1. Reproductive Health into HIV Care Integration Diane Cooper Women’s Health Research Unit, School of Public Health & Family Medicine, UCT

2. Background and Significance South Africa has one of the highest rates of HIV infection in the world -29.3% prevalence among pregnant women attending antenatal clinics in 2008 (NDOH, 2009) -In 2002, 53% of pregnancies were unplanned (36%) or unwanted (17%), even though 64% of sexually active 15-49 year-old SA women currently use contraception. (NDOH, 2007) South African women experience high rates of unintended pregnancy despite the availability and use of family planning services

3. Background & Significance (contin) Relatively little is known about the impact of an HIV diagnosis on contraceptive practices and fertility intentions of HIV+ men and women in developing countries –11% of women attending HIV Care in Cape Town had been pregnant since knowing dx, and 2/3 pregnancies were unintended (Cooper et al 2009) –Nearly 50% of recently diagnosed HIV+ women and men who enter the HIV care system are seeking or are open to the possibility of having children; this was confirmed in larger study (Cooper et al. 2009)

4. Linkages between SRH and HIV ( Source: WHO 2005 ) HIV+ conception and fertility intentions

5. Why integration? Health service integration involves some form of combining interdependent health programs or service elements Integration can occur both at the level of direct service provision to clients as well as at the level of the structure of management and organisational support of services By providing joint services, integration hopes :  to avoid duplication of program structures and services  maximize use of scarce resources  Allow greater program cost efficiency &effectiveness  allowing clients greater convenience of being able to receive a range of services simultaneously - promotes better client access to health services, with potentially positive consequences for client health

6. Integration of HIV & other services Sexually transmitted infection services Contraceptive services TB SRH into HIV care & treatment

7. Integration of SRH into HIV care & treatment Most people living with HIV (PLWH) are in the reproductive & productive years Important to:  Prevent unintended pregnancies  Prevent horizontal (to partners) & vertical (to infant) transmission  Ensure safer conception & pregnancy

8. Overview of intervention study integrating SRH into HIV care 4.5-year, multi-level structural intervention targeting HIV+ persons accessing public sector HIV Care Clinics in Cape Town, South Africa Addresses poor access to contraceptive services and at same time introduces enhanced counseling approaches that maximize sexual risk-reduction based on clients’ individual situations Combines quantitative and qualitative methodologies to address both clinic- and client-level factors Consists of three phases NIMH R01 MH078770-01

9. Enhanced Intervention vs. Standard of Care ENHANCED On site non-barrier contraception available from HIV care nurses On-site free male and female condoms SRH training, counseling and contraception Posters of HIV+ persons’ reproductive rights in waiting rooms/IEC Systematic, ongoing technical support STANDARD OF CARE No non-barrier contraception available On-site free male & female condoms No specific SRH training, counseling & contraception No systematic IEC promotion No systematic, ongoing technical support

10. Preventing pregnancy Methods available & dual method or dual protection Methods best for WLWH – ARV treatment Emergency contraception (‘morning after pill’) Termination of pregnancy Involvement of men Components of SRH-HIV integration

11. Safer conception Seroconcordant Male & female HIV-infected Serodiscordant Male HIV- infected Serodiscordant Female HIV- infected Resource limited - Ensure viral load in both woman and man are as low as possible (preferably on HAART) - Can try having unprotected sex only during the woman’s most fertile period -Explain the risks of contracting another viral strain of HIV. - PMTC - Encourage them to attend ANC once pregnant to ensure that they receive the best possible advice to minimize MTCT risk and to attend regularly. -The only very risk reduced method is through the HIV-infected man having his sperm washing to remove the HIV in a laboratory. This reduces the risk but is not risk-free -Can try manual self- insemination with a partner’s sperm - There are no risks of the man becoming infected in this way -Explain the risks of mother-to-child transmission and what can be done about this through PMTC - Encourage them to attend ANC once pregnant to ensure that they receive the best possible advice to minimize MTCT risk and to attend regularly.

12. Other SRH needs Sexual desire & functioning: women & men Erectile dysfunction & ageing: men Women: Cancer of the cervix & ageing: women STI & cross infection of HIV strains

13. Young people living with HIV (1) Growing concern - high number of HIV infected young people, in particular young women HIV cases among the young people - those were vertically infected (VIY), whose life expectancy has been increased through use of HAART) & those behaviourally infected (BIY) Behavioural infections among the youth account for large portion of new infections globally (45% of new HIV infections world wide in 2007 among young people 15-24 years) In S.A in particular, estimated that 38% of school learners have had sexual intercourse Of those that have begun sexual activity 13% initiated sexual activity before the age of 14

14. Young people living with HIV (2) Early age sexual debut - youth at > risk for HIV/AIDS & unintended pregnancies, other STIs & forces them to deal with SRH needs & rights at early age Adolescence: period of rapid change -children become adults & r ability to negotiate numerous physiological & social transitions smoothly largely dependant on health With changes in sexual activity young people often lack confidence & knowledge to assert reproductive needs & rights In countries with a high HIV prevalence - need to improve quality of SRH services available to the young people is urgent In many settings current SRH services offered do not adequately meet needs of young people

15. Proposed Study among young people living with HIV Understanding SRH needs of young people living with HIV in particular - critical to ensure health services adequately resourced & programs appropriately designed to meet diverse, common & specific needs Without this knowledge - difficult to advocate for program devt addressing SRH needs of young people living with HIV during critical stage of development & change in their lives Study will provide unique information on SRH needs of both vertically and behaviourally infected HIV positive youth in Cape Town. This formative research will be small collaborative project providing information on SRH needs of HIV positive youth -will be used to guide further counselling interventions - funding being sought

16. Agenda & needs: integrating SRH into HIV care: Assessment of SRH needs of WLWH & MLWH Provide knowledge of SRH for women living with HIV (WLWH) and men (MLWH) – esp. how fertility works Preventing conception in people living with HIV (PLWH): Contraception Safer conception and PMTCT for PLWH Other SRH needs SRH needs of young people living with HIV These models & agenda can be used in business sector too