Integration of Family Planning in PEPFAR-Supported PMTCT and Treatment Programs

ART in Pregnancy, Breastfeeding and Beyond Workshop South Africa, June 18-20

Milly Kayongo - USAID- GHB; Office o f HIV/AIDSAndrew Abutu -CDC Division of Global HIV & AIDS

Presentation Outline

USG Policy and Guidance for Integration Global Health InitiativePEPFAR Integration Guidelines 2011-

2012Global Plan towards Elimination of MTCT

Research and Scientific Updates on FP/HIV

Integration Models and Case Studies

Program Considerations for FP/HIV integration

PMTCT: FP is Prevention

Family planning and effective use of contraceptives

FP- HIV Linkages Bolster Prevention

• Pregnant women are at an approximately 2-fold increased biological risk of acquiring HIV (Gray, Kigozi et al Lancet. 2005 Oct ).

Due to high total fertility rate in sub-Saharan Africa, a high proportion of new infections in women occur in pregnancy.

Partner discordance rates -documented to be high (up to 50%) among HIV infected persons.

• Couple counseling and involving male partners in MNCH service delivery to reduce risk– Partner testing – Treatment of the Infected Partner and referral of the negative man to

VMMC, – Counseling both partners on mutual fidelity– Other PLHIV/prevention with positives (PWP) interventions

FP- HIV Linkages cont’d

Women with HIV, like all women, have right to determine number and spacing of children

Women with HIV have unmet need for contraception.

Expand access to contraception Prevent unintended pregnancy Improves quality of life -

PLWHA

Research on FP and PMTCT

Benefits and costs of expanding access to family planning programs to women living

with HIV– FP is cost-effective in reducing number of HIV+ births– Cost is $61 per birth averted in 14 PEPFAR countriesHalperin DT, Stover J, Reynolds HW. AIDS 2009, 23 (suppl 1):S123-

S130

Contribution of Family Planning towards Prevention of Vertical HIV Transmission in Uganda

– Expanding FP services can substantially contribute towards PMTCTHladik W, Stover J, Esiru G, Harper, M, Tappero J (2009) PLoS One

4(11): e7691. doi:10.1371/journal.pone.0007691

Global Plan towards Elimination of MTCT

• PEPFAR support for Global Plans for Elimination of MTCT 14 countries implementing PMTCT

acceleration plans

• Many acceleration countries have incorporated PMTCT Prong 2 to plan

* Ref: Countdown to zero. Global plan for the elimination of new HIV infections among children by 2015 and

keeping their mothers alive. UNAIDS, 2011.

Overall Targets: 1.Reduce the number of new paediatric HIV infections by 90%2.Reduce the number of AIDS-related maternal deaths by 50%. *3.Reduce population-level MTCT rate to <5%

What will it take? A comprehensive

approachMahy et al. Sex Transm Infect 2010

FY2011 PEPFAR Technical Considerations

Integration central to PEPFAR goals on Prevention, PMTCT ,Care and Treatment

Harmonize HIV/PMTCT with RH/FP and MNCH services

Specific Language :PMTCT/PwP section of Guidance

o Minimizing unintended pregnancies (Prong 2) is a key component of strategy to eliminate new pediatric infections.

o Efforts should support the availability of FP services to all women who desire them; includes training FP providers on integrated FP-HIV care

o Programs should explicitly explore opportunities for- integration of FP and HIV services including PMTCT Treatment and Care

FP and safe pregnancy counseling key component of PLHIV package of care.

Who funds what?

U.S. funding through PEPFAR, and Reproductive Health and/or MNCH programs can pay for various components within context of appropriate legislative and policy guidelines and requirements.

