (FP) methods among HIV serodiscordant and HIV seroconcordant couples in Zambia. Data for the study came from a cohort of 1502 couples who were recruited through couples voluntary counseling and testing (CVCT) clinics, and then enrolled in a randomized controlled trail. There were four arms to the study. The methods group viewed one video that provided information on modern contraceptives. The motivational group viewed the second video that demonstrated positive future planning behaviors such as will preparation and pregnancy prevention. The third group viewed both videos. The control group watched a video on other healthy behaviors. Counselors were available after the groups watched the videos to answer any questions. Couples were given the opportunity to initiate, add, or change their modern contraceptive method free of charge. It was found that at baseline only 21.5 percent of couples reported use of a modern FP method. After the intervention, 1407 couples chose a new method or wanted to continue their current method. The most popular methods among new users were injectables (40.7 percent) and oral contraceptive pills (OCPs) (40.5 percent). OCPs were the most popular method chosen postintervention among the 324 couples who were already using a contraceptive method at enrollment (62.7 percent) with injectables following (33 percent). It was also found that when couples switched from one method to another they most likely switched from OCP to Norplant and injectables. The study was highly successful in increasing the uptake of modern FP methods to high-risk couples.
Systematic Review of Integration of Maternal, Neonatal and Child Health and Nutrition, Family Planning, and HIV
Kennedy, G., Kennedy, C., Lindegren, M., et al; for the GHTech Project (2011).
The paper presents the findings from a Cochrane systematic literature review of peer-reviewed and gray literature on the effectiveness of the integration of HIV/AIDS services with maternal, neonatal, and child health and nutrition services, including family planning (MNCHN/FP) services. The paper also describes factors that support or limit service integration as well as lessons that were learned from program experiences. The review includes 20 studies from the peer-reviewed literature as well as 14 reports from unpublished and non–peer-reviewed sources. They all were published between 1990 and 2010 and evaluated programs that integrated HIV/AIDS and MNCHN/FP services. It was found that integration is possible and successful. Women’s and children’s health outcomes improved with the integration of services as well as the quality of services. Interventions that provided community and staff support, resources to train and supervise staff, and were simple and inexpensive were shown to be successful. The authors noted that the research methods should be more rigorous, use biomarkers (e.g., HIV incidence), and measure sociocultural factors (e.g., stigma, gender) as well as cost.
The Cost-Effectiveness of Family Planning in Reducing the Number of Children with HIV Infection
Stover, J. International Conference on AIDS/STIs in Africa (ICASA), Addis Ababa, Ethiopia (2011).
The 12-slide presentation given at ICASA in 2011 demonstrates the cost-effectiveness of providing family planning to HIV-positive women. Overall expenditures can be reduced in prevention of mother-to-child-transmission, maternal and child health, and antiretroviral services if family planning programs are expanded.
Unmet Need for Contraception among HIV-positive Women in Lesotho and Implications for Mother-to-Child Transmission
Adair, T. Journal of Biosocial Science (2009), Vol. 41 No. 2, pp. 269–278.
Despite one of the highest HIV prevalence rates in the world—26.4 percent among women of reproductive age (WRA)—few WRA in Lesotho know their HIV status. Furthermore, only 35 percent of WRA are using contraception. As such, increased contraceptive use has considerable potential in reducing mother-to-child transmission (MTCT) of HIV in Lesotho. Data from the 2004 Lesotho Demographic and Health Survey indicate only 34 percent of women with HIV used contraception. Furthermore, nearly one-third of these women have an unmet need for contraception—that is, they do not want another child or want to wait two or more years to have a child, but are not using any contraceptive method. In addition to scaling up family planning (FP) services for all women in Lesotho, integrating FP services into prevention of MTCT (PMTCT) and voluntary counseling and testing programs can help all women achieve their fertility preferences while reducing the pediatric HIV burden.
Benefits and Costs of Expanding Access to Family Planning Programs to Women Living with HIV
Halperin, D. T., Stover, J.,& Reynolds, H. W. AIDS (2009), Vol. 23 Supplement 1, pp. S123-S130.
