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Family Planning and HIV Service IntegrationPotential synergies are recognized. |
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In most settings throughout the world, family planning services and HIV services traditionally have been offered separately, with little or no integration. Family planning services primarily target married women of reproductive age. HIV prevention services primarily target individuals at high risk of HIV infection. But the potential benefits of integrating these services are increasingly apparent as ever more women of reproductive age become infected with HIV or are at risk of infection.
In developing countries, most HIV infection is sexually transmitted among men and women. About half of the 40 million people now living with HIV are women of reproductive age; percentages approach 60 percent in some African countries.1 Many HIV-infected women likely need family planning services, but unmet need for these services is often greatest in countries with high HIV prevalence.2 This need can be better met if family planning services are offered where such women access HIV or other services, in addition to being offered through family planning programs. Meanwhile, clients accessing family planning services may well need HIV prevention, diagnosis, and treatment services. Many of these clients are married women, who are usually considered at low risk for HIV infection. But evidence from several countries suggests that marriage may offer women little protection against HIV infection since, in some settings, even married women may have little or no power to negotiate safe sexual practices with their husbands. In Kisumu, Kenya, and Ndola, Zambia, teenage brides are becoming infected with HIV at higher rates than are single, sexually active young women of the same age.3 Forty percent of new HIV infections in Thailand occur between spouses, and 90 percent of those infections are transmitted from husband to wife.4 Service integration holds the potential for helping women and others — such as men, youth, and couples — prevent unintended pregnancy and HIV infection. Experience with integrating a variety of health services, such as maternal and child health and family planning or family planning and management of sexually transmitted infections (STIs), has been mixed. But the most successful experiences suggest that integration enables providers to offer more convenient, comprehensive services. Integration is also expected to expand access to services and make them more cost-effective.5
Types of integration Where services are currently integrated, some HIV services are usually provided through family planning programs6 (see HIV Services for Family Planning Clients). These services may include diagnosis and treatment of STIs, sexual risk-reduction counseling, condom promotion, and HIV voluntary counseling and testing (VCT). Integration is also starting to move in the opposite direction. Pilot efforts have begun to add family planning counseling and services to HIV services such as VCT and prevention of mother-to-child transmission (PMTCT). (See Integrating Family Planning into VCT Services and Averting HIV-Infected Births, respectively.) Such integration aims to give all VCT and PMTCT clients, regardless of their HIV status, the opportunity to avoid unintended pregnancies and space the births of their children. For HIV-infected women, ready access to family planning can help avert unintended pregnancies and thus reduce numbers of HIV-infected infants. Also being explored is the integration of family planning into care and support for people living with HIV. An FHI study is assessing integration of family planning promotion into the services provided by volunteer caregivers in a home-based care program for people living with HIV in South Africa, and results are expected by the end of 2004. Managers of a similar program in Kenya, the HIV/AIDS Care, Support, and Prevention (COPHIA) program carried out by U.S.-based Pathfinder International, decided that it was important to train community health workers in family planning services and HIV prevention so that they could respond to the reproductive health needs of clients and family members. Questions unanswered The reproductive health impact of integrating HIV services into family planning programs has not been rigorously evaluated. Even less is known about the feasibility and impact of integrating family planning into HIV services. Research is essential to demonstrate not only that integration will not overburden and thus compromise the quality of existing services, but also that it will actually improve reproductive health. Such research should assess the effects of different models of integration on service quality, adoption and continuation of family planning methods and HIV prevention strategies, acceptability and use of services, and cost-effectiveness.7 Pilot studies with experimental designs are urgently needed to generate evidence-based recommendations for programs since, in general, "little is known about how integrated services can best be configured, and what impact they have on prevention of infection and unwanted pregnancy," caution the coauthors of an article about gaps in knowledge about STI service integration activities in sub-Saharan Africa.8 Even when successful models of integration are identified, their