1. Integration of FP into HCT, PMTCT, and ART Services Training Package Powerpoint Content

2. 1. Overview of Training Course This Family Planning/HIV Integration course is intended for trained, practicing HIV providers working in HCT, ART, and PMTCT services. It presents key family planning (FP) information for: Providing high-quality, efficient FP counseling on all contraceptive methods and on safer pregnancy into HIV services Initiating clients on condoms, contraceptive pills, and injectables Making FP considerations specific to HIV+ clients Recording FP/HIV integration services and referring clients appropriately

3. 2. Unit 1 Introduction Unit 1 includes: Rationale and benefits of FP/HIV integration Importance of dual method use Challenges of integration and solutions for successful implementation

4. 3. Levels of FP/HIV Integration Level 1: Risk assessment for unintended pregnancy; provision of FP; provision of condoms and pills (including emergency contraceptive pills). Level 2: Includes all elements of the first level and the provision of injectable contraceptives. Level 3: Includes everything in level 2 as well as the provision of intrauterine contraceptive devices (IUDs) and implants. Level 4: Includes provision of all contraceptive methods including permanent/surgical methods.

5. 4. Unit 2 Introduction Unit 2 includes: FP decision-making rights of clients FP counseling principles and practice Importance of informed choice and informed consent Special issues for counseling for clients with HIV, men, and adolescents

6. 5. Basic Rights of FP Clients Information Access Choice Safety Privacy Confidentiality Dignity Comfort Continuity Opinion

7. 6. Reasons for Choosing Contraception Desire to delay the birth of a first child Space the birth of children Limit number of births/children PMTCT Ensure dual method use/dual protection Protect sexual and reproductive health Economic reasons

8. 7. FP Counseling Explores contraceptive options Provides accurate and unbiased information about the methods Clarifies client feelings and values about using contraception Identifies client reproductive goals, and concerns about safety, effectiveness, and reversibility Supports client to come to his or her individual decision

9. 8. Informed Choice For informed choice, the client needs to know: The range of all methods available, Characteristics of each method, Possible side effects, and The risks of not using any method.

10. 9. Informed Consent Means a client has been counseled thoroughly regarding all the components described in the section on informed choice, and that based on this information, s/he has freely and voluntarily decided which method s/he wants to use.

11. 10. Screening for FP Need 3 Key Questions: 1.Are you currently pregnant? 2.Do you want to become pregnant in the next year? 3.Are you currently using a contraceptive method? Conclusions: Unmet FP Need, No FP Need, or Met FP Need

12. 11. Unit 3 Introduction Unit 3 includes: Full information for initiating clients on condoms, contraceptive pills, and implants Key information for counseling and referring clients for implants, IUD, permanent methods, and natural and fertility-awareness based methods FP considerations specific to HIV+ clients (including contraindications with ARVs and common OI drugs)

13. 12. Essential Principles of FP Counseling in HIV Services Every HCT, ART, and PMTCT client should be assessed for FP need. HCT, ART, and PMTCT clients have the right to make their own FP choice, including safer pregnancy for HIV+ women. Quality FP counseling and services should reinforce clients’ ability to limit HIV transmission to HIV-negative partners and to infants, if desired.

14. 13. Key Messages for FP Counseling in HIV Services Generally, HIV-positive clients can use most contraceptive methods, even on ARVs. Dual method use, using condoms to protect against HIV/STIs and unintended pregnancy, as well as a second contraceptive method for better protection from unintended pregnancy, should be included in FP counseling for clients with HIV.

15. 14. Contraceptive Methods Male and female condoms Oral contraceptive pills (OCPs), including combined oral contraceptives (COCs) and progestin-only pills (POPs) Injectable contraceptives (DMPA, NET-EN) Implants (Jadelle, Implanon) Intrauterine contraceptive devices (IUDs) Permanent methods (tubal ligation and vasectomy) Emergency contraceptive pills (ECPs) Natural and fertility-awareness methods

16. 15. Essential Elements of FP Client Education How the method works, Method effectiveness, Advantages and disadvantages of the method, Side effects and complications of the method, and How to use the method correctly.

17. 16. Safer Pregnancy Considerations HIV+ clients desiring a pregnancy need to consider: HIV and STI transmission to their partner HIV transmission to their baby Client health status

18. 17. Safer Pregnancy Recommendations HIV+ clients desiring a pregnancy should: Ensure both partners have been tested for HIV and have disclosed their status to each other Get appropriate care and treatment Avoid sex without a condom except during fertile days of the woman’s menstrual cycle Not take EFV (HIV+ women desiring a pregnancy) Reduce the risk of mother-to-child transmission by making sure: the HIV+ woman’s viral load is not high and her CD4 count is not low, the, the HIV+ pregnant woman attends regular ANC and PMTCT visits (to get ARV medicine and infant feeding counseling).

19. 18. Dual Protection and Dual Method Use Dual protection is the use of condoms to protect against HIV/STIs and pregnancy. Condoms are very effective at preventing HIV/STIsand pregnancy when used correctly and consistently. Dual method use means using condoms to protect against HIV/STIs and unintended pregnancy and as well as a second contraceptive method for better protection from unintended pregnancy. Dual method use is preferable for couples who do not desire a pregnancy because it improves unintended pregnancy prevention.

