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Reproductive Health |
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Averting HIV-Infected BirthsIntegrating family planning services can help achieve goal. |
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In the midst of an unrelenting AIDS epidemic, attention is increasingly being paid to the prevention of HIV infection among the world's most vulnerable individuals: its newborns.
In 2003, an alarming number of new HIV infections — about 700,000 — occurred among children, the vast majority of whom were infected by their mothers. Four main approaches to reducing such infections have been promoted by the World Health Organization (WHO) and its United Nations partners.1 To date, funding for developing countries has primarily supported an approach of providing voluntary counseling and testing (VCT) for HIV during pregnancy and then a short course of antiretroviral (ARV) drug therapy to HIV-infected pregnant women and their newborns. This is to prevent HIV transmission from mother to infant during delivery. Another approach is to provide care and support to women, infants, and families infected and affected by HIV/AIDS. But minimizing HIV-infected births will likely be best achieved through a combination of approaches that includes preventing unintended pregnancies among HIV-infected women (see Preventing Pregnancy Among HIV-infected Women) and preventing HIV infection among reproductive-age women (see Preventing HIV Infection among Pregnant Women).2 Pursuing these latter two approaches requires new thinking about how various reproductive health and HIV services can be integrated in settings where women are likely to seek health care. Such integration can contribute to the prevention of mother-to-child transmission (PMTCT) of HIV in several ways:
In all of these scenarios, family planning services can play an essential role in achieving PMTCT goals. Yet, employing family planning services to avert HIV-infected births — particularly, offering contraceptive services to infected women — requires more than simply combining services. It involves operational challenges that, as yet, have not been explored in depth. It also requires that providers be trained to understand the special reproductive and contraceptive needs of HIV-infected women. An infected woman's decisions are likely to be shaped by many factors, including her own health and that of her partner and existing children, access to long-term ARV drug therapy, whether she can disclose her HIV status, the possible impact of HIV infection and ARV use on contraceptive method options, and the possible impact of contraceptive method use on her health and infectivity.
However, policy guidelines indicate increasing support for the integration of family planning services to achieve PMTCT goals. More than three-quarters of international guidelines, national HIV/AIDS policies, and PMTCT and VCT policies reviewed in a recent analysis mention family planning.3 Three recent analyses suggest that family planning services can both have a marked impact on averting HIV-infected births and be cost-effective (see Family Planning: Considerable Impact at Relatively Low Cost). And, in May 2004, some 70 health professionals, representatives from governmental and nongovernmental organizations, and donors met in Glion, Switzerland, to consider the contributions family planning could make to PMTCT. The meeting, supported by WHO, the United Nations Population Fund, the U.S. Agency for International Development (USAID), and private donors, resulted in a "Call to Action" to strengthen linkages between family planning and PMTCT. The declaration acknowledged that all four approaches recommended by WHO and its United Nations partners are necessary to meet PMTCT goals. It also recommended strengthening family planning and PMTCT links through advocacy, policy and program development, resource mobilization, monitoring and evaluation, and research. Challenges for family planning, ANC providers In many settings, family planning staff will need additional training, support, and motivation to effectively serve women at risk of HIV infection and women who are already infected. Staff must be prepared to provide HIV prevention counseling for women at risk. And, they are likely to need considerably more training to counsel and serve women whose HIV infection makes reproductive and contraceptive choices far more complex than those for uninfected women (see Preventing Pregnancy Among HIV-infected Women). Staff will need to be able to explain issues related to mother-to-child transmission of HIV. Concerns that working with HIV-infected clients will stigmatize and discredit existing family planning services must be overcome. Training about universal infection-control precautions may be necessary to quell providers' fears of being infected by HIV-infected clients. Concerns that working with HIV-infected women will increase already heavy workloads and might compromise scarce family planning funds must also be addressed.4 Finally, unless they receive by referral women who have already been identified as HIV infected, family planning services face the challenge of integrating VCT services to identify infected clients (see HIV Services for Family Planning Clients). Like family planning services, ANC services face the challenge of determining a woman's HIV status. The introduction of VCT provision into the antenatal setting has the potential to be quite effective.5 For example, in a pilot study of same-day VCT in six urban antenatal clinics in Lusaka, Zambia, 84 percent of pregnant women requested testing, and a quarter of those women tested positive.6 However, many pregnant women are reluctant to accept VCT. In a four-year study to examine the introduction of PMTCT services within maternal and child health programs in Kenya and Zambia, about two-thirds of more than 22,000 women who sought antenatal care as new clients received pretest counseling. But fewer than one-third went on to have an HIV test.7 Reasons for disappointing VCT uptake at ANC/PMTCT sites throughout Africa may include logistical barriers (e.g., results are unavailable the same day or tests are expensive) and fears that test results will not remain confidential.8 Even when women are tested, a substantial number do not return for their results.9 ANC services that attempt to integrate family planning services must confront other