Preventing unwanted pregnancies is known to be an effective way of averting mother-to-child transmission (MTCT) of HIV. This study, funded by USAID, models the effects of providing contraception to all women of reproductive age (WRA) and the cost-effectiveness of this strategy in 14 countries with the highest HIV prevalence among WRA. It also models the aggregate effect for 139 countries worldwide. The annual cost per infant infection avoided by offering antiretroviral (ARV) drugs to all women living with HIV was estimated to be $543 for the 14 high prevalence countries ($609 was the estimated cost worldwide), whereas the cost of a birth averted, if all women who wanted contraceptives received them, was $61 ($63 worldwide) by comparison. The authors believe that it is critical for high prevalence countries to offer and promote family planning as a cost effective means of preventing MTCT. The article is one of 14 articles in the AIDS supplement devoted to family planning and women living with HIV.
Family Planning and HIV
Wilcher, R., Cates, W., & Gregson, S. (eds.). AIDS (2009), Vol. 23 Supplement 1, pp. S1-S130.
The article is the first of 14 in the AIDS 2009 supplement devoted to family planning and women living with HIV. The goal of the supplement is to address the key gaps in the literature. It provides an introduction to the supplement by giving an overview of the evidence and studies contained within it. The article starts with a history of the programmatic relationship between family planning and HIV services. It is stated that the two fields have supported integration of services for over 15 years but oftentimes funding streams made it challenging to successfully fulfill this goal. There has been an emergence of new evidence and policy support to better integrate services which has been followed by increased funding and programs. In the supplement, there are articles devoted to behavioral, biomedical, and programmatic research. The authors hope that the supplement will further the discussion, support, and actual implementation of joint family planning and HIV services.
The Contribution of Family Planning Towards the Prevention of Vertical HIV Transmission in Uganda
Hladik, W., Stover, J., Esiru, G., et al. PLoS One (2009) Vol. 4 No. 11, p. e7691.
Data on fertility, HIV infection, FP use, and MTCT of HIV were used to create projections on the pediatric HIV burden in Uganda. These mathematical estimates indicate that FP use—by virtue of preventing pregnancies among women living with HIV—is more effective in preventing pediatric HIV than antiretroviral therapy (ART) for PMTCT. Furthermore, the study finds that unwanted fertility is a significant contributor to pediatric HIV cases. These greater benefits of FP use remain true even if ART use was scaled-up to 80 percent among pregnant women. Thus, comprehensive strategies to reduce MTCT of HIV must include FP. The authors argue that FP should be integrated in PMTCT programs, HIV CT programs, and postnatal care for all women of reproductive age, regardless of HIV status.
Reproductive Intentions and Outcomes Among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study
Homsy, J., Bunnell, R., Moore, D., et al. PLoS ONE (2009) Vol. 4 No. 1, p. e4149.
In a cohort of rural Ugandan women receiving ART, sexual activity and incidence of pregnancy significantly increased during follow-up, yet more than 93 percent of the women repeatedly expressed not wanting or not planning to have more children. In addition, more than 86 percent of sexually active women not desiring children were not using any modern contraceptive method other than condoms after two years on ART. In conclusion, women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility and be regularly offered free and comprehensive FP services as part of their standard package of care.
Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations
WHO/HIV, UNFPA, IPPF-HIV, UNAIDS, & UCSF. (2009).
This report reviews 58 studies (peer-reviewed research and promising practices) documenting linkages between SRH and HIV services. Overall, findings indicate that integrated services improve behavioral, health, and societal outcomes. Results are disaggregated by type of clinic (antenatal, CT, HIV treatment, FP, primary health care, sexually transmitted infection [STI]), and factors that facilitate or impede effective integration are identified. The contributing authors provide recommendations for policymakers, program managers, and research evaluators to guide the implementation of integrated SRH and HIV service delivery.
Family Planning and Safer Sex Practices among HIV Infected Women Receiving Prevention of Mother-to-Child Transmission Services at Kitale District Hospital
Bij SC, Otieno-Nyunya B, Siika A, et al. East African Medical Journal (2008), Vol. 85, No. 1, pp. 46-50.
This descriptive cross-sectional study of 146 women in western Kenya assessed the usage of family planning services and safer sex practices among HIV-infected mothers who had received prevention of mother-to-child transmission (PMTCT) services. The women were recruited from an existing PMTCT program at Kitale District Hospital between April and July 2005, and asked to complete a structured questionnaire. It was found that less than half of the women used a modern family planning method (44 percent). Of the women who were using a modern family planning method, the hormonal injectable (15 percent) was the most popular followed by bilateral tubal ligation (13 percent) and oral contraceptive pills (11 percent). Those who were married were more likely to use a family planning method compared to single women. Married women were also more likely to use a condom during sexual intercourse compared to single and widowed/divorced/separated women. Women aged 20-34 years old also were more likely to use a condom compared to women who were older or younger. Women who disclosed their status to their partner were more likely to use condoms compared to those who did not. The majority of women in this study were no longer planning to have children (73 percent), yet about half of these women (55 percent) were not using any form of family planning. There was a high level of unmet need among this group of women. This study demonstrates that family planning programs need to be strengthened in PMTCT programs.
The Value of Contraception to Prevent Perinatal HIV Transmission
Reynolds, H. W., Janowitz, B., Homan, R., et al. Sexually Transmitted Diseases (2006) Vol. 33 No. 6, pp. 350–356.
This study estimates the costs and effectiveness of traditional, vertically delivered FP programs to prevent HIV-positive births. In a hypothetical cohort of 100,000 WRA in sub-Saharan Africa, contraception averted 33.1 HIV-positive births while a single dose of nevirapine for PMTCT averted 32.5 HIV-positive births. The estimated cost per HIV-positive birth averted was $663 for contraception and $857 for nevirapine. The assumptions used vary depending on contraceptive and HIV prevalence, service delivery costs, and other factors in a country. In general, increasing contraceptive use is a viable and cost-effective strategy in averting HIV-positive births. The authors conclude that HIV prevention programs would benefit from including increased FP as part of their strategy for PMTCT and should fund such efforts accordingly.
Hormonal Contraceptive Use and Female-to-Male HIV Transmission: A Systematic Review of the Epidemiologic Evidence
Polis, C.B., Phillips, S.J., & Curtis, K.M. AIDS (October 2012), e-publication ahead of print.
This systematic review examines epidemiological evidence of the effects of hormonal contraceptives (HC) on the risk of HIV transmission from an HIV-positive woman to an HIV-negative man. The authors reviewed 12 studies with both direct evidence on HC use and HIV transmission and indirect evidence based on such proxy measures for infectivity in women as genital shedding or plasma viral load. The review identified only one study with direct evidence that both oral contraceptive pills and injectable HCs raise HIV risk (although only the estimates for injectables are significant). The 11 studies that yielded indirect evidence were very heterogeneous in size and approach, using different methods and providing a wide range of largely inconclusive results. For example, evidence of association with genital viral shedding was inconsistent for oral contraceptives and limited for injectables. The authors strongly recommend that, given how little direct evidence is available, more research be conducted on different HCs to determine their impact on HIV transmission. They note that understanding the effect of HCs on HIV transmission is especially important to support programmatic efforts to expand contraceptive choice for women in developing countries while simultaneously promoting HIV prevention efforts.
Medical Eligibility Criteria for Contraceptive Use, Fourth Edition.
World Health Organization. (2009).
This guide, intended for policymakers, program managers, and the scientific community, provides evidence-based recommendations on whether an individual can safely use a contraceptive method. The 2008 update includes more detailed information on ARVs.
Strengthening Family Planning in a Large-Scale PEPFAR-Supported HIV Program
FHI 360 (September 2012).
