Preventing HIV and Unintended Pregnancies: Strategic Framework In Support of the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive Lynn Collins

Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive

Reduce the number of new HIV infections among children by 90%. Two global targets by 2015 : Reduce the number of new HIV infections among children by 90%. Reduce the number of AIDS-related maternal deaths by 50%. 22 priority countries: Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.

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As women and their partners cycle between their communities and health services, they will accrue mutually reinforcing benefits from action taken within both spheres Page 6

Guiding Principles 1. Address structural determinants of HIV & SRH 2. Focus on human rights & gender 3. Promote a coordinated & coherent response (Three Ones Principle) 4. Meaningfully involve People Living with HIV (GIPA Principle) 5. Foster community participation by young people, key populations at higher risk, & the general community 6. Reduce stigma & discrimination 7. Recognize the centrality of sexuality as an essential element in human life and in the individual, family and community well-being. Page 17

Page 9 Offers guidance to: 1. Implement a package of services for preventing HIV and unintended pregnancies within stigma-free integrated SRH and HIV services 2. Utilise key entry points to integrating services for HIV and sexual and reproductive health 3. Strengthen national programme implementation, including to deliver prong 1 and 2 interventions e.g. national implementation check lists and service delivery checklists 4. Carry out five key strategies: Strategy 1: Link SRH and HIV at the policy, systems and service delivery levels Strategy 2: Strengthen community engagement Strategy 3: Promote greater involvement of men Strategy 4: Engage organizations of people living with HIV Strategy 5: Ensure non-discriminatory service provision in stigma-free settings 5. Outlines goals, targets and indicators 6. Identifies areas in need of operational research Page 9

Prong 1: primary prevention of HIV Target: 50% reduction in HIV incidence in women of reproductive age Page 18 & 64

Why prong 1 is important Supporting HIV-negative women to remain HIV negative especially during pregnancy and breastfeeding will: reduce the number of reproductive age/maternal deaths; and reduce the number of new HIV-positive infants, and improve child survival. Page19

Sero-conversion during pregnancy Women may be at increased risk of HIV during pregnancy & breast-feeding Page 19

Prong 1 Package of Essential Services Information and counselling to reduce the risk of sexual HIV transmission HIV testing & counselling; referral for or on site treatment Treatment for prevention STI screening and management Condoms (female and male): promotion, provision and building skills for negotiation & use Blood safety and anaemia prevention to reduce blood-related transmission GBV prevention and impact mitigation The Package of Essential Services (Table 2) for primary prevention of HIV is intended for use by programme managers and health providers. This package builds on the existing key elements of primary prevention of HIV in the context of maternal and child health (see Compendium of Annexes, Annex 4). It goes further, however, by providing the rationale for each service, related guidance to carry out each of the key actions, and reflects the most recent issues and research (e.g. treatment for prevention). All of these services can be carried out within maternal health and other SRH, and HIV services, and some can be carried out within the community (e.g. media, schools, workplace, community groups), (see Section 7 Entry Points). Note that the package of services should be modified according to the key features of the HIV epidemic and sexual and reproductive health needs in each country. For example, in settings where injecting drug use is a common mode of HIV transmission, increased emphasis should be given to harm reduction (see Section 3 Related programming guidance). The package of services consists of: Description of service How it contributes to prevention of unintended pregnancies Key Actions with references. Page 22 - 25

Challenges prong 1 Engaging male partners Potentially increased risk of infection (seroconversion) for women during pregnancy, postpartum and breastfeeding period Insufficient coverage & quality of HIV counselling and testing Inadequate condom use. GBV and STI management Eliminating stigma & discrimination Lack of access to ARV treatment (for prevention) Page 20 - 21

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Prong 2: prevention of unintended pregnancies Target: reduce unmet family planning need to zero (among all women) MDG 5B Page 26 & 64

Why prong 2 is important Reducing unintended pregnancies will: reduce the number of maternal deaths and improve maternal health, reduce the number of new HIV-positive infants, improve child survival by keeping their mothers alive, & empower women . Page 6 & 27

Prong 2 Package of Essential Services Information and counselling to support reproductive rights, including preventing unintended pregnancies Clinical management of HIV Rights-based family planning counselling and services STI screening and management GBV prevention and impact mitigation Stigma and discrimination eradication Each strategy recommends key actions at the policy, systems and service delivery levels with a corresponding set of reference numbers linked to related guidance documents in References to Key Strategies and Actions, and Packages of Essential Services. . These actions may be carried out by policy makers, programme managers, health providers and other members of the community. The package of services consists of: Description of service How it contributes to prevention of unintended pregnancies Key Actions with references. Page 32 - 34

Challenges prong 2 High level of unintended pregnancies and unmet need for family planning Lack of awareness of reproductive rights Stigma in health care settings and community Inadequate availability of and access to family planning services Page 27

Specific FP needs of HIV+ women Strengthened or additional information, counselling, & services are needed on : rights, including reproductive rights: respecting fertility, sexuality, and contraceptive method choices, which do not force or coerce women into abortion or sterilization; drug interactions: between some antiretroviral drugs and hormonal contraceptives; contraceptives: see WHO medical eligibility criteria for contraceptive use for HIV+ women . treatment for infertility: HIV+ women may be more likely to have difficulty in getting pregnant as a consequence of either her own reduced fertility or that of her partner; . potential risk to the woman’s health, if become pregnant: i.e. women with low CD4 counts, more susceptible during pregnancy to malaria and anaemia, HIV increases the risk of preterm birth and low birth weight, and more likely to be affected by reproductive health complications such as miscarriage, postpartum haemorrhage, puerperal sepsis and complications of caesarean section and unsafe abortion. Page 30 - 31

