AIDS Policy: Integrating HIV Prevention Services for Women
April 7, 2008
During his recent Africa tour, President Bush rightly highlighted the significant results of his HIV/AIDS strategy, but indicated that he would be willing to “change the tactics” if the strategy was not working. Despite impressive gains, there is an important area where U.S. AIDS policy is lacking: prevention of HIV infection for women. Curbing the epidemic requires expanding women’s access to effective HIV prevention services and preventing babies from being born with HIV infection. This means integrating HIV/AIDS and reproductive health/family planning programs.
Legislation now before Congress (H.R. 5501, S. 2731) would authorize $50 billion over the next five years to renew the U.S. international AIDS program, the President’s Emergency Plan for AIDS Relief (PEPFAR). But this legislation does not increase funding for reproductive health programs. Despite the ideologically charged atmosphere in Congress about family planning, the clear benefits of integrating HIV/AIDS goals with reproductive health programs make it crucial to move beyond this polarization. The next phase of PEPFAR needs to emphasize HIV prevention, and this should include integrating family planning and HIV/AIDS programs.
This is critical. Women now constitute 60 percent of those living with HIV/AIDS in sub-Saharan Africa, and infection rates among women are rising globally. Providing access to family planning for women living with HIV/AIDS can reduce the number of unintended pregnancies leading to children born with HIV as well as the number of child deaths. HIV-infected women who want to have babies stand a much better chance of safely doing so when they have access to information and services to prevent mother-to-child-transmission (PMTCT) during pregnancy and infant feeding. Similarly, integrating HIV services at family planning clinics extends the reach of HIV programs to large numbers of sexually active women who could be at risk of HIV.
Programs in AIDS-affected countries demonstrate that substantial progress and innovation is being made in the area of integration. Field examples from three key countries – Kenya, South Africa, and India – illustrate how reproductive health and HIV can be linked together. The range of integrated programs include several PEPFAR-supported projects, which demonstrates that U.S. HIV/AIDS programs can create space for reproductive health-HIV integration.
In Kenya, for example, a program run by Family Health International (FHI) combines HIV testing and family planning services to address the common needs and concerns of those clients. In particular, both groups are sexually active and in their reproductive years, both are at risk of HIV infection or might be infected, and if the clients have an interest in preventing unintended pregnancies, both require access to contraceptives and need to know how HIV affects contraceptive options. FHI contends that adding family planning to programs to prevent mother-to-child transmission (PMTCT) helps achieve HIV/AIDS goals and that even moderate decreases in unintended pregnancies to HIV infected women will reduce as many HIV+ births as PMTCT programs.
Another project, piloted by the Population Council, integrates counseling and testing into family planning clinics. The rationale for integrating these services is fourfold:
• sexually transmitted infections (STIs) and HIV are common in clients at family planning clinics, yet family planning providers often miss opportunities to integrate information about other services
• family planning services in Kenya offer an opportunity to reach a large number of sexually active women
• repeated visits offer the opportunity for follow up
• reducing unwanted pregnancies in HIV positive women is a key PMTCT strategy.
The Population Council developed a model of integration that educates family planning clients about voluntary counselling and testing (VCT) and offers those services as part of routine family planning visits. At the same time, the program developed another model that educates family planning clients about VCT and refers them for testing to stand-alone testing services. The study has found that integration of HIV prevention and provider-initiated testing into family planning is acceptable to both clients and providers, and is feasible even in contexts of staff shortages. The quality of family planning services did not decline in either model; in fact, the project found significant improvements. On the government side, the departments involved have proved to be interested in integration and have requested assistance in scaling up these interventions.
PEPFAR’s contribution to Reproductive Health (RH)-HIV integration is a critical factor in Kenya. Yet many challenges remain with PEPFAR funding, especially concerning unclear guidelines on how PEPFAR funds can be used for integration. It is unfortunate that the reduction of unwanted pregnancies in HIV infected women has received little attention as a PMTCT strategy, even in contexts where HIV prevalence and rate of unwanted pregnancy is high, as in Kenya and South Africa. There are limited PEPFAR resources available for interventions based in family planning services, despite the huge potential to reach large numbers of women. Still, PEPFAR presents many opportunities for RH-HIV integration, and some favorable PEPFAR guidelines are emerging in Kenya to support integration.