20. 19. Condoms Effective if they are used correctly every time you have sexual intercourse Provide protection from HIV/STIs, as well as pregnancy when properly used Not as effective for pregnancy prevention as other contraceptive methods in typical use Safe and have virtually no side effects Require motivation and partner cooperation to use consistently and correctly Female condoms may require partner cooperation PLHIV and their partners, and everyone, young and old, need to know how to use condoms

21. 20. COCs Safe and 98% effective if taken every day; Less effective if the woman sometimes misses a pill Easy to initiate and discontinue; Fertility returns immediately Beneficial non-contraceptive effects: regular/light menses, protection from ovarian and endometrial cancer, protection from symptomatic PID and anemia Common side effects: breakthrough bleeding and spotting, headaches, nausea, breast tenderness, weight gain (serious complications very rare) Not for breastfeeding women No protection against STIs, including HIV

22. 21. POPs Safe and very effective; Must be taken at approximately the same time every day Do not affect the quantity or quality of breast milk Easy to initiate and discontinue; Fertility returns immediately Beneficial non-contraceptive effects: light menses Common side effects: nausea, dizziness, headaches, breast tenderness, irregular menses/spotting (serious complications very rare) Do not have estrogen-related side effects and complications Do not protect against STIs, including HIV

23. 22. Injectables Highly effective, safe, and easy to use Reversible, with some delay in return to fertility Have no affect on quality or quantity of breast milk Beneficial non-contraceptive effects: protection from endometrial cancer, symptomatic PID, sickle cell crises, and anemia Common side effects: irregular bleeding, prolonged/heavy bleeding, absence of menstrual bleeding Provide no protection from STIs, including HIV

24. 23. Implants Highly effective, safe, and easy to use Long-term pregnancy protection, but easily reversible Do not interfere with intercourse, private Have no affect on quality or quantity of breast milk Beneficial non-contraceptive effects: protection from symptomatic PID and anemia Insertion involves a minor surgical procedure and some discomfort for a day or two Provide no protection from STIs, including HIV Provider needed to insert and remove

25. 24. IUDs Highly effective, safe, and easy to use No constant supplies needed Does not interfere with intercourse Rapid return to fertility Provider needed to initiate and discontinue use No protection against STIs, including HIV Beneficial non-contraceptive effect: possible endometrial cancer protection Common side effects: mild cramping and bleeding (serious complications very rare)

26. 25. Voluntary Surgical Contraception Highly effective, safe, and easy to use Permanent (male sterilization takes 3 months to become effective); Chance of regret Has no chemical or hormonal side effects No protection from STIs, including HIV Can be used by women and men of any age or reproductive parity, who are certain they do not want/must not have additional children. Beneficial non-contraceptive effect of female sterilization: protective from ovarian cancer and symptomatic PID Does not interfere with intercourse Surgical procedure (with some discomfort)

27. 26. Emergency Contraceptive Pills Prevent or delay the release of eggs from the ovaries Do not work if taken accidentally when woman is already pregnant Prevent fertilization Prevent transport of the sperm and egg Effective when taken within the first 5 days after unprotected intercourse; the sooner the better

28. 27. Natural Methods Includes: Abstinence, Coitus Interruptus, Fertility-Awareness Based Methods/Periodic Abstinence (such as Standard Days Method) – Require partner cooperation, no side- effects, difficult to practice, no STI/HIV protection – Can be combined with condom use during fertile period for better effectiveness Lactational Amenorrhea Method (LAM) – highly effective when conditions met (no menses, first 6 months, feeding 8-10 times day/night), temporary, no STI/HIV protection

29. 28. FP Considerations for HIV- Positive Clients (1) FP/HIV Integration Provider Reference Tool: Family Planning Considerations Specific to HIV-Positive Clients is a useful tool to show key messages for FP/HIV integration counseling and to identify the interactions between contraceptives and safer pregnancy, and ARVs and common OI treatment. It shows that most FP choices are appropriate for HIV+ clients with no reservations.

30. 29. FP Considerations for HIV- Positive Clients (2) It also shows that it is generally possible for: Clients on NNRTIs to use COCs, POPs, NET-EN injectables, or implants, but these clients should be advised to practice dual method use by adding condoms and practicing perfect use of the method (taking pills at the same time every day, returning for injection on time). Clients on Ritonavir/Ritonavir-boosted Protease Inhibitors to use NET-EN injectables or implants, but these clients should be advised to practice dual method use and practice perfect use of the method. Clients with clinical AIDS (not doing well on ARVs) to undergo VSC unless the risk of infection outweighs the client’s desire for the procedure.

31. 30. FP Considerations for HIV- Positive Clients (3) Finally, it shows that it is NOT recommended for: HIV+ clients desiring a safer pregnancy to use EFV, Certain Anti-Convulsants, or Systemic Anti-Fungals. Also, clients desiring a safer pregnancy should not have untreated Chlamydia and/or gonorrhea, or have clinical AIDS (not doing well on ARVs). Clients on Ritonavir/Ritonavir-boosted Protease Inhibitors to use COCs or POPs. Clients on Rifampicin and/or Certain Anticonvulsants to use COCs or POPs. Clients with untreated Chlamydia and/or gonorrhea, or clinical AIDS (not doing well on ARVs) to initiate IUD use.

32. 31. Unit 4 Introduction Unit 4 includes: Reporting on FP counseling and services Referring HIV clients for FP services Putting FP/HIV integration into practice through planning

33. 32. FP/HIV Integration Recordkeeping Three columns are useful to collect FP counseling and service information: 1. FP Need – “Met”, “Unmet”, or “No need’ 2. Method Provided – method name, also indicate new or continuing user 3. Referral – method name and facility location Providers trained in FP/HIV integration should negotiate adaptations to register forms with local health management.

34. 33. Referrals Co-located services (same physical location) may not require any referral. Intra-facility referral integrated services are offered through different services within the same facility. Inter-facility referral is when the client will have to see another provider in another facility to get their method of choice. All HIV service sites should have FP referral directories that list which services are available—these should include intra- and inter-facility services, and should also indicate costs, distances, and contact persons, if possible.

35. Thank You June 2010 Alden Nouga MPH, Pathfinder International Alemayehu Ayalew MD, Pathfinder International/Ethiopia