SRH/HIV Linkages: What’s The Rationale? Ward Cates, MD, MPH Family Health International World Bank...
-
Upload
tabitha-leonard -
Category
Documents
-
view
214 -
download
1
Transcript of SRH/HIV Linkages: What’s The Rationale? Ward Cates, MD, MPH Family Health International World Bank...
SRH/HIV Linkages:What’s The Rationale?
Ward Cates, MD, MPHFamily Health International
World BankWashington, DC
November 19, 2008
Protect Women’s Health
• Family planning:
– Delays first births
– Lengthens birth intervals
– Reduces the total number of children born to one woman
– Prevents high-risk and unintended pregnancies
– Reduces the need for unsafe abortion
Source: USAID
Protect Women’s Rights
• All women have the right:
– “To decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.”
Source: Convention on the Elimination of All Discrimination against Women
Contraception is HIV Prevention
• Contraception as HIV prevention: evidence of individual-level efficacy and effectiveness
• Family planning/HIV integration: evidence of population-level effectiveness
• Considerations for scale-up
Contraceptive Pregnancy RatesContraceptive Pregnancy Rates
Oral Contraceptives
Source: Trussell (2004); NCHS (2005)
Percent of Women Pregnant in First Year of Use
Rate during typical use
Rate during perfect use
Female/male sterilization
Norplant/Depo-Provera
Spermicides
Diaphragm w/spermicides
Male condom
IUD (TCu-380A)
0 10 15 20 255
Female condom
Four-component Strategy for Perinatal HIV Prevention
Prevention of HIV in women, especially young women
Prevention of unintended pregnancies in HIV-infected women
Prevention of transmission from an HIV-infected woman to her infant
Support for mother and family
Component 1 Component 2 Component 3 Component 4
Pregnancies are Often Unintended or Unwanted
Source: DHS and other surveys
0%10%20%30%40%50%60%70%80%90%
100%
Niger
ia
Moza
mbiq
ue
Tanza
nia
Vietn
am
Côte d
'Ivoire
Rwanda
Ethio
pia
Uganda
Zambia
Kenya
Namib
ia
South A
frica
Haiti
Botswan
a
% births unintended % births unwanted
28%
13%
Women with HIV Also Have Unintended Pregnancies
• 84% unintended pregnancies among PMTCT clients in South Africa
• 74% unintended pregnancies among women in an ART program in Rwanda
• 85% of women in Malawi who learned their HIV+ status reported desiring no more children
Sources: Rochat et al., JAMA 2006:295:1376-8; Bangendanye, et al., presented November 2007; Hoffman, et al. JAIDS 2008;47:477-83
• DHS surveys – basis for estimates
• 15% of women in SSA using effective contraception
• 7.8 M unintended births averted by contraception
• Average HIV prevalence in SSA women 7.4%
Effect of Current Contraceptive Use by HIV+ Women – Assumptions
800
700
600
500
400
300
200
1000
Contraception as HIV Prevention –Compared to ARVs
# unintended births prevented
ARVs(cumulative over 3 years)
# infants spared HIV infection
157
Effective Contraception(over 1 year)
735
# o
f in
fan
ts/b
irth
s, i
n 1
000s
220
Sources: PEPFAR (2008), Reynolds (in press)
Contraception – The BEST KEPT SECRET in HIV Prevention
Effective contraception for HIV-infected women who do not wish to become pregnant
• Prevents more infants becoming infected than ART
• Decreases the number of future orphans
From Contraception Efficacy to Family Planning/HIV Effectiveness
• FP/HIV integration – the key strategy to reducing unintended pregnancies among HIV+ women
• Crucial questions – what are the opportunities and challenges to translating efficacy into effectiveness?
FP/HIV Integration: Opportunities and Challenges
• International level – policies and funding trends
• Country level – Ministry of Health structures and other coordinating bodies
• Service delivery level – operationalizing SRH and HIV linkages
International Level Opportunities
• FP/HIV integration supports the reproductive rights of HIV+ women
• Increasing international policy support for stronger RH/HIV linkages– Glion Call to Action – New York Call to Commitment– Maputo Plan of Action
Appropriations for the Global HIV/AIDS Initiative and International
Family Planning 2004 - 2009
0500
100015002000250030003500400045005000
2004 2005 2006 2007 2008 2009
GHAI
Fam Pln
$ A
pp
rop
ria
ted
in (
X0
00)
Country Level Opportunities
• Emerging policy support– Strategy for the Integration of FP and VCT Services
(Kenya)– High priority FP strategies (Mozambique, Rwanda)
• Country-specific technical working groups on RH/HIV integration
• Increasing number of integrated RH/HIV bilateral programs– Kenya and Rwanda
Service Delivery Opportunities
• Unmet need for FP and high levels of unintended pregnancy among clients of HIV services is well documented
• Integrated services are acceptable to HIV providers and clients
• Integrated services do not appear to negatively affect the quality of the basic service – whether VCT, PMTCT, etc.
Long-standing inadequacies lead to new opportunities for improved health care
The Interface Between HIV Programs and Health Systems
An organizational culture of service fragmentation
Inadequacies OpportunitiesIntegrated services in concept and in practice
“The medicines [contraceptives] that we use are in this room. They can’t be put in another room [the
HIV care and treatment room].”
Key Linkages
Learn HIV status
Promote safer sex
Optimize connection between HIV/AIDS and STI services
Integrate HIV/AIDS with maternal and
infant health
HIV/AIDS
• Prevention
• Treatment
• Care
• Support
SRH and HIV: Key LinkagesSRH and HIV: Key Linkages
SRH• Family Planning
• Maternal & infant care
• Management of sexually transmitted infections
• Management of other SRH
problems
Source: WHO/UNAIDS, IPPF/UNFPA (2005)
Conclusions
• Comprehensive MCH programs are needed to reach UNGASS goals for perinatal HIV
• Decreases in unintended pregnancies to HIV+ women will prevent a similar number of HIV+ births as current ARV programs
• Contraception is the “best-kept secret” in HIV prevention
• We have a unique opportunity to leverage HIV resources