In South Africa, a program run by the Reproductive Health Research Unit (RHRU) of the University of Witwatersrand to prevent mother-to-child transmission of HIV has found that providing adequate anti-retroviral regimens to infected women can effectively reduce pediatric HIV and infant and child mortality. The HIV prevalence rate among pregnant women in South Africa is about 29 percent, and the transmission rate about 20 percent, leading to some 63,000 infants being infected in 2006. RHRU contends that PMTCT can be used to fight HIV more broadly.
Like family planning clinics, PMTCT programs have a captive audience – that is, women in the health system that are still largely healthy. Health care providers should use that opportunity to determine these women’s HIV status and, if they are HIV infected, to stage them and initiate them on ART while in the health system. Moreover, there is an opportunity to extend the reach of the health services to their other children who might be HIV infected, to their partners who might not have been tested and who might need care and treatment. By treating women adequately and correctly, pediatric HIV and infant and child mortality can be effectively reduced.
RHRU emphasizes the need to improve PMTCT services to care for HIV-infected women, and to shift the focus from preventing HIV infection in children to caring for HIV infected women. In addition, this approach will lead to improvements in maternal and pediatric health, decreases in pediatric HIV, increased HIV awareness in communities, reductions in the HIV treatment gap. This calls for integrating reproductive health into PMTCT, including pre-conception management, family planning, and post-natal care.
In India, an innovative program, the Aastha Project, is run by the Family Planning Association of India (FPAI) and FHI. The project aims to reduce the incidence of STIs and HIV among sex workers and their partners. The context of the Aastha project is the situation of sex work in Mumbai, India’s largest city and capital of Maharashtra state. Out of a population of 20 million, there are 65,000 identified sex workers, and the HIV prevalence among sex workers in Maharashtra is 23%. As is often the case, condom use with regular partners is quite low. These sex workers are subject to violence and police harassment, and are largely uncovered by the public health system. The project promotes and distributes condoms, and works to provide information on the prevention and treatment of STIs, HIV/AIDS, and services for reproductive health.
Over the past three years, the Aastha project can point to a number of achievements. Over 25,000 sex workers are registered with the project, and 18,565 sex workers have accessed clinical services at least once. On average, 9,900 sex workers access Aastha services every month, and 5,000 sex workers access clinical services every month. As a result of these services, symptomatic visits have declined from 43 percent in September 2006 to 11 percent in September 2007. Over 7 million condoms have been distributed.
As important as it is to integrate family planning and HIV/AIDS programs, it won’t be easy. One major challenge involves the enormous disparity in resources between HIV/AIDS and family planning programs. While U.S. funding for AIDS programs has risen exponentially, family planning funding has been reduced. Another obstacle is the reality of competing priorities. At a time when many policymakers, experts, and advocates are debating whether U.S. funding for HIV/AIDS is undermining other critical health priorities – including child survival, maternal health, and family planning – the promising approaches toward reproductive health-HIV integration illustrate ways to help strengthen the health sector overall. Indeed, family planning-HIV integration represents the kind of efficiency and long-term cost-effectiveness that should make it a priority.
The innovation and richness of the experiences from Africa and Asia offer great promise for moving forward with family planning-HIV integration. With the reauthorization of PEPFAR in 2008, a new U.S. administration in 2009, and PEPFAR’s ongoing choices about implementing programs, the United States has an unprecedented opportunity to apply these lessons in order to strengthen U.S. HIV/AIDS strategy. Having accomplished so much in PEPFAR’s first phase, U.S. policymakers should heed the evidence and promote integrated reproductive health and HIV/AIDS programs as a key component of U.S. AIDS policy.
Janet Fleischman is senior associate of the CSIS HIV/AIDS Task Force and chair of the gender committee. The article is based on a report she wrote for CSIS, Voices from the Field: The Role of Integrated Reproductive Health and HIV/AIDS Programs in Strengthening U.S. Policy, published in February 2008, and an op-ed that appeared in The Philadelphia Inquirer on March 11, 2008, “U.S. HIV/AIDS Policy Must Include Family Planning.” In October 2007, Fleischman hosted a meeting at CSIS, "Reproductive Health and HIV/AIDS Services: Lessons From the Field for PEPFAR Reauthorization," which is avaliable in podcast.
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