expansion will require changes in government and donor policies that currently encourage vertical programs.9 Before attempting to integrate services, program managers need to be aware of the challenges confronting them (see Potential Benefits and Challenges of Integration) and consider whether integration makes sense (see To Integrate or Not to Integrate?). The likelihood that combining the two kinds of services will be cost-effective depends on clients' needs, the prevalence of HIV in the area, and the strength of family planning programs.10 The appropriate level of integration depends on a program's capacity and the costs and resources available to support and maintain integrated services, directly or through referrals.11 Regardless of when, where, and how family planning and HIV services are integrated, family planning remains one of the most effective ways to enhance the well-being of women and their families. By enabling women to avoid unintended pregnancies and by reducing the risks associated with age at pregnancy, too many pregnancies, or pregnancies spaced too closely together, family planning prevents about 2.7 million infant deaths and 215,000 pregnancy-related deaths in the developing world each year.12 These benefits of family planning may be particularly important for HIV-infected women, whose health is already compromised, and for their children. — Kathleen Henry Shears References
HIV Services for Family Planning Clients When the HIV epidemic emerged in the 1980s, family planning organizations responded with some of the first HIV prevention projects in the developing world. Yet, a review of the contribution of sexual and reproductive health services to HIV prevention, conducted in 2003 for the World Health Organization (WHO), found that integrating HIV prevention into family planning services had not yet been implemented effectively, except in a few cases.1 Still, it would be premature to conclude that integrating HIV prevention into family planning services does not work, says Dr. Ian Askew, the Population Council's representative in its office in Nairobi, Kenya, who helped conduct the review. Much has been learned, moreover, from implementing various strategies designed to achieve that goal. Such strategies include diagnosis and treatment of sexually transmitted infections (STIs) that increase the risk of acquiring HIV, sexual risk-reduction counseling, condom promotion, and voluntary counseling and testing (VCT) for HIV. Diagnosis and treatment of STIs STI service introduction at family planning and maternal and child health (MCH) clinics never received adequate financial support and was undertaken without strengthening the systems needed for effective service delivery. Moreover, the ability of providers in low-resource settings to detect and treat STIs in women is severely limited by the lack of simple, affordable diagnostic methods.2 In such circumstances, WHO recommends syndromic management of STIs, which involves recognizing and treating STIs based on a group of clinical findings and patient symptoms. But most women with STIs do not have symptoms, and the syndromic approach is not effective for determining how to treat women with vaginal discharge.3 Nevertheless, family planning and MCH providers still have a role to play in STI management, says Dr. Irina Yacobson, an associate medical director at FHI, who worked with colleagues at WHO and the Population Council to develop a guide for STI management in family planning and MCH settings. This draft publication incorporates WHO's current recommendations on STI management, which advise providers to treat a woman who has a vaginal discharge for vaginitis (bacterial vaginosis, trichomoniasis, and possibly candidiasis), which is often caused by infections that are not sexually transmitted. However, when a woman has clinical signs of cervical infection or there are reasons to believe that she was exposed to gonorrhea or chlamydia, treatment for cervicitis should be added.4 Family planning and antenatal care providers with the necessary skills and supplies can also use the syndromic approach to manage genital ulcer disease in women and can screen pregnant women for syphilis. All providers should at least educate their patients about the risks and consequences of untreated STIs, adds Dr. Yacobson. Sexual risk-reduction counseling Incorporating STI/HIV prevention messages into family planning services has been an appealing strategy because family planning programs attract clients who generally do not access HIV program services. Family planning staff can be trained to provide basic HIV prevention information, and family planning programs can offer an infrastructure of clinics and community-based programs for service delivery.5 But providing STI/HIV prevention services through family planning programs is problematic because these programs usually do not reach those at greatest risk of HIV infection, including men, youth, and single women.6 Even when married women are among those at highest risk of HIV, they often do not have the power to protect themselves by either abstaining from sex or insisting on fidelity or condom use by their husbands. A comprehensive review commissioned by WHO found that efforts to integrate STI/HIV prevention activities with family planning and MCH services had improved providers' attitudes and counseling skills, increased user satisfaction, and, in