operational issues. For example, in Africa, adding family planning services can burden government ANC services, which are "notoriously overcrowded, understaffed, and have limited physical space for group or individual counseling," says Elizabeth Preble, an international health consultant who specializes in HIV/AIDS and reproductive health and has studied operational barriers to integrating family planning and PMTCT services in Africa and Asia. "Adding family planning services requires additional skills, space, and staff capable of dispensing contraceptives. In the African context, many ANC staff have already expressed resentment at having to take on additional PMTCT responsibilities, let alone family planning demands as well." Training issues require considerable attention. In Africa, "at present, PMTCT and VCT curricula do not always cover family planning issues in detail, especially as they might relate to HIV-infected women," Preble says. But, at a minimum, providers should be able to offer information about the importance of family planning as a PMTCT intervention, and to explain the basics of contraception. They also need to be able to offer contraceptive methods that can be adopted immediately postpartum, or be able to refer clients for postpartum family planning services and contraceptive methods. Family planning referrals, in themselves, can be problematic. "While many PMTCT programs now pledge to follow women, test their babies, and refer them for family planning, ARV therapy, and other AIDS-related care, this is not universally happening in African PMTCT settings," Preble says. An evaluation of a PMTCT pilot program in South Africa showed that clients referred to family planning services had poor access to health facilities. Distances were long and women lacked affordable transportation. Furthermore, poor patient records impeded continuity of care, and clients had to wait long times to be served.10 Another challenge is to ensure that PMTCT programs meet the family planning needs of their adolescent clients. Adolescents seen at antenatal clinics are more likely than older women to be pregnant for the first time. They may face strong social pressure to bear a child to prove their fertility and may continue childbearing — regardless of HIV status — if appropriate postpartum family planning counseling and services are unavailable to them. For this reason, FHI researchers are conducting a study in Kenya to identify and evaluate strategies for meeting adolescents' HIV and reproductive health needs within PMTCT programs.11 Missed opportunities, but progress continues In a recent evaluation of pilot PMTCT projects supported by the United Nations and initiated in 11 primarily African countries in 1999-2000, all national-level program managers reported that their PMTCT programs (centered within ANC and maternal and child health care) included family planning services. Most sites offered both family planning counseling and contraceptive methods, either in the same building or next to it, as part of clients' routine care. However, PMTCT programs had made relatively little progress in addressing the prevention of HIV infection in reproductive-age women and the prevention of unintended pregnancy in infected women.12 The extent to which pilot PMTCT programs address family planning (and vice versa) was also evaluated as part of a four-year intervention study conducted at two sites in Kenya and one in Zambia by Horizons, the Network of AIDS Researchers in East and Southern Africa (NARESA) in Kenya, the MTCT Working Group in Zambia, and the United Nations Children's Fund (UNICEF).13 Among its findings:
Further analysis by Population Council researchers of the integration of family planning and PMTCT services, reported in April of 2004 and based on field experiences in Cameroon, Kenya, Namibia, South Africa, Uganda, Brazil, the Dominican Republic, India, and Thailand,14 found that the availability of family planning services at PMTCT sites did not ensure integration of HIV and family planning messages. Family planning was usually provided in PMTCT training but was a low priority and was given little time. Human resources were not readily available in some settings to place greater emphasis on family planning. At the national level, family planning and PMTCT services tended to be separate programs, often with separate funding. Finally, little monitoring and evaluation of family planning as a PMTCT service existed. Of note, however, "we found strong positive views about the use of condoms by HIV-infected women for dual protection against unintended pregnancy and HIV transmission — either used alone or in combination with a more effective contraceptive method," says Dr. Naomi Rutenberg, senior program associate with the Population Council and lead author of the report summarizing findings of the analysis. "Condoms were seen as safe, cheap, easily available, promoted by PMTCT providers, and preserving the women's health by preventing infection with sexually transmitted infections and reinfection with HIV." The researchers recommended integrating family planning support and services targeted to the needs of HIV-infected women into PMTCT services. They suggested that providers build on positive attitudes toward condoms among HIV-infected women and involve men to promote dual protection. They also recommended improving mechanisms for postnatal follow-up and offering a continuum of care for HIV-positive women. Despite the many identified barriers to integration, the researchers concluded that many pilot activities showed promise and that "national and international leadership to integrate family planning as an essential component of PMTCT programs is bearing fruit and should be continued." — Kim Best References
