Hi, my name is Jason Smith and I am a Deputy Director of the MEASURE Evaluation project at the University of North Carolina at Chapel Hill and today I’m going to talk about translating contraception into practice in the era of HIV/AIDS.
I don’t have any conflicts of interest to disclose.
The United Nations International Conference on Human Rights, held in Tehran in 1968, declared (Article 16): &quot;Parents have a basic human right to determine freely and responsibly the number and spacing of their children.&quot; All of the other conferences & conventions on this slide reinforced the same or a similar notion. We have the technology and the knowledge to prevent unintended pregnancies. The methods are safe, inexpensive and relatively easy to use. From a social justice point of view, giving women and their families the ability to control the number and spacing of their pregnancies, provides them with a meaningful way to control a major component of their lives. We can do it and we should it, because it’s the right thing to do. ---------------------------------------------------------------------------------------------
As part of the public health imperative, family planning can help address many of the most pressing global health issues, such as those articulated by the Millennium Development Goals. In truth, family planning contributes to the advancement of all of Millennium Development Goals, but in the interest of time, today we will focus on how it impacts goal 5 (maternal health) and goal 6 (HIV, malaria and other diseases). ----------------------------------------------------------------------------
Taking family planning first, there are an estimated 200 million women worldwide, who do not want to become pregnant, and who do not use contraception. Furthermore, UNFPA estimates that unmet need for contraception will grow by 40% in the next 15 years. This chart shows level of contraceptive use by level of development. From a social justice perspective, it’s worth noting that the world’s poorest countries also have the lowest levels of contraceptive use.
Research in the area of international family planning has been ongoing, in earnest, for almost a half century. However, in the earlier years of population research, the results of research efforts were often siloed and otherwise poorly disseminated. As a consequence, the scientific evidence was not always used as a basis for policy or intervention design. In the last decade or so however, there has been a trend in the area of family planning to use the principles of social and behavioral science to improve the dissemination of research results and to actively facilitate the use of scientific evidence to improve policy and program development. The meetings and mechanisms shown on this slide are only a few selected examples of recent efforts to review the scientific evidence, improve global agreement about what should be done, and facilitate the use of evidence-based practice in developing family planning policy and service delivery programs. -------------------------------------------------------------------------------------
For this talk I tried to distill a manageable list of best practices that are ready to be deployed now from the many candidate practices available in the literature. Improving contraceptive security means making sure that adequate supplies of contraceptives are purchased and that supply chains are established to ensure reliable stocks at the service delivery level. Increasing the range of methods has been linked to increasing contraceptive prevalence. In addition, from a social justice viewpoint, increased method choice is a part of increased autonomy for end users. Increasing the emphasis on long acting methods is related to increasing the range of available methods but it is also related to improving financial availability through lowering system costs, and to reducing harm to individuals that can occur in the case of method failure. Screening women who present at primary care service sites to assess their family planning need is not only a way to improve system efficiency, but also a way to provide more wholistic care for the women who come into contact with the health system. Providing post-partum and post abortion family planning is another way to take advantage of contact with the health system and, behaviorally, it’s also a way to take advantage of a teachable moment to talk to women about their contraceptive plans. Strengthening services in the community is often the only viable way to reach remote and/or medically underserved populations. While not all contraceptives can be safely provided by community health workers, many, like pills, condoms, injectables, the standard days method, and the lactational amenorrhea method, can be. Training and supporting community health workers, including drug shop owners, can help to improve coverage in isolated areas,
Okay so now we’re going to shift to the topic of HIV for a bit. Family planning and HIV prevention seem like they should have a lot in common but, in practice, there has really been less overlap than one might imagine. Historically, the two fields have been siloed, with separate funding streams, government departments, programs, and policies. However, in recent years there has been a growing call for integration of family planning and HIV programs. Major donors such as PEPFAR and the Global Fund have begun to support integration of services, something that will likely spur others to continue the trend.