some cases, increased condom distribution and the adoption of other contraceptive methods.7 Little evidence exists, however, that STI/HIV prevention activities among traditional family planning clients have reduced risky sexual behavior or increased condom use.8 Condom promotion Male condoms — when used consistently and correctly — are an effective way to prevent HIV infection and unintended pregnancy.9 But promoting condom use through family planning may have limited impact because these services tend to target women, rather than the men who must agree to use condoms. Client and provider attitudes are another barrier to effective condom promotion. Condom use is rare in marriage and other steady relationships because it is often considered a sign of distrust.10 And many family planning providers are reluctant to promote condoms because they fear that greater use of a contraceptive method that is less effective than some methods will lead to more unintended pregnancies and abortions. Little is known about the success of promoting the use of condoms plus another contraceptive method for dual protection against HIV and unintended pregnancy, although studies from South Africa11 and Kenya12 found that 13 percent to 16 percent of condom users also use another method. The addition of dual protection counseling and female condom promotion to family planning services in Ibadan, Nigeria, showed that integration of these activities is feasible but that interventions should also reach male partners to have a strong impact.13 In settings with high HIV prevalence, renewed emphasis on condom use alone for contraception among couples in long-term relationships might be a more effective way to encourage dual protection than is dual method use because it would allow couples to discuss condoms without accusations of infidelity.14 Voluntary counseling and testing Providing VCT at family planning facilities enables providers to offer more targeted family planning counseling because clients know their HIV status, and it may motivate clients to adopt dual protection strategies.15 Moreover, anecdotal evidence from pilot projects conducted in India, Côte d'Ivoire, and Ethiopia suggests that integrating VCT into reproductive health services can reduce the stigma associated with HIV, increase awareness of healthy sexual behavior, increase access to and use of VCT services, and reduce the cost of establishing VCT services.16 None of these pilot projects has been rigorously evaluated. But the Rwandan family planning association, Association Rwandaise pour le Bien-Etre Familial (ARBEF), and FHI's Implementing AIDS Prevention and Care project are assessing the impact of VCT services on clients' sexual behavior at three ARBEF clinics as part of a broader evaluation of VCT programs supported by FHI. Results are expected by the end of 2004. The Population Council's FRONTIERS in Reproductive Health program and the South African Department of Health are designing a study to compare quality of counseling, use of VCT services, sustained use of dual protection, and cost per client of direct provision of VCT with counseling and referral for HIV testing among family planning clients in South Africa's Northern Province.
Meanwhile, program managers need to consider whether providing VCT services or referrals in family planning settings is necessary, feasible, or cost-effective. Some family planning clinics in areas with high HIV prevalence may be able to provide VCT, while other clinics may only be able to offer counseling and refer clients for testing services.17 If neither option is possible, risk assessments offer a theoretical way to help clients assess whether they may be infected or at high risk of infection, and thus help them make appropriate reproductive and contraceptive choices.18 However, such assessments may prove difficult, and their effectiveness for screening low-risk populations has not been demonstrated. More research is needed to improve these assessment tools.19 The way forward Family planning program providers are often reluctant to offer HIV services. Many are concerned about the potential negative effects of new HIV responsibilities on workload, job security, allocation of scarce family planning resources, and overall quality of services. Others fear occupational exposure to HIV or worry that providing HIV services will discredit family planning programs.20 And providers who are not trained to provide HIV services may not feel confident doing so. Nevertheless, providers have an obligation to their clients to do what they can, says Dr. Ndugga Maggwa, regional director of FHI's Institute for Family Health in East and Southern Africa. "Wherever family planning services are offered, providers should be equipped to counsel clients about STIs and HIV and to refer them for services." Dr. Maggwa and the Population Council's Dr. Askew advise family planning programs to reach out to men and youth, while reorienting routine consultations toward protection against both STIs/HIV and unintended pregnancies. "Strategies that seek to assess the woman's overall situation, counsel her on her risks and options, and respect her right to make the final decision concerning her behavior appear to be the most promising ways of helping her obtain the protection she needs," they recommend.21 — Kathleen Henry ShearsReferences
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