Mera, September 2006: Averting HIV-infected births: integrating family planning services can help achieve goal

By Kim Best, Senior Science Editor, Family Health International, Research Triangle Park, NC, USA

Key points Family planning services can greatly reduce HIV-infected births. Family planning providers will need considerable additional training, support, and motivation to serve HIV-infected women effectively. Opportunities to prevent pregnancies among HIV-infected women and to prevent infection among reproductive-age women are being missed, but progress is being made.

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 2005, an alarming number of new HIV infections -- about 700 000 -- occurred among children, the vast majority of whom were infected by their mothers.¹ Four main approaches to reducing such infections have been promoted by the World Health Organization (WHO) and its United Nations partners.² To date, funding for developing countries has primarily supported an approach of providing voluntary counselling 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 unplanned pregnancies among HIV-infected women and preventing HIV infection among reproductive-age women.³

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 healthcare. Such integration can contribute to the prevention of mother-to-child transmission (PMTCT) of HIV in several ways:

• Integrating HIV counselling into family planning services helps prevent infection among women of reproductive age. Integrating VCT, as well, helps identify infected women who can then receive targeted family planning counselling and services.

• Integrating family planning services into VCT services and other HIV services helps those women who test positive prevent unintended pregnancy. It also helps those who test negative (but are sexually active, of reproductive age, and at risk of infection) avoid unintended pregnancy.

• Integrating HIV counselling and VCT into antenatal care (ANC) services (the usual site of PMTCT efforts) helps prevent infection among pregnant uninfected women. It can also identify pregnant women who are HIV infected. Integrating family planning services into ANC can help pregnant, infected women to later avoid an unintended pregnancy. 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.⁴ 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 non-governmental organisations, 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 US Agency for International Development, 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 programme development, resource mobilisation, 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 counselling 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. 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 stigmatise and discredit existing family planning services must be overcome. Training about universal infection-control precautions may be necessary to quell provider 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.⁵ 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.

Like family planning services, ANC services face the challenge of determining a woman's HIV status. The introduction of VCT provision into the antenatal care setting has the potential to be quite effective. For example, in a pilot study of same-day VCT in six urban antenatal care clinics in Lusaka, Zambia, 84% 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 4-year study to examine the introduction of PMTCT services within maternal and child health programmes in Kenya and Zambia, about two-thirds of more than 22 000 women who sought antenatal care as new clients received pretest counselling. 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 unavailable the same day or tests are expensive) and fears that test results will not remain confidential. Even when women are tested, a substantial number do not return for their results.

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 counselling. Adding family planning services requires additional skills, space, and staff capable of dispensing contraceptives.

Training issues require considerable attention. 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, while offering informed choice counselling that respects the reproductive rights of HIV-infected women. Providers 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. An evaluation of a PMTCT pilot programme in South Africa, for example, 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.⁸

Another challenge is to ensure that PMTCT programmes meet the family planning needs of their adolescent clients. Adolescents seen at antenatal care 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 counselling and services are unavailable to them.

Missed opportunities, but progress continues

In an evaluation of pilot PMTCT projects supported by the United Nations and initiated in 11 primarily African countries in 1999-2000, all national-level programme managers reported that their PMTCT programmes (centred within ANC and maternal and child healthcare) included family planning services. Most sites offered both family planning counselling and contraceptive methods, either in the same building or next to it, as part of clients' routine care. However, PMTCT programmes 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.⁹

The extent to which pilot PMTCT programmes address family planning (and vice versa) was also evaluated as part of a 4-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.¹⁰ Among its findings:

• Opportunities to counsel clients about family planning were missed. In Zambia, for example, slightly more than a third of PMTCT clients -- regardless of HIV serostatus -- received family planning counselling during their antenatal care visit. At the two Kenya sites, about a fifth of clients discussed family planning during their antenatal care visit, and women rarely received postpartum family planning counselling. Although many women reported current use of a family planning method, they did not receive family planning counselling linked to PMTCT goals or the particular needs of HIV-infected women.

• PMTCT services did not appear to influence uptake of contraceptive methods (except for condoms) in settings of low contraceptive prevalence, scarce resources, and high HIV prevalence. Notably, in these settings, family planning and PMTCT services are generally parallel rather than integrated. In both Zambia and Kenya, for example, postpartum family planning prevalence among women who received antenatal care at a PMTCT site was comparable to contraceptive prevalence reported in recent Demographic and Health Surveys. Also, HIV-infected women were no more likely than uninfected women to be using a modern method of family planning.

• At two sites (one in Zambia and one in Kenya), 39% and 65%, respectively, of HIV-infected women reported that they had a regular sexual partner but were using no family planning method.

An analysis by Population Council researchers of the integration of family reported in April of 2004 and based on field experiences in Cameroon, Kenya, Namibia, South Africa, Uganda, Brazil, the Dominican Republic, India, and Thailand,¹¹ 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 tended to be separate programmes, often with separate funding. Finally, little monitoring and evaluation of family planning as a PMTCT service existed.

Of note, however, the researchers 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. 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 re-infection 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 towards condoms among HIV-infected women and to 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 programmes is bearing fruit and should be continued.

References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO). AIDS Epidemic Update. Geneva, Switzerland: UNAIDS/WHO, 2005.
2. World Health Organization (WHO). Strategic Approaches to the Prevention of HIV Infection in Infants. Report of a WHO meeting, Morges, Switzerland, March 20-22, 2002.
3. O'Reilly K. Preventing HIV in infants and young children. PMTCT and integration. Reproductive Health in the Age of HIV/AIDS, San Juan, Puerto Rico, May 28-30, 2003.
4. Strachan M, Kwateng-Addo A, Hardee K, et al. An Analysis of Family Planning Content in HIV/AIDS, VCT and PMTCT Policies in 16 Countries. POLICY Working Paper Series No. 9. Washington, DC: The Futures Group, 2004.
5. Preble EA, Huber D, Piwoz EG. Family Planning and the Prevention of Mother-to-Child Transmission of HIV: Technical and Programmatic Issues. Arlington, VA: Advance Africa, 2003.
6. Bakari JP, McKenna S, Myrick A, et al. Rapid voluntary testing and counseling for HIV. Acceptability and feasibility in Zambian antenatal care clinics. Ann NY Acad Sci 2000; 918: 64-76.
7. Rutenberg N, Nduati R, Mbori-Nagcha D, et al. HIV Voluntary Counseling and Testing: An Essential Component in Preventing Mother-to-Child Transmission of HIV. Washington, DC: Population Council, 2003.
8. Health Systems Trust and Department of Health, Republic of South Africa. Interim findings on the national PMTCT pilot sites: lessons and recommendations (PDF, 356 KB), 2002.
9. Rutenberg N, Baek C, Kalibala S, et al. Evaluation of United Nations-Supported Pilot Projects for the Prevention of Mother-to-Child Transmission of HIV. New York, NY: United Nations Children's Fund and Population Council, 2003; Rutenberg N, Baek C, Siwale M, et al. Family Planning and PMTCT Services: Examining Interrelationships, Strengthening Linkages. Washington, DC: Population Council, 2003.
10. Rutenberg, Baek, Siwale.
11. Rutenberg N, Baek C. Review of Field Experiences: Integration of Family Planning and PMTCT Services. New York, NY: Population Council, 2004.

This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk).