HIV Prevention Knowledge Base
Biomedical Interventions: Contraception to Prevent Unplanned Pregnancies among Women with HIV
Impact of Integrated Family Planning and HIV Care Services on Contraceptive Use and Pregnancy Outcomes: A Retrospective Cohort Study
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
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
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
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
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
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
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
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
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
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
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
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
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.