Preventing Pregnancy among HIV-Infected Women Providing family planning counseling and services to HIV-infected women — to prevent initial or subsequent unintended pregnancy — is critical to the prevention of mother-to-child transmission (PMTCT) of HIV. Indeed, without such family planning services, achieving international goals to reduce the proportion of HIV-infected infants by 20 percent by 2005 and by 50 percent by 2010 may not be possible.1 HIV-infected women must be carefully counseled about the risk of transmitting HIV to their infants during pregnancy and delivery. Those women who wish to either limit or space childbearing should have access to highly effective contraception.2 And, because all women have the right to decide the number and timing of their children, anyone counseling an HIV-infected woman should support her family planning decisions.3 HIV-infected women who have not ruled out childbearing need to know that pregnancy does not appear to accelerate HIV disease progression.4 However, maternal HIV infection might affect infant health. A recent study found that miscarriage, abortion, ectopic pregnancy, and stillbirth rates among HIV-infected women — some of whom received antiretroviral (ARV) drug therapy — were no higher than those among uninfected women.5 However, in other studies, maternal infection has been associated with adverse neonatal and obstetrical outcomes, including premature birth, low birth weight, and postpartum hemorrhage.6 HIV-infected women using ARV drugs may want to use family planning until the effects of these drugs on maternal and child health are better understood. Clinical trials of the effects of zidovudine show no increase in birth defects,7 but certain ARV drugs may be toxic for pregnant women and fetuses. The drug efavirenz (EFZ), for example, is believed to be a potent early teratogen, and recent World Health Organization (WHO) draft guidelines state that "EFZ should not be given to women of childbearing potential unless effective contraception can be assured."8 Other concerns have been raised about whether a woman's use of nucleoside reverse transcriptase inhibitors (such as zidovudine and lamivudine) could affect the mitochondrial or nuclear DNA of her child, potentially causing such side effects as lactic acidosis and anemia and increasing susceptibility to cancer.9 Contraceptive options for HIV-infected women WHO also provides guidance as to the suitability of each major contraceptive method (including sterilization) for family planning clients in three HIV/AIDS categories: high risk of HIV, HIV-infected, and AIDS. Women in all categories are eligible for most major methods. Of note, based on the latest clinical and epidemiological data, recent revisions to the guidelines (see News Briefs on page 2 of pdf version of this issue -- 2.59MB) have removed some barriers to intrauterine device (IUD) use. Initiation of IUD use is usually not recommended for a woman with AIDS who either is not receiving ARV therapy or has not clinically improved while on it. (This is because such a woman may have a suppressed immune system and thus be more vulnerable at the time of IUD insertion to infections, such as other sexually transmitted diseases [STIs] that could lead to pelvic inflammatory disease.) Otherwise, all other HIV-infected women, including those with AIDS, are now eligible to initiate or continue IUD use.10 Hormonal contraceptives may also be a good choice for many HIV-infected women. For long-lasting contraception, the Norplant implant has been found to be safe, efficacious, and well tolerated in the immediate postpartum period among asymptomatic HIV-infected women.11 However, there is some concern that nevirapine and EFZ can alter the metabolism of oral contraceptives, thus requiring an adjustment in contraceptive dosage or change to another contraceptive method.12 Due to concerns about drug interactions, WHO guidelines state that the use of oral contraceptives and hormonal patches, rings, and implants is usually not recommended for women taking rifampicin, an antibiotic used to treat tuberculosis. Meanwhile, use of hormonal methods may be associated with increased risks of cervical HIV shedding (and thus HIV transmission),13 as well as HIV disease progression.14 More data on these possible associations will be forthcoming this year. For HIV-infected women who have decided against childbearing, female sterilization is a good option. The procedure should be delayed, however, if a woman has an AIDS-related illness.15 The use of diaphragms (with spermicide) or cervical caps is usually not recommended for HIV-infected women and those with AIDS, according to WHO's 2003 recommendations. Finally, an HIV-infected woman should be counseled about dual method protection — using a condom for disease prevention (HIV transmission to her partner or the woman's reinfection with other HIV strains or STIs) and another, more effective method for contraception (see figure below).
Family planning providers also should be aware that the contraceptive behavior of HIV-infected women may differ from that of uninfected women. Numerous studies suggest that contraceptive use by HIV-infected women can be surprisingly low. Many become pregnant. One reason is that infected women may very much want to have children, particularly in cultures that are pronatalist.16 The increasing availability of ARV drugs may also make pregnancy more appealing, since treatment offers hope for better health, better quality of life, and survival.17 Fears of the health effects of contraceptive use may also play a role. This suggests the need to provide ample information about contraceptive options and reliable follow-up to reduce method discontinuation related to side effects.18 Contraceptive needs of postpartum HIV-infected women are the same as those of nonpregnant infected women, with two exceptions. An infected woman's risk of transmitting HIV to her infant may grow with subsequent pregnancies, since the risk of such transmission increases as maternal infection progresses.19 Also, an infected woman may be less likely than an uninfected woman to breastfeed, since breastfeeding can transmit HIV to infants. But nonbreastfeeding women miss the contraceptive benefits of lactational amenorrhea. As is the case for nonpregnant HIV-infected women, contraceptive uptake may be low for postpartum infected women.20 Why this is so remains poorly understood. However, many infected women are reluctant to share their HIV status with their partners and thus are unable to argue for family planning. For example, in Zaire, a study of fertility rates among 238 HIV-infected women followed for three years postpartum found that the women's nearly uniform unwillingness to inform partners of their HIV status largely accounted for the "disappointingly high fertility rates in women who had been provided with a comprehensive program of HIV counseling and birth control."21 Thus, men's involvement in family planning may be a key to preventing subsequent pregnancies among infected women.22 — Kim Best References
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