Definition of the Prevention Area
From an HIV prevention perspective, family planning (FP) is a strategy to prevent vertical transmission of HIV (mother-to-child transmission or MTCT). Reducing the number of unplanned pregnancies in HIV-positive women reduces the number of infants exposed to HIV. Helping women with HIV meet their own goals for family size and child spacing is one of four elements of the World Health Organization’s (WHO) 2002 strategic approach to prevent mother- to-child transmission (PMTCT) of HIV. In April 2012, the World Health Organization (WHO) released a programmatic update, "Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants." In the executive summary, the WHO said: "Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life."
There are several key factors to consider when planning and implementing programs to meet the family planning needs of women living with HIV:
- The program's social behavioral communication strategy should reinforce and complement approaches for meeting the family planning needs of women living with HIV, and should extend between community outreach activities and the messages given at the health facility.
- Managers should discuss and plan which family planning commodities (modern, traditional, and hormonal) to provide; what training health providers will need; and the type of health information system needed to document programmatic challenges and successes.
- Programs and providers should carefully consider evidence on specific interactions between or among drugs to ensure that both the contraceptive and HIV treatment drugs a woman is taking are safe and effective when taken together.
- Programs and providers should stress the importance of using a condom for dual protection regardless of other methods of family planning that may be used. Condoms can prevent both an unplanned pregnancy and HIV transmission. Male and female condoms are effective at reducing the risk of HIV transmission among serodiscordant couples.
Epidemiological Justification for the Prevention Area
During the PEPFAR expansion period, USAID funded several modeling studies showing that reducing the number of unplanned pregnancies among women with HIV can be as effective in reducing infant HIV infections as giving antiretrovirals (ARVs) to HIV-positive pregnant women. It is estimated that each year, contraceptive use prevents an estimated 577,200 unplanned pregnancies among HIV-positive women in sub-Saharan Africa, thus averting an estimated 173,000 HIV-positive births. Although many countries are working to implement the new WHO Option B+ policies to prevent MTCT and provide HIV treatment for women, family planning is a critical component for meeting the needs of all HIV-positive women.
Core Programmatic Components
Contraception as an HIV prevention intervention is most cost-effective when implemented in settings with generalized HIV epidemics that disproportionately affect women of reproductive age. Given that most women do not know their HIV status, Ministries of Health and collaborating programs should make FP services available to all women, both to maximize their HIV-prevention impact and to help all women achieve their fertility goals.
Women living with HIV should have access to high-quality information and services so they can make informed decisions about future pregnancies. This includes information about the effectiveness, side effects, and possible interactions of contraceptive drugs with ARVs; and about the advantages of dual protection, delivered as part of measures to prevent vertical transmission of HIV. Discussing pregnancy intentions and providing access to contraceptives is an important service in HIV care and treatment settings to help women achieve their fertility goals, and because certain ARVs have toxicities that can affect the fetus. Trained counselors who can provide comprehensive information that addresses the needs of HIV-positive women, including details about all available family planning methods, are critical to high-quality family planning programs.
In 2014, WHO issued a guidance statement on hormonal contraceptive methods for women at high risk of HIV and living with HIV. In general, women with HIV, including those taking ARVs, can use almost all contraceptive methods safely and effectively. However, the guidance notes that special consideration may be need for women using some hormonal methods with certain regimens for antiretroviral therapy (ART), specifically those including efavirenz or nevirapine, and some protease inhibitors. It specifies recommendations for hormonal contraceptive use for women living with asymptomatic or mild HIV clinical disease, and for those living with severe or advanced HIV clinical disease. WHO retains its position that women at high risk of HIV who choose progestin-only injectable contraceptives should also use condoms and other HIV-preventive measures, and that such women should be informed that progestin-only injectable contraceptives may or may not increase their risk of HIV acquisition.
Current Status of Implementation Experience
Although integrated FP/HIV services are scaling up globally, a number of obstacles continue to impede this process. These include separate funding streams for FP and HIV programming; the vertical organization of health ministries and service facilities; and lack of evidence for the effectiveness of integrated service delivery models. A publication by the WHO, USAID, and FHI 360 provides program planners, implementers, and managers with strategic considerations for implementing or strengthening integrated FP/HIV services.
The global health community has recently increased attention and investment aimed at expanding FP, and linking family planning and HIV services. Toolkits and case studies have continued to document best practices and technical considerations, as well as ongoing challenges. The Country Operational Plan guidance issued by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) urges country teams to consider co-locating FP and HIV services, particularly at the primary health care level. PEPFAR encourages the programs it supports to train health workers to deliver an enhanced package of maternal, newborn, and child health services, including FP, for women living with HIV.