SRH/HIV Linkages: What

1
SRH/HIV LinkagesWhats The Rationale?

• Claudes Kamenga
• Family Health International
• Woodrow Wilson Center
• Washington, DC
• December 3, 2009

2
What do we mean by integration?

• How different kinds of RH and HIV services or
  operational programs can be joined with the aim
  of maximizing collective outcomes. This includes
  referrals from one service to another, for
  example. It is based on the need to offer
  comprehensive services.

Source Rapid Assessment Tool for SRH Linkages A
Generic Guide (UNFPA, UNAIDS, WHO, IPPF, GNP,
ICW)
3
In practical terms it means

• Range of services that meet several needs
  simultaneously, where
• Providers screen clients for unmet needs (HIV or
  FP)
• Service provision offered only to clients who
  need services (e.g., VCT client not using FP but
  doesnt want a pregnancy)
• Service organization options
• Fully integrated, e.g., one stop shop
• Some services available (e.g., counseling) and
  others (e.g., method provision) available via
  referral

4
Why integrate?
Clients Seeking HIV-related Services
AND
Clients Seeking RH Services

• Share common needs
• - Often both sexually active and fertile
• - Are at risk of HIV infection or might be
  infected
• - Need access to contraceptives
• - Need to know how HIV affects contraceptive
  options and vice versa

5
Protect Womens 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
6
Protect Womens 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

7
Contraception is HIV Prevention

• UNGASS goals cannot be met without increasing
  access to family planning
• Even moderate decreases in unintended pregnancies
  to HIV women will reduce same number of HIV
  births as current PMTCT programs

Source Sweat et al, AIDS 2004 18(12) 1661-71
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WHO Four Element PMTCT Strategy
PMTCT-Plus
PMTCT
FP
SRH
Prevention of HIV in uninfected 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
Element 1
Element 2
Element 3
Element 4
General Population
FP Postnatal Clinics
ANC Clinics
HIV Care/ Treatment
VCT
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Pregnancies are Often Unintended or Unwanted
100
90
80
70
60
50
40
30
20
10
0
Haiti
Kenya
Nigeria
Zambia
Vietnam
Ethiopia
Uganda
Namibia
Rwanda
Tanzania
Botswana
Côte d'Ivoire
South Africa
Mozambique
births unintended
births unwanted
Source DHS and other surveys
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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 20062951376-8
Bangendanye, et al., presented November 2007
Hoffman, et al. JAIDS 200847477-83
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Effect of Current Contraceptive Use by HIV Women
Assumptions

• 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

12
Contraception as HIV Prevention Compared to ARVs
800 700 600 500 400 300 200 1000
735
of infants/births, in 1000s
220
86
ARVs (over 1 year)
Effective Contraception (over 1 year)
infants spared HIV infection
unintended births prevented
Sources WHO (2009), Reynolds (2008)
13
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
  NVP
• Decreases the number of future orphans
• Is a cost-effective HIV prevention intervention
• Key Question how best to achieve SRH/HIV
  integration?

14
SRH/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

15
International Level Opportunities

• SRH/HIV integration supports the reproductive
  rights of HIV women
• Increasing international policy support for
  stronger SRH/HIV linkages
• Glion Call to Action
• New York Call to Commitment
• Maputo Plan of Action

16
International Level Opportunities

• Global Fund
• SRH components advocated
• Can be used to purchase commodities
• PEPFAR
• Prevention with Positives
• New COP guidance encourages integration

17
International Level Challenges

• International donor funding lacks FP indicators
  what gets measured gets done
• PMTCT has focused mostly on antiretrovirals

18
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
  SRH/HIV integration
• Increasing number of integrated SRH/HIV bilateral
  programs
• Kenya, Nigeria, Zimbabwe

19
Country Level Challenges

• Parallel RH and HIV departments and funding
  within Ministries of Health
• Lack of policies, guidelines, and training
  programs for integrated RH and HIV services
• Limited coordination between departments
• Turf issues

20
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.

21
Service Delivery Challenges

• Various operational considerations
• Commodities/logistics
• Human resource capacity
• Supervision
• Reporting
• Referral systems
• Community involvement
• Must address FP provider biases against and
  preparedness to serve HIV clients

22
Moving forward

• Evidence-base for SRH/HIV integration growing
• Bulletin of the WHO (Nov 2009)
• AIDS supplement on FP and HIV (Nov 2009)
• New tools available to support integration
  programming