1. SRH/HIV Linkages: What’s The Rationale? Ward Cates, MD, MPH Family Health International World Bank Washington, DC November 19, 2008

2. Protect Women’s Health Family planning: –Delays first births –Lengthens birth intervals –Reduces the total number of children born to one woman –Prevents high-risk and unintended pregnancies –Reduces the need for unsafe abortion Source: USAID

3. Protect Women’s Rights All women have the right: –“To decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights.” Source: Convention on the Elimination of All Discrimination against Women

4. Contraception is HIV Prevention Contraception as HIV prevention: evidence of individual-level efficacy and effectiveness Family planning/HIV integration: evidence of population-level effectiveness Considerations for scale-up

5. Contraceptive Pregnancy Rates Oral Contraceptives Source: Trussell (2004); NCHS (2005) Percent of Women Pregnant in First Year of Use Rate during typical use Rate during perfect use Female/male sterilization Norplant/Depo-Provera Spermicides Diaphragm w/spermicides Male condom IUD (TCu-380A) 010 15 2025 5 Female condom

6. Four-component Strategy for Perinatal HIV Prevention Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV- infected women Prevention of transmission from an HIV- infected woman to her infant Support for mother and family Component 1Component 2Component 3Component 4

7. Pregnancies are Often Unintended or Unwanted Source: DHS and other surveys 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Nigeria Mozambique Tanzania Vietnam Côte d'Ivoire Rwanda Ethiopia Uganda Zambia Kenya Namibia South Africa Haiti Botswana % births unintended% births unwanted 28% 13%

8. Women with HIV Also Have Unintended Pregnancies 84% unintended pregnancies among PMTCT clients in South Africa 74% unintended pregnancies among women in an ART program in Rwanda 85% of women in Malawi who learned their HIV+ status reported desiring no more children Sources: Rochat et al., JAMA 2006:295:1376-8; Bangendanye, et al., presented November 2007; Hoffman, et al. JAIDS 2008;47:477-83

9. DHS surveys – basis for estimates 15% of women in SSA using effective contraception 7.8 M unintended births averted by contraception Average HIV prevalence in SSA women 7.4% Effect of Current Contraceptive Use by HIV+ Women – Assumptions

10. 800 700 600 500 400 300 200 100 0 Contraception as HIV Prevention – Compared to ARVs # unintended births prevented ARVs (cumulative over 3 years) # infants spared HIV infection 157 Effective Contraception (over 1 year) 735 # of infants/births, in 1000s 220 Sources: PEPFAR (2008), Reynolds (in press)

11. 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 ART Decreases the number of future orphans

12. From Contraception Efficacy to Family Planning/HIV Effectiveness FP/HIV integration – the key strategy to reducing unintended pregnancies among HIV+ women Crucial questions – what are the opportunities and challenges to translating efficacy into effectiveness?

13. FP/HIV Integration: Opportunities and Challenges International level – policies and funding trends Country level – Ministry of Health structures and other coordinating bodies Service delivery level – operationalizing SRH and HIV linkages

14. International Level Opportunities FP/HIV integration supports the reproductive rights of HIV+ women Increasing international policy support for stronger RH/HIV linkages – Glion Call to Action – New York Call to Commitment – Maputo Plan of Action

15. Appropriations for the Global HIV/AIDS Initiative and International Family Planning 2004 - 2009 $ Appropriated in (X000)

16. Country Level Opportunities Emerging policy support –Strategy for the Integration of FP and VCT Services (Kenya) –High priority FP strategies (Mozambique, Rwanda) Country-specific technical working groups on RH/HIV integration Increasing number of integrated RH/HIV bilateral programs –Kenya and Rwanda

17. Service Delivery Opportunities 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.

18. Long-standing inadequacies lead to new opportunities for improved health care The Interface Between HIV Programs and Health Systems An organizational culture of service fragmentation InadequaciesOpportunities 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].”

19. Starting point … Hospitalization wards Labs

22. Key Linkages Learn HIV status Promote safer sex Optimize connection between HIV/AIDS and STI services Integrate HIV/AIDS with maternal and infant health HIV/AIDS Prevention Treatment Care Support SRH and HIV: Key Linkages SRH Family Planning Maternal & infant care Management of sexually transmitted infections Management of other SRH problems Source: WHO/UNAIDS, IPPF/UNFPA (2005)

23. Conclusions Comprehensive MCH programs are needed to reach UNGASS goals for perinatal HIV Decreases in unintended pregnancies to HIV+ women will prevent a similar number of HIV+ births as current ARV programs Contraception is the “best-kept secret” in HIV prevention We have a unique opportunity to leverage HIV resources

24. The Sexual Health Triad “Divided We Fail” Unintended Pregnancies STD HIV