Meeting the family planning needs of women living with HIV in US government global health programs

Abstract

The integration of health programs, including HIV and voluntary family planning, is a priority for US government foreign assistance. One critical component of family planning and HIV integration that has significant positive health outcomes is ensuring that all women living with HIV have access to both a full range of contraceptives and safe pregnancy counseling. This article outlines the US government global health strategy to meet the family planning needs of women living with HIV based on three key principles: a focus on reproductive rights through voluntarism and informed choice, quality service provision through evidence-based programming, and development of partnerships.

Introduction

As defined by the seminal 1994 International Conference on Population and Development (ICPD) Program of Action in Cairo, of which the US government is a signatory, reproductive rights rest on the recognition that all couples and individuals have the basic right to freely decide the number, spacing, and timing of their children. To fulfill this right, all couples and individuals should have access to the highest standard of sexual and reproductive health, including access to the information and means necessary to make informed reproductive health decisions. These decisions should be free of discrimination, coercion, and violence [1]. The US government is committed to meeting the reproductive health needs of people living with HIV (PLHIV) by improving their access to voluntary family planning counseling and services, including safe pregnancy counseling, through integration of family planning services into HIV prevention, care, and treatment programs.

Increasing PLHIV’s access to family planning services can have a positive impact on other health outcomes. Women living with HIV (WLHIV) are at greater risk of adverse obstetrical or neonatal outcomes and are almost twice as likely to die in childbirth as HIV-negative women [2–4]. Although maternal deaths have decreased worldwide since 1980, modeling data indicate that maternal mortality rates would have decreased even further if the HIV epidemic had not contributed to substantial increases in maternal mortality in eastern and southern Africa [3]. Modeling data also suggest that programs must address unmet need for family planning among WLHIV to achieve virtual elimination of new pediatric HIV infections [5]. Ensuring all WLHIV have access to a full range of contraceptives and safe pregnancy counseling, therefore, can significantly reduce unintended pregnancies among WLHIV, maternal deaths related to HIV, and new pediatric infections.

Unfortunately, many studies indicate that men living with HIV and WLHIV continue to face difficulties accessing family planning services. In one Ugandan study, 75% of PLHIV (men and women) reported an unmet need for contraception, compared with 33% of uninfected individuals [6]. Rates of unintended pregnancy among WLHIV range from 51 to 91% in studies in three countries [7–9]. Further data are needed to determine whether HIV status exacerbates the already high levels of unmet need in sub-Saharan Africa. In addition, some PLHIV who wish to have children report experiencing stigma and discrimination from their communities and healthcare providers. Challenges to family planning service provision are numerous and include poor coordination between HIV and family planning programs, inadequate forecasting and supply chain systems, and lack of adequate training for HIV care providers on family planning service provision.

Recently, the global health community has set ambitious goals related to both HIV and family planning. These goals include working toward an AIDS-free generation [10], keeping mothers alive [11], and enabling an additional 120 million women to obtain contraceptives by 2020 [12]. The US government is fully committed to reaching these targets, with President’s Emergency Plan for AIDS Relief (PEPFAR) leading the US global response to HIV/AIDS, and the U.S. Agency for International Development (USAID) leading the US effort to strengthen and expand access to voluntary family planning and related reproductive health information and services.

The integration of health programs, including HIV and family planning programs is a priority for the US government and is outlined as a key strategy to strengthen existing foreign assistance programs in the Global Health Initiative (GHI) [13]. USAID’s Family Planning/Reproductive Health (FP/RH) program has prioritized the integration of HIV and family planning services for several years. More recently, PEPFAR-supported programs have been increasingly optimized as a platform to integrate, among other health services, family planning services, including safe pregnancy counseling, to women and men living with HIV. Effective and efficient integration of HIV and family planning services makes use of diverse entry points, reduces organizational ‘silos’, and improves comprehensive care for clients. More importantly, integrated services can ensure that all PLHIV have access to family planning services that support their fertility choices. Integrated HIV and family planning programming is promoted in US government programs through the support of research studies, documentation of good and promising practices, and technical assistance to national programs to scale up integration models. As there is no ‘one size fits all’ approach to HIV and family planning service integration, USAID’s FP/RH program and PEPFAR have supported different models of integration based on consideration of the country-specific context (e.g., modern contraceptive prevalence rate, HIV prevalence) and other factors including cost–effectiveness, supply chain management, and policy environment.

Guiding principles of the United States government’s response on HIV and family planning integration

All HIV and family planning programs supported by US government foreign assistance funds are subject to legislative and policy requirements outlined by the US Congress. These requirements state that the choice to accept a family planning method should be completely voluntary; free of coercion, duress, or stigmatization; and informed by accurate, comprehensible information. In addition, the provision of health services, including antiretroviral treatment, should never be conditioned on acceptance of a family planning method.