This map gives us a quick look at the HIV epidemic. At the end of 2008 there were an estimated 33 million people living with HIV, and about 2 million of those were children. More than 90% of newly infected children are babies born to women with HIV , who acquire the virus during pregnancy, labor or delivery, or through their mother's breast milk. Over nine-tenths of such transmissions occur in sub-Saharan Africa. Drawing in the social justice theme again, it’s also worth noting that many of the poorest countries and countries with low levels of met need for contraception are also countries experiencing serious HIV epidemics. ---------------------------------------------------------------------------------
Between pregnancy, birth, and breastfeeding, infants born to HIV+ mothers have a raw 30-40% chance of being infected with HIV. Prevention programs utilizing antiretroviral drugs have been able to cut that risk to between 2-5%. However, fewer than half of HIV+ women in low and middle income countries currently have access to these programs. So, preventing unintentional pregnancies from occurring in the first place reduces transmission, especially in low-resource settings and where treatment options are scarce. At least hypothetically, integrated services should help more HIV+ women prevent unintended pregnancies and also help pregnant women discover their HIV status thereby improving their access to appropriate treatment. Making both services available in one location is more convenient for clients and therefore more likely to be used
Integration plans should consider the type of epidemic as well as the level of available resources. &quot;In countries with a generalized epidemic, where a large proportion of the total population is infected but the vast majority do not know their sero-status, increasing access to family planning for everybody is an important strategy for reducing unintended pregnancies among women with HIV.&quot; By contrast, in concentrated epidemics, resources can be conserved by focusing efforts primarily on individuals in most at-risk groups.
Integrating HIV services into family planning service sites can be especially useful in generalized epidemics, because it offers a chance to provide HIV services to a larger number of clients. Implications for integration include: Training family planning workers to perform HIV testing and counseling Offering treatment programs Ensuring a secure supply of necessary commodities like testing kits and anti-retrovirals at the family planning sites and Structural improvements like: Supportive supervision for integrated services Modifying monitoring and evaluation systems to capture integration-related data, and Strengthening referral systems Possible benefits of offering HIV services to family planning clients include: Increased opportunities to test sexually active people Increased overall use of HIV treatment and Ability to reach HIV+ individuals who would not otherwise consider using family planning services. ----------------------------------------------------
Integrating family planning services into HIV service delivery sites is a better fit for concentrated epidemics, because it provides a way to target the most at-risk individuals. However, it may also be used as an adjunctive approach in generalized epidemics to maximize coverage. Integration can occur by training HIV service providers to counsel and refer clients on family planning methods, and, if possible, to actually provide contraceptives. In addition to training, providing family planning also requires ensuring a secure supply of contraceptives in the HIV clinic. Again, other structural improvements like supportive supervision, adaptation of monitoring and evaluation systems and strengthening of referral systems are likely to be necessary. The benefits of this approach include: Helping HIV+ women to prevent unintended pregnancies Opportunities to provide men with family planning information and services Resupply and message reinforcement for repeat clients and Greater client comfort due to less fear of disclosing sero-status
During the last few years great progress has been made towards articulating the logical case for integration gathering the collective experience with integrated programs, and synthesizing the what we know into knowledge translation products for various audiences. These three products in particular : The AIDS Journal supplement on Family Planning and HIV The joint WHO, USAID, FHI document on Strategic Considerations for Strengthening Family Planning and HIV/AIDS Policies, Programs and Services and The joint WHO, EngenderHealth, FHI Toolkit for Increasing Access to Contraception for Clients with HIV, are all high quality sources containing state of the art information on the topic of integration.
Breastfeeding has implications for vertical HIV transmission, as well as family planning, and should be included in any integrated program. Breastfeeding protects against early childhood mortality. Unfortunately, it is also a major contributor to HIV transmission, and causes somewhere between 30-60% of all vertical transmission cases. Naively, it might seem logical to assume that HIV+ mothers should not breastfeed. However, in many developing country settings, other infant feeding methods pose serious risks to the infant as well. Providing antiretroviral treatment for either breastfeeding mothers or infants can slash infant HIV infection rates to less than 5%. However, at present treatment is not universally available, despite global scale-up efforts. So what to do?
