Contraception to Prevent Unplanned Pregnancies among Women with HIV

Introduction

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:

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.

What we know

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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 Upholds Guidance on Hormonal Contraceptive Use and HIV

World Health Organization. (2012).

WHO note on the results of the technical guidance on hormonal contraception and HIV.

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USAID Communication to the Field (February 21, 2012): WHO Expert Consultation Assessing Evidence on Hormonal Contraception and HIV

USAID. (2012). 

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.

UNAIDS. (2011).

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

GHI/USAID. (2012).

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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PEPFAR Country Operation Plans FY 2012 Technical Considerations

PEPFAR. (2011).

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.

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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.

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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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Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs, and Services

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.

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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.

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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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