For nearly 50 years, USAID’s FP/RH program has supported national governments and nongovernmental organizations to implement technically sound and rights-based activities that improve access to voluntary family planning information, services, and commodities. USAID’s FP/RH expertise in this area is increasingly being shared across PEPFAR implementing agencies through a newly created task force on family planning/HIV integration. This task force, made up of representatives from USAID’s FP/RH program and PEPFAR implementing agencies [i.e., USAID’s Office of HIV/AIDS, U.S. Centers for Disease Control and Prevention (CDC), the U.S. Department of Defense (DoD), and the Office of the Global AIDS Coordinator (OCAC)], has agreed on three key principles to guide the US government’s HIV and family planning integration efforts: a focus on reproductive rights through voluntarism and informed choice, quality service provision through evidence-based programming, and development of partnerships.

USAID’s FP/RH program and PEPFAR have consistently incorporated emerging scientific evidence and lessons learned in the field into guidance documents and strategies. This includes underscoring the importance of partnering with national governments, other bilateral donors, and civil society to optimize the delivery of various health services within existing programs. Partnerships are a key guiding principle to US government global health assistance. Worldwide, USAID is the largest bilateral family planning donor, whereas PEPFAR is the largest bilateral HIV donor. However, unless significant and sustainable partnerships are in place, US government efforts will fall short. Therefore, US government global health assistance is focused on strengthening the capacity of countries to deliver effective, comprehensive, and equitable health services. In line with the GHI principles of country ownership, PEPFAR and USAID’s FP/RH program are committed to partner with and support all key stakeholders to ensure a strengthened national response for both HIV and family planning programs. Table 1 provides illustrative examples of how US government programs have incorporated the three guiding principles into existing programming.

Table 1.

Illustrative examples of how United States government foreign assistance programs have incorporated the three guiding principles for family planning/HIV integration into existing programming.

Principle 1: Reproductive rights through voluntarism and informed choice

Guiding principles respecting voluntarism and informed choice were included in the Fiscal Year (FY) 2013 PEPFAR Country Operational Plan (COP) Guidance [14].

Training materials for specific programmatic contexts (e.g., PMTCT, HIV care and treatment, etc.) were developed to ensure all US government-supported family planning-HIV activities uphold the highest standards.

Resources and processes have been developed by each PEPFAR implementing agency, with guidance from USAID FP/RH, to ensure compliance with US government requirements.

Principle 2: Quality service provision

To scale up family planning-HIV integration activities, PEPFAR’s FY13 Technical Considerations and FY13 Country Operational Plan Guidance directs country teams to prioritize opportunities to integrate voluntary family planning services into PEPFAR-supported care, treatment, and PMTCT platforms.

PEPFAR guidance also encourages country teams to focus on addressing structural and institutional barriers to family planning-HIV integration including lack of trained health personnel, weak commodity supply chains, gender inequality, stigma and discrimination, and lack of involvement of PLHIV in the development, provision, and monitoring of family planning-HIV services [14,18].

Technical assistance to national programs has been provided by both USAID FP/RH and PEPFAR to scale up family planning-HIV integration models that are suitable to the country and regional context.

Particular attention has been paid to supporting evidence-based interventions to increase access to family planning services including promoting family planning as a part of routine HIV services, and ensuring early postpartum visits include both family planning and HIV services [15].

USAID’s FP/RH program has supported dissemination of best practices for family planning-HIV integration through a Cochrane review [16]; documentation of promising programmatic models from Nigeria, Uganda, Zambia, Malawi and Tanzania; and development of a technical guidance document for program planners, implementers, and other country level stakeholders in collaboration with FHI 360 [17].

Principle 3: Development of partnerships

PEPFAR has supported multiple countries including Tanzania, Namibia, Kenya, Rwanda, Ethiopia, Cote d’Ivoire, Mozambique, Nigeria, Malawi, and South Africa to develop national guidelines and trainings for integrating family planning services into facility-based care for PLHIV.

PEPFAR has also supported integration of family planning into community care services including support groups and home-based care programs in Kenya, Democratic Republic of Congo, Ethiopia, Zambia, and Tanzania.

In Rwanda, USAID’s FP/RH program and PEPFAR supported the development of a national level HIV and family planning integration work plan that focused on improving supply chain management [18].

In the Democratic Republic of the Congo, PEPFAR and USAID’s FP/RH program worked together to ensure that contraceptive commodities procured by USAID are available at every PEPFAR-supported PMTCT site.

In Ethiopia, PEPFAR and the United Nations Population Fund (UNFPA) have supported preservice training on family planning-HIV integration in the emergency surgical officer program and the health extension worker program.

In Zambia, PEPFAR works with the Ministry of Health to ensure family planning counseling is a core element of HIV services offered at more than 380 health facilities in six provinces. As a result, the number of counseling and testing clients referred for family planning services increased from 75 to more than 2500 and the number of treatment clients referred for family planning services increased from 0 to 329 [19].

In Tanzania, PEPFAR supports the Ministry of Health to integrate family planning counseling at PMTCT sites by supporting training for clinical providers, supervision, quality assurance, and capacity building. As a result of this work, over 80% of PMTCT clients are receiving family planning information [20]. In addition, private funding is being leveraged to complement PEFPAR funds to provide family planning services as part of a community-based HIV care program using community-based distributors.