The most recent WHO Guidelines on HIV and Infant Feeding based on the best scientific evidence available, were released earlier this year, and they address this exact question. There is no one simple answer, but in a nutshell the recommendations hinge on two factors: the availability of antiretroviral treatment, and the safety of replacement feeding. (using a pointer may be helpful to guide the audience to the right block) (yes, yes) If replacement feeding is safe and anti-retroviral treatment is available, the WHO defers to national and sub-national authorities to decide what recommendations to make to their HIV+ mothers. (yes, no) If replacement feeding is safe and anti-retroviral treatment is not available, then WHO recommends exclusive replacement feeding as the safest method of infant feeding. (no, yes and no, no) If conditions are not safe for replacement feeding, then the new guidelines recommend that all mothers should exclusively breastfeed for the first six months, regardless of anti-retroviral treatment availability. Exclusivity is key here - during the first six months, mixed feeding increases the risk of HIV transmission. After six months, complementary foods can be introduced with breastfeeding continuing until the end of the 1 st year.
Breastfeeding itself is a natural and highly effective method of contraception. The Lactational Amenorrhea Method, or LAM for short, which consists of exclusive, on-demand, around the clock, breastfeeding for the first 6 months, can be as effective at preventing pregnancy as combined oral contraceptive pills (98%). This method provides ideal benefits for both the infant and the mother. However, it is a labor-intensive method that may be especially difficult for women who work outside of the home. Many breastfeeding women will choose to supplement the contraceptive effect of breastfeeding with another method. In general, breast feeding women should avoid estrogen-based methods, since they can interfere with milk production. However, progesterone-only and non-hormonal methods are safe for use. Progesterone-only methods can be started six weeks after birth, and may include the progestogen-only pill, implants such as Implanon and the Sino-implant, and progestin-only injectables like Depo-Provera. Non-hormonal methods include male and female condoms, spermicidal gels and foams, copper IUDs, the standard days method, or permanent sterilization methods.
Family planning, by itself, is important from a social justice perspective and as part of the public health imperative. We have the methods and we know what to do. Family planning is an important , though sometimes underappreciated, tool in preventing vertical HIV transmission. There is still a lot we don’t know about integrated programs, but what we do know has been recently consolidated so that programs can go forward, now, with the best advice we have to give them. Looking to the future, more work needs to be done to evaluate integration’s effectiveness and efficiency compared to separate programs, as well as its feasibility in different settings. Breastfeeding, Family Planning and HIV are all intertwined. We know how to deliver family planning for breastfeeding women. The latest guidance from WHO on breastfeeding for HIV+ women and women with unknown status helps to clarify what to do, adjusting for local safety of replacement feeding and availability of anti-retroviral therapy.
Lastly, I just want to make sure that it’s clear that the opinions expressed in this presentation are those of the authors alone and do not necessarily reflect the views of the United States Government or the World Health Organization. That said, I would like to thank The US Agency for International Development and the World Health Organization for their support.
