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Family Planning and HIV: New Evidence That Integration Works

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Co-authored by Rose Wilcher

An AIDS-free generation. Eliminating pediatric HIV infections and keeping mothers alive. Providing 120 million more women with more convenient choices of effective contraceptives to avoid unintended pregnancies.

At this week's International Conference on Family Planning (ICFP), we are examining the latest evidence on integrating family planning and HIV service delivery. It shows that stronger linkages between family planning and HIV programs are critical to helping us realize these ambitious goals for global health.

A small but growing number of HIV prevention, care and treatment programs offer women a range of contraceptives, along with counseling about family planning and safe pregnancy. The aim of these programs is to save lives by supporting the fertility choices of women living with HIV.

For women with HIV who want to have children, preconception planning, good prenatal care and emergency obstetric care are crucial to ensure safe pregnancies and healthy outcomes. Closely spaced pregnancies are more likely to lead to adverse outcomes -- such as low birth weight, premature birth, infant death and maternal death -- and HIV infection compounds that risk. Compared to HIV-negative women, women living with HIV are almost twice as likely to die in childbirth.

For women with HIV who do not want to have children, access to effective contraception offers the added benefit of preventing mother-to-child transmission of HIV. About two-thirds of HIV-positive women report that their most recent pregnancy was unintended. At the same time, studies have found relatively low levels of contraceptive use among HIV-positive women who say that they do not want more children. This unmet need for family planning must be addressed if we are to achieve the goal of eliminating pediatric HIV infections.

New evidence shows promise

Four years ago, a systematic review of interventions linking family planning and HIV services found only four studies published from 1990 to 2007 that reported contraceptive use as an outcome; just one of them demonstrated a significant increase in contraceptive use among clients of HIV services.

The results of a new FHI 360 review are far more promising.

The review revealed that there is growing evidence on the benefits of integrating family planning into HIV services. Out of 12 studies published from 2008 to 2013, eight documented significant gains in contraceptive use by clients of HIV services, and three reported increases in successful referrals from HIV services to family planning clinics.

The review also pointed to weaknesses in the implementation of integrated services. The services provided at public-sector facilities had modest effects compared to those offered within clinical trials. Process evaluations of some programs showed that they had not been implemented as intended.

Published in a special supplement on family planning and HIV to the journal AIDS, these findings highlight the need to strengthen health systems to remove barriers to effective integration. Investments in implementation research are also needed to guide efforts to improve the reach and impact of integrated services.

In addition to articles about the integration of family planning and HIV services, the supplement contributes new evidence to a variety of ways in which the two fields intersect. For example, two articles examine the complexities of the inconclusive findings on injectable contraception and the risk of HIV acquisition. One article addresses preconception care for women and couples living with HIV, and another articulates the U.S. government's policy commitments to strengthening the linkages between family planning and HIV programs.

Some of the cutting-edge research and evidence-based recommendations that were published in the supplement are being presented during an ICFP panel discussion on November 13. This new evidence can help us advance the science and practice of family planning and HIV integration to meet the reproductive health needs of women living with HIV and move closer to an AIDS-free generation.

Ward Cates, M.D., M.P.H., is President Emeritus with FHI 360
Rose Wilcher, M.P.H., is a Technical Advisor in Research Utilization with FHI 360