FP, family planning; PMTCT, prevention of mother-to-child transmission.

Contraceptive security

Contraceptive security is imperative for HIV and family planning integration to be successful. Contraceptive security exists when women and men can choose, obtain, and use a wide range of high-quality, affordable contraceptive methods, including male and female condoms, to prevent acquisition and transmission of HIV and other sexually transmitted infections (STIs). Contraceptive security programs must include financing for supplies, systems, staff, and facilities; a commitment by local political and health leaders to ensure availability of contraceptives including selection, regulation, quality, pricing, and authorizing services by a cadre of health workers; capacity of staff and systems to manage/report on products and services; and coordination with global, regional, national, and local stakeholders.

For over a decade now, USAID’s FP/RH program has been working with national governments, bilateral and multilateral donors, and other partners on establishing and strengthening national level contraceptive security committees. Such bodies are responsible for a number of commodity security components, including national level forecasting and quantification of family planning commodities as well as strengthening distribution systems. In coordination with the Global Fund to Fight AIDS, Tuberculosis and Malaria and other partners, PEPFAR supports similar national level committees for HIV commodities, including antiretrovirals. In order for sustainable HIV and family planning service integration at a large scale, it is critical that the contraceptive commodity needs of HIV platforms be considered during contraceptive security processes at the national and global levels. Both PEPFAR implementing agencies and USAID FP/RH programs have an important role to play in ensuring that contraceptive commodities reach the populations that need them, including condoms in family planning programs and a broad range of contraceptive commodities in HIV programs.

Although PEPFAR funds cannot be used to directly procure contraceptive commodities other than male and female condoms (which serve the dual purpose of HIV prevention), contraceptives procured from other sources, including USAID’s FP/RH program can be provided as part of PEPFAR-supported facility and community-based programs. PEPFAR is committed to working with USAID’s FP/RH program and other family planning and HIV donors to improve forecasting and supply chain management systems to ensure contraceptive commodities are available in HIV programs.

United States government support for multipurpose prevention technologies and women-initiated HIV prevention technologies

Multipurpose prevention technologies (MPTs) are defined as products that prevent unintended pregnancy, HIV infection, and/or other STIs. Male and female condoms are currently the only MPTs available. USAID’s FP/RH research and development portfolio includes investments in new MPTs, such as intravaginal rings and vaginal gels and films that are effective for up to 90 days. In addition, new female condoms are currently in development. For now, US government programs continue to procure and promote the current male and female condom to a variety of target populations. In addition, given gender inequities that fuel the spread of HIV, it is important to consider HIV prevention and contraceptive alternatives that are woman-initiated. In response, over the last decade, PEPFAR has made significant investments in woman-initiated HIV prevention technologies such as vaginal microbicides.

Future directions

Although much has been done by the US government to support HIV and family planning integration, there is still a great deal more to do. Key challenges that must be addressed include lack of coordination between family planning and HIV government programs both on the donor and host country side leading to vertical service delivery and commodity security systems; lack of trained providers to deliver high-quality integrated services; lack of data on the effectiveness of different models for integration; and inadequate monitoring and evaluation of integrated services. USAID’s FP/RH program and PEPFAR will continue to work together to ensure that integration maximizes resources and results across our foreign assistance programs – with a focus on overcoming the challenges outlined above. In particular, the PEPFAR Blueprint and PEPFAR Technical Considerations have outlined key areas of focus for family planning integration within HIV platforms. In addition, improving access to voluntary family planning information, services, and commodities regardless of an individual’s HIV status remains at the core of USAID’s FP/RH program, and integration will continue as a technical priority for the foreseeable future.

Moving forward, the US government will expand its efforts to achieve the following goals:

1. Strengthen public health and primary healthcare systems, including commodity procurement, information systems, and logistics and distribution systems to improve the availability of HIV and family planning commodities within integrated programs;

2. Strengthen the policy environment for smart integration of HIV and family planning platforms and services;

3. Evaluate the efficiency and effectiveness of integrated HIV and family planning service delivery;

4. Support quality assurance efforts that support integrated HIV and family planning activities;

5. Conduct implementation science research on effective HIV and family planning integration approaches;

6. Develop and disseminate technical guidance materials related to HIV and family planning integration and;

7. Document successful and promising approaches.

In summary, the US government remains committed to increasing PLHIV’s access to voluntary family planning information and services, including safe pregnancy counseling. GHI and PEPFAR guidance provide a supportive framework to pursue strategic integration of family planning services in HIV platforms. Promising practices are already emerging and important lessons are being learned from current integration activities, some of which can be replicated in other countries and settings. The US government will continue to partner with local organizations, Ministries of Health, the private sector, civil society, multilateral and bilateral donors, as well as other key stakeholders to strengthen both the policy environment and programming for HIV and family planning integration.