Specific FP needs of HIV+ women STIs: PLHIV may be at greater risk, specifically for: human papillomavirus (HPV): risk factor for cervical and anal cancers; syphilis: may manifest differently and require more aggressive treatment; genital herpes (HSV-2 or HSV-1), may be severer, as well as prolonged or atypical in presentation, particularly in those with low CD4 counts. Asymptomatic and symptomatic HSV-2 reactivation is also more frequent; serodiscordance: lowering the risk of HIV infection to serodiscordant partner, if intend to get pregnant (Treatment for Prevention); and potential risk to the woman’s health, if become pregnant. potential risk to the woman’s health, if become pregnant: i.e. women with low CD4 counts, more susceptible during pregnancy to malaria and anaemia, HIV increases the risk of preterm birth and low birth weight, and more likely to be affected by reproductive health complications such as miscarriage, postpartum haemorrhage, puerperal sepsis and complications of caesarean section and unsafe abortion. Page 30 - 31

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Preventing HIV and Unintended Pregancies: Strategic Framework supports the Global Plan 1. Implement package of services within stigma-free integrated SRH and HIV services 2. Utilise key entry points to integrating services for HIV and sexual and reproductive health 3. Strengthen national programme implementation 4. Carry out five key strategies Page 2

Checklists for national programme implementation Country implementation actions 10-point plan from Global Plan IATT tools and guidelines in support of Global Plan Checklists for prongs 1 & 2 The questions in the following two checklists for prongs 1 and 2 (Table 8 and 9) were derived from a case study in Swaziland on the implementation of prongs 1 and 2 (see Boxes 5: Linking SRH and HIV: Gateways to Integration - a Case Study from Swaziland: Towards elimination of mother-to-child transmission of HIV). They will help an organization assess whether it is effectively providing prongs 1 and 2 services. Page 40 - 50

Five Key Strategies 2: Strengthen community engagement 1: Link SRH and HIV at the policy, systems and service delivery levels 2: Strengthen community engagement 3: Promote greater involvement of men 4: Engage organizations of people living with HIV 5: Ensure non-discriminatory service provision in stigma-free settings Each strategy recommends key actions at the policy, systems and service delivery levels with a corresponding set of reference numbers linked to related guidance documents in References to Key Strategies and Actions, and Packages of Essential Services. . These actions may be carried out by policy makers, programme managers, health providers and other members of the community. Page 51

Strategy 1: Link SRH and HIV Page 52

Rapid Assessment Tool for SRH and HIV Linkages Assess HIV and SRH bi-directional linkages at the policy, systems, and service-delivery levels. Identify current critical gaps in policies and programmes. Contribute to the development of country-specific action plans to forge and strengthen these linkages. Focus primarily on the health sector. This tool was developed to help countries assess their current situation in relation to linkages. The purpose of this tool is (READ SLIDE) Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009. Page 53

Strategy 2: Engage Community Page 57

Strategy 3: Engage Men Fast‐tracking men/couples who come for ANC Providing clinical services for men who come (e.g. blood pressure screening, health check‐ups) Peer support for men living with HIV. Performance‐based agreement, with male engagement as one of the reportable indices Male champions to encourage other men to act Letters to partners encouraging clinic visits Transport vouchers for couples CHWs mobilising men Ecole de Mari (“husband schools”) Men often influence women’s access to and utilization of SRH and HIV services. Couples HIV counselling and testing can: increase awareness of HIV status; foster mutual disclosure, enhance the uptake of services, including ART for an HIV positive serodiscordant partner; and support each other to access and adhere to ART and eMTCT interventions. Treatment for prevention requires that men know their status and access ART, which will benefit themselves and serodiscordant partners. Page 57

Strategy 4: Engage PLHIV/Key Pop. All people living with HIV must be provided with accurate, non-judgmental information, counselling and other services, enabling them to exercise their rights and protect their SRH-related services. Meaningful involvement of people living with HIV requires investing in the development of organizations and groups of people living with HIV. It is the surest and most effective way to ensure accountability and is the cornerstone of any rights-based approach to eMTCT. Peer counsellors and support groups play a vital role in successful eMTCT and in maximizing outcomes for families living with HIV. The greater involvement of people living with HIV (GIPA) is recognized as a core principle of the HIV response, and is fundamental to eMTCT programming. Page 60

People Living With HIV Stigma Index Strategy 5: Eliminate Stigma & Discrimination People Living With HIV Stigma Index The People Living with HIV Stigma Index provides a tool that measures and detects changing trends in relation to stigma and discrimination as experienced by people living with HIV. (internal stigma, workplace, health services, family, personal relationships, etc.) Page 62

Cutting Edge Issues Box 4: Treatment as prevention Box 6: Specific family planning needs of women living with HIV Box 7: Hormonal contraceptives and HIV Page 21, 29, 30

Operational Research linked services targeting men and boys; Gaps: linked services targeting men and boys; gender-based violence (GBV) prevention; stigma and discrimination; and comprehensive SRH services for PLHIV, including addressing unintended pregnancies and planning for safe, desired pregnancies. Page 66