This case study discusses the Zambia Prevention, Care and Treatment Partnership (ZPCT II), a five-year project funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) that integrates family planning (FP) into HIV clinical services to prevent vertical HIV transmission and reduce unintended pregnancies. Implemented by FHI 360 and several partners, ZPCT II works with the Zambian Ministry of Health to strengthen HIV clinical and prevention services at more than 380 health facilities in six provinces. At most of these sites, FP counseling is a core element of counseling and testing, prevention of mother-to-child transmission, and antiretroviral therapy services. For these and other activities—including community mobilization, provider training, and monitoring and evaluation—FP content and messages are tightly woven into service delivery. The result has been a sharp increase in client access to and use of FP; for example, the number of counseling and testing clients referred for FP rose from 75 to more than 2,500 after ZPCT II was launched. While ZPCT II has helped many women and couples living with HIV meet their contraceptive needs, time and budgetary constraints limit the project’s ability to offer more than basic FP counseling and support for clients. The case study concludes by predicting that ZPCT II, which is slated to end in 2014, will likely provide essential lessons learned on FP integration to other PEPFAR-funded HIV projects.
10 Essential Steps: How to Strengthen Family Planning and HIV Service Integration
Family Health International. (2010).
This one-page document outlines 10 steps to help develop and implement an integrated family planning and HIV program. The 10 steps are: 1) generate demand for integrated services, 2) organize services, 3) ensure commodity security, 4) train providers, 5) screen all clients from an unmet need for contraception, 6) foster dual protection and dual-method use, 7) challenge provider bias, 8) reinforce referral systems, 9) strengthen skills for supportive supervision, and 10) monitor and evaluate performance.
Integration of Family Planning into HIV Counseling and Testing, Prevention of Mother-to-Child Transmission, and Antiretroviral Therapy Services, Training Facilitator’s Guide
Pathfinder International. (2010).
Designed to train practicing HIV service providers in family planning (FP) counseling and service provision for FP/HIV integration, this new training resource includes a trainer’s guide, participant’s guide, presentations, and job aid. Participants trained with this manual will be able to implement effective FP counseling and services for HIV counseling and testing, preventing maternal-to-child transmission of HIV, and antiretroviral therapy clients.
Rapid Assessment Tool for Sexual & Reproductive Health Linkages: A Generic Guide
IPPF, UNFPA, WHO, et al. (2009).
The objective of this tool is to assess HIV and SRH linkages at the policy, systems, and service delivery levels. It may be used to identify gaps and to guide the development of country-specific action plans to forge and strengthen these linkages.
Family Planning Discussion Topics for Voluntary Counseling and Testing: A Reference Guide for FP Counseling of Individuals, Couples, and Special Groups by Trained VCT Counselors
Pathfinder International. (2009).
This job aid provides information to help providers of HIV CT integrate FP messages into their counseling sessions.
Assessing Integration Methodology: A Handbook for Measuring and Assessing the Integration of Family Planning and Other Reproductive Health Services
Population Council & the U.S. Agency for International Development (USAID). (2008).
This handbook offers methodological guidance on describing, measuring, or assessing the integration of FP with other facility-based health services, including those for HIV/AIDS.
Increasing Access to Contraception for Clients with HIV: A Toolkit
USAID, FHI, & ACQUIRE Project. (2008).
This toolkit provides in-depth training and performance support materials for trainers, providers, and program managers who want to provide FP services for their clients with HIV.
HIV and Family Planning Integration in Tanzania, Building on the PEPFAR Platform to Advance Global Health
Fleischman, Janet. Center for Strategic & International Studies (July 2012).
The report describes how Tanzania was able to integrate family planning and HIV services to improve the lives of women, girls, and ultimately, their families and communities. The President’s Emergency Plan for AIDS Relief (PEPFAR) as well as the United States Agency for International Development’s (USAID) Office of Population and Reproductive Health and other bilateral programs worked together to increase the access and availability of health services targeting women and adolescents. The authors note the successes and challenges of the program, and state that the approach could be replicated and scaled up in other countries.
Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised Recommendations for the Use of Hormonal Contraception Among Women at High Risk for HIV Infection or Infected with HIV
U.S. Centers for Disease Control and Prevention (June 2012).
