Global SRH/HIV Integration National HIV Prevention Conference “Integration of Services: National and International Perspectives” Atlanta, GA August 24, 2009
The Three Cultures FP STD HIV
Access to HIV Prevention Tools – Low Resource Countries, 2004 -2006/7 Estimates of Coverage HIV testing 5% 80% 85% 10% Male Circumcision 20% 9% 15% Condom Use Antiretrovirals for PMTCT Unmet Need for HIV Prevention 90% 9% Contraception for PMTCT 14% 0% 32% 68% 85% 15% 2004 40% 2006/7 60% 80% 100% Unmet HIV Prevention Need Sources: UNAIDS, 2004; UNICEF, 2008; UNGASS, 2008
Dual Protection - Key Concepts • Risks of pregnancy and infection • Effectiveness of contraception – ideal use – typical use • Effectiveness of HIV prevention – ideal use – typical use
Risk of HIV Acquisition, By Consistency of Condom Use, Discordant Couples HIV Incidence/ 100 PY 7 6. 5 5. 1 5 3 1 0 0. 9 Always Sometimes “Consistent” “Inconsistent” Never “Nonuse” Source: Davis and Weller (1999)
WHO - Four Phases of PMTCT 4 Phase Approach to Perinatal HIV Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIVinfected women Prevention of transmission from an HIVinfected woman to her infant Phase 1 Phase 2 Phase 3 Support for mother and family Phase 4
Women with HIV Also Have Unintended Pregnancies • 84% unintended pregnancies among PMTCT clients in South Africa • 51% unintended pregnancies among women with HIV in Cote d’Ivoire • 74% unintended pregnancies among women in an ART program in Rwanda Sources: Rochat et al. , JAMA 2006: 295: 1376 -8; Desgrées-du-Loû et al. , Int J STD AIDS 2002; 13: 462 -468; Bangendanye, et al. , Presented November 2007.
# of infants/births, in 1000 s Contraception as HIV Prevention – Compared to ARVs 800 700 600 500 400 300 200 100 0 735 220 50 ARVs (over 1 year) Effective Contraception (over 1 year) # infants spared HIV infection # unintended births prevented Sources: PEPFAR (2009), Reynolds (2008)
Contraception – The BEST KEPT SECRET in HIV Prevention • Effective contraception for HIV-infected women who do not wish to become pregnant – Prevents more infants becoming infected than NVP – Decreases the number of future orphans • Key Question – how best to promote the SRH/HIV linkages?
SRH and HIV: Key Linkages SRH • Family Planning • Maternal & infant care • Management of sexually transmitted infections • Management of other SRH problems Key Linkages Learn HIV status Promote safer sex Optimize connection between HIV/AIDS and STI services HIV/AIDS • Prevention • Treatment • Care • Support Integrate HIV/AIDS with maternal and infant health Source: WHO/UNAIDS, IPPF/UNFPA (2005)
FP/HIV Integration Challenges • Operational models • Data inadequacies • Existing infrastructures
The Interface Between HIV Programs and Health Systems Long-standing inadequacies lead to new opportunities for improved health care Inadequacies An organizational culture of service fragmentation Opportunities Integrated services in concept and in practice “The medicines [contraceptives] that we use are in this room. They can’t be put in another room [the HIV care and treatment room]. ”
Service Delivery Opportunities: FP Added to HIV • Unmet need for FP and high levels of unintended pregnancy among clients of HIV services is well documented • Integrated services are acceptable to HIV providers and clients • Integrated services do not appear to negatively affect the quality of the basic service – whether VCT, PMTCT, etc.
Starting point … Hospital Ward Laboratory
FP/HIV Integration Catalysts • Rationale for FP/HIV integration wellestablished • Strong international FP/HIV policy support • Global Fund/World Bank/ PEPFAR/Foundation resources • Emerging focus on Health Services Strengthening
The Sexual Health Triad “Divided We Fail” FP STD HIV
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