Translating Contraception into Practice in the Era of HIV/AIDS
Translating Contraception into Practice in the Era of HIV/AIDS Jason B. Smith University of North Carolina at Chapel Hill and Rose Wilcher Family Health International
Presenter Disclosures <ul><li>Jason B. Smith </li></ul><ul><li>I have no conflicts of interest to disclose </li></ul>
Family Planning & Social Justice <ul><li>UN International Conference on Human Rights, Tehran, 1968 </li></ul><ul><li>World Population Conference, Bucharest, 1974 </li></ul><ul><li>Convention on the Elimination of All Forms of Discrimination Against Women, New York, 1979 </li></ul><ul><li>International Conference on Population, Mexico City, 1984 </li></ul><ul><li>International Conference on Population and Development, Cairo, 1994 </li></ul>
Family Planning and the Public Health Imperative
Use of Modern Contraception Worldwide Percent of Married Women 15 to 49 Using Modern Methods Note: More developed regions include Australia, New Zealand, Europe, North America, and Japan. Less developed regions include Africa, Asia (excluding Japan), and Latin America and the Caribbean; the UN designates 49 countries within these regions as least developed. Source: Population Reference Bureau, 2009 World Population Data Sheet . From Population Reference Bureau Graphics Bank 2010
Best Practices in Family Planning <ul><li>WHO Medical Eligibility Criteria and Selected Practice Recommendations </li></ul><ul><li>Cochrane Collaboration Systematic Reviews </li></ul><ul><li>Implementing Best Practices Consortium </li></ul><ul><li>Various Best Practice Compendia (e.g., Advance Africa) </li></ul><ul><li>Kampala Family Planning Conference recommendations (2009) </li></ul>
Taking FP to Scale Now: <ul><li>Improve contraceptive security </li></ul><ul><li>Provide a wider range of methods </li></ul><ul><li>Emphasize long acting methods </li></ul><ul><li>Screen women attending primary care services for family planning need </li></ul><ul><li>Provide counseling and methods immediately post-partum and post-abortion at the service delivery site </li></ul><ul><li>Strengthen communications, outreach and services in the community </li></ul>
Integrating FP and HIV Services <ul><li>Prevent unintended pregnancies in HIV+ women. </li></ul><ul><ul><li>Reduce spread of HIV through vertical transmission </li></ul></ul><ul><ul><li>Reduce number of orphaned children </li></ul></ul><ul><ul><li>Protect the reproductive rights of HIV+ women </li></ul></ul><ul><li>How? </li></ul><ul><ul><li>Increasing use of both services </li></ul></ul><ul><ul><li>Joint programs can more completely and efficiently meet the public’s needs </li></ul></ul>HIV services Family planning
Integrating FP and HIV Services <ul><li>How to integrate? </li></ul> Generalized Concentrated
<ul><li>How? </li></ul><ul><li>Train and equip FP workers to perform HIV testing & counseling </li></ul><ul><li>If possible, provide HIV treatment services (ART, PMTCT) </li></ul><ul><li>Provide commodities </li></ul><ul><li>Structural improvements (supervision, M&E, referral) </li></ul><ul><li>Benefits </li></ul><ul><li>Provides opportunities for HIV testing with sexually active women and men </li></ul><ul><li>May increase use of HIV treatment </li></ul><ul><li>Can attract HIV+ clients who would not otherwise seek out FP services </li></ul>HIV services Family planning sites
<ul><li>How? </li></ul><ul><li>Train HIV service providers to counsel & refer on FP methods </li></ul><ul><li>Provide commodities </li></ul><ul><li>Structural Improvements (supervision, M&E, referral) </li></ul><ul><li>Benefits </li></ul><ul><li>Prevent unplanned pregnancies in HIV+ women </li></ul><ul><li>Opportunities to provide men with FP services/information </li></ul><ul><li>Repeat visits = opportunity for resupply and reinforcement </li></ul><ul><li>Less stigma than at FP centers </li></ul>Family planning services HIV service sites
Infant feeding and HIV: WHO Guidelines Is replacement feeding safe and supported? Is ARV treatment available? Yes No Yes Depends on national guidelines and local conditions Exclusive replacement feeding No Exclusive breastfeeding for 6 months, followed by 6 months of mixed feeding Exclusive breastfeeding for 6 months, followed by 6 months of mixed feeding
Breastfeeding & Family Planning <ul><li>Lactational Amenorrhea Method (LAM) </li></ul><ul><li>Safe methods for breastfeeding women </li></ul><ul><ul><li>Hormonal: Progesterone ONLY </li></ul></ul><ul><ul><li>Non-hormonal </li></ul></ul>
This presentation is based on work done by MEASURE Evaluation and Family Health International with support from the U.S. Agency for International Development (USAID) and the World Health Organization (WHO). Views expressed in this presentation do not necessarily reflect the views of the United States government, USAID or WHO.