These revised recommendations by the U.S. Centers for Disease Control and Prevention (CDC) affirm previous guidance stating that there is no definitive link between hormonal contraceptives and an increased link of HIV infection among women, and that all women who use contraceptive methods other than condoms should be counseled on condom use and prevention of sexually transmitted infections. This report follows a thorough review by the CDC of recent studies examining this link. The CDC concludes, as does the World Health Organization, that women at risk for HIV infection or HIV-positive women can continue to use all hormonal contraceptive methods without restriction. This revision does include a clarification for women at high risk for HIV infection who use progestin-only injectables about the inconclusive nature of the evidence regarding the association between use of these injectables and HIV acquisition. It also stresses the importance of condom use and other HIV prevention measures, outlines the various contraceptive methods, and recommends the use of a contraceptive method mix.
Hormonal Contraception and HIV: Technical Statement
World Health Organization. (2012).
WHO convened a meeting from January 31 to February 1, 2012, with 75 key stakeholders to review recent epidemiological evidence on the effects of hormonal contraception on HIV transmission and acquisition. One of the goals of the meeting was to determine if the Medical Eligibility Criteria for Contraceptive Use, Fourth Edition (2009) guidelines should be modified in light of the new evidence. It was found through the thorough review of existing evidence that WHO should continue to recommend that there be no restrictions on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, a clarification is added stating that women who use progestogen-only injectable contraception should also always use a male or female condom correctly because there is conflicting evidence on the increased risk of HIV acquisition. The paper also provides sections summarizing the evidence and listing recommendations based on that evidence.
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WHO note on the results of the technical guidance on hormonal contraception and HIV.
USAID Communication to the Field (February 21, 2012): WHO Expert Consultation Assessing Evidence on Hormonal Contraception and HIV
USAID’s message sent to all Missions regarding the technical guidance outcome on hormonal contraception and HIV.
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Global HIV/AIDS Response. Epidemic Update and Health Sector Progress Towards Universal Access. 2011 UNAIDS Progress Report.
Chapter 7.3 provides a global overview and update on preventing unintended pregnancies among women living with HIV.
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Implementation of Global Health Initiative: Consultation Document
The Obama administration wishes to strengthen global health around the world. In this 2012 document, goals on HIV/AIDS, malaria, tuberculosis, neglected tropical diseases, maternal and child health, family planning and reproductive health, and nutrition are outlined. The new model for the U.S. Government global health assistance program has dedicated $63 billion over six years, an unprecedented level. The implementation of the model began in 2010. One of its goals is to move from an emergency response to a sustainable, country-owned effort. An emphasis on having a woman- and girl-centered approach is a guiding principle. Other principles include increasing the impact through strategic coordination and integration; strengthening and leveraging key multilateral organizations, global health partnerships, and private sector engagement; encouraging country ownership and investing in country-led plans; building sustainability through health systems strengthening; improving metrics, monitoring, and evaluation; and promoting research and innovation. Criteria on how countries will be selected are listed, and up to 20 countries will be chosen by fiscal year 2014.
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The technical considerations document is to be used by the PEPFAR Technical Working Groups for program planning purposes. It is not to be used as policy guidance or required criteria for programs. For family planning (FP) and contraceptive use, PEPFAR is highly supportive of providing integrated FP and HIV services. “What’s New for 2012” calls for an increased focus on integration, specifically integrating family planning services into HIV and maternal, neonatal, and child health programs. In addition, there are sections on integration of maternal child health and family planning, family planning and safer pregnancy counseling, prevention for people living with HIV, preventing mother-to-child transmission, and HIV-free survival.
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What Will it Take to Achieve Virtual Elimination of Mother-to-child Transmission of HIV? An Assessment of Current Progress and Future Needs
Mahy, M., Stover, J., Kiragu, K., et al. Sexually Transmitted Infections (2010), Vol. 86, pp. ii48-ii55.