Examples of integrated program models: Pooled procurement instruments- APHIA

Kenya Program coordination to ensure service

delivery in similar geographic sites; e.g. Malawi, Tanzania

Development of MoU between USAID-PRH and PEPFAR programs to coordinate and support RH/FP-e.g Uganda and MSI

PEPFAR Funds will not be used to purchase contraceptive commodities

Multilateral partners and donors; --Global Fund (GFATM) UNFPA, UNICEF, partner country governments, and the private sector

HC-HIV research update:

Heffron Study

Prospective studies of injectables & HIV acquisition

* Unadjusted estimate, ₴ May contain DMPA and Net-EN

Mostly injectable, some OC

Mostly injectable, some OC

Limitations Of Heffron 2011 Small sample sizes, few HC users, limited power Exposure measurement High and possibly differential attrition rates Generalizability Self-reported information on sensitive sexual

behaviors Self-selection into HC use affects risk of HIV exposure

HC users may have higher coital frequency and lower condom use; thus greater exposure to HIV due to behavioral differences

HC users often compared to “non-users”; definition of “non-users” varies, often includes condom-contraceptors

Unmeasured confounding Condom use, HIV status of partners, differences in type/frequency of

sexual activity

Conclusion of WHO HC-HIV consultation

o All hormonal methods remain Medical Eligibility Criteria

(MEC )Category 1 (no restrictions)

o Clarification added for injectables for women at high risk of HIV (see statement for

full text)

o In part: “women using progestogen-only injectable

contraception should be strongly advised to also always use condoms, male or female,

and other HIV preventive measures”

FP/HIV promising practice: Malawi Lighthouse clinic 2011

Center of Excellence in Integrated Continuum of HIV prevention, Treatment Care and Support

Integrated HIV and FP programs ART in PMTCT settings and linkage to Treatment

Preliminary Results- Over 95% ART uptake in Pregnancy

- Increased FP uptake across MCH & Treatment

- Condoms routinely given to all women and men

- 247 (57%) injectables

- 144 (31%) IUCD

- 59 (13%) Pills

17 (3%) Implants Lessons learned:

HIV/FP (Including LARC) can be integrated Clients are interested in integrated services

FP/HIV promising practices: Kenya

Partners HSV/HIV Transmission Study 213 HIV Discordant Couples Multipronged contraceptive

intervention• Staff training• Couples FP counseling• Free hormonal contraception on-site

Non-barrier contraception( Excludes Condoms):

• HIV-positive – from 32% to 65%• HIV-negative – from 29% to 47%

Other Kenyan sites – minimal change

Service Delivery- Entry points for Integration

• Opportunities for FP integration at PMTCT sites– Opportunity for counseling in ANC, Immunization– High unmet need for FP in post partum period– Reach sero- discordant couples; increasing male participation– FP information to WRA that are sexually active, known HIV status

• Opportunities at HIV treatment and care/support sites– Reach HIV positive clients- prevent unintended pregnancies and

contribute to PMTCT– Regular repeat visits for drugs and resupply - follow up on side

effects/complications of ART and fertility intention/contraceptive need– Linkages with community support enhances adherence /nutritional

counseling for ART and FP follow up– Less stigma and discrimination

FP-HIV integration: Service Delivery considerations

What model suitable for your setting? no “one-size” fits all

To what extent should services be integrated?o Human resource capacity o Physical set-up of facilityo Strength and organization of existing serviceso Client flow and volume; Availability of financial resources

What information is needed to measure progress ?o Indicators for routine monitoring and evaluationo M & E systemso Opportunities for rigorous operations research and special

studies Indicators related to FP (draft)- London MTG/ proposed with IATT

o Proportion of PMTCT clients screened for FP, Proportion of PMTCT sites/ HIV service delivery points with FP services etc..

o Reducing Unmet Need; Proportion of Demand satisfied with contraceptive use

Discussion in Small groups on DAY 3

Q& A

Discussion:• Policy

– What are the policy/ funding support for integration in your country?– Do you have a national RH/HIV TWG? Who are the key stakeholders in

your country for FP/RH support- do you have USAID PRH office, Other key partners?

– What are key facilitating/ inhibiting factors for integration?

• Systems– What are key systems barriers/ constraints in your context for

integration- Planning and administration, HRH, logistics , M & E, etc – What can PEPFAR do to address these barriers? What is required

• Service Delivery– What are some of the specific entry points along both the life cycle and

service delivery points that present opportunities for integration– Where are the challenges?– How can Integration between PMTCT and ART – structure(program

management and service delivery)be strengthened?