The paper describes five different preventing mother-to-child transmission (PMTCT) scenarios to estimate their results in the reduction of infant infections from 2010 to 2015. The World Health Organization’s (WHO’s) goal for its new PMTCT guidelines is to virtually eliminate mother-to-child transmission, which is defined as less than 5 percent transmission of HIV from mother to child or 90 percent reduction of infections among young children by 2015. Data was used from 25 countries with the largest number of HIV-positive pregnant women. Two software packages, Estimation and Projection Package (EPP) and Spectrum, were used to compute the results. The five scenarios were: 1) no PMTCT services; 2) WHO’s 2009 recommendations are implemented through 2015; 3) in 2010, women currently on antiretrovirals (ARVs) were switched to the 2010 WHO recommended regime of starting ARVs at 14 weeks or earlier and continuing throughout breastfeeding; 4) included data from number 3 plus ensured that incidence was reduced by half for women of reproductive age and met all unmet need for family planning; 5) in addition to number 4, the average length of time for breastfeeding was reduced to one year. It was found that even in the best scenario (scenario number 5) that new child infections would be reduced by 79 percent among the 25 countries. Thus, although the reductions shown in some of the scenarios are positive, the 90 percent reduction in new child infections will be challenging to achieve. Enormous gains have been made in the last 10 years of PMTCT, but huge strides must be made if new pediatric infections are to be eliminated by 2015.
The Case for Integrating Family Planning and HIV/AIDS Services: Evidence, Policy Support, and Programmatic Experience
Family Health International. (2010).
Eight short policy briefs summarize the current state of integration between the family planning (FP) and HIV/AIDS fields. The briefs highlight recent developments in FP/HIV integration, including changes in the policy environment, new programmatic examples, and the latest operations research results. Some briefs include links to additional key tools and resources.
Making the Case for Interventions Linking Sexual and Reproductive Health and HIV in Proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria
World Health Organization. (2010).
This report provides the rationale for seven different interventions to HIV programming that can make good programs better through a holistic approach to HIV. Among these interventions is “PMTCT-Plus,” which includes integrating family planning into services to prevent mother-to-child transmission of HIV.
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A Practical Guide to Integrating Reproductive Health and HIV/AIDS into Grant Proposals to the Global Fund
Hardee, K., Gay, J., & Dunn-Georgiou, E. (2009).
This document provides help to countries and organizations in integrating reproductive health, including family planning and HIV/AIDS, in proposals submitted to the Global Fund. Grounded in the research, programmatic, and policy literature on linkages and integration, this document addresses the following: 1) What is integration?; 2) Given a country’s context, what policies and programs could be linked and integrated?; 3) What are the implementation challenges to integration to be aware of when writing a proposal?; and 4) How can integration be monitored and evaluated? In addition to providing evidence that integration makes a difference to HIV/AIDS outcomes, it also provides examples from country programs and the integration components of successful Round 8 proposals.
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World Health Organization, USAID, and Family Health International. (2009).
This document is designed to help program planners, implementers, and managers, including government officials and other country-level stakeholders, make appropriate decisions about whether to pursue the integration of family planning and HIV services. It also explains how to approach integration in a strategic and systematic manner in order to achieve maximum public health benefit. Links are given to resources that will support implementation, such as facility assessment tools, training curricula, and job aids.
Resources for HIV/AIDS and Sexual and Reproductive Health Integration
Johns Hopkins University-Center for Communication Programs. (2010).
A selected collection of documents and other materials that reflect field experience and the latest thinking of the health community on the integration of HIV and sexual and reproductive health services.
Strategic Approaches to the Prevention of HIV Infection in Infants
World Health Organization. (2003).
The report is based on a WHO meeting convened in March 2002 in Morges, Switzerland, to discuss the optimal approach to prevent HIV infection in infants. The goal of the United Nations General Assembly Special Session on HIV/AIDS was to reduce the proportion of infants infected by HIV by 20 percent by 2005 and by 50 percent by 2010. The approach decided upon during the meeting includes four pillars: 1) improving primary prevention to reduce overall HIV infection rates; 2) strengthening the prevention of unintended pregnancies among HIV-infected women; 3) improving the prevention of HIV transmission from HIV-infected women to their children; and 4) increasing care to HIV-infected mothers and their infants.
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