1. Integrating HIV/AIDS & Family Planning Services: Experiences From Sub-Saharan Africa Dr. Placide Tapsoba Dr. Naomi Rutenberg Repositioning Family Planning in West Africa Regional Conference, 15-18 February 2005 La Palm Royal Beach Hotel Accra, Ghana

2. African Family Planning Clinics  Busy  Long waits  Short visits

3. Reproductive Health challenge Dealing with unmet needs of RH in developing Countries: a huge task:  Over 120 million women have unmet need for FP  350 million women lack access to full range of contraceptive methods  120,000 HIV + women get pregnant each year  # of young people 10-24 yrs increased by 50% in 30 yrs  Between 1994 and 2015, 3 billion people will enter reproductive years  500,000 women die a year from pregnancy related causes

4. CPR remains low & unmet need high in most countries of Sub- Saharan Africa

5. Both Unmet Contraceptive need and Adult HIV Prevalence are high

6. HIV/AIDS Challenge  40 million people worldwide; approx.70% in SSA  14,000 new daily infections ( mainly through sexual contact) {UNAIDS}  Women and young people especially vulnerable  50% new infections in 15-24 yr olds  50% new infections among women  Annually 1.8 million infected pregnant women deliver approx 600,000 infected infants (UNICEF)

7. Effect of unmet need and high HIV prevalence Estimated 20 million women living with HIV 25% of women with an unmet need for contraception Therefore an estimated 5 million HIV positive women are in need of contraception

8. What is integration? “ Arrangement for the provision of multiple but related services concurrently during a same visit” –Provider of one service actively encourages clients to use other services during the same visit. =>FP - HIV/AIDS (prevention and care)

9. Why integrate? FP and HIV/AIDS services are both elements of RH care for individuals & families health FP is a key strategy in reducing vertical transmission of HIV To maximize use of scarce financial & human resources, & respond to client needs by offering services to meet clients multiple needs ‘…’

10. How to integrate? Policy / Advocacy –Providers’ framework and enabling environment Programmatic –Provides clear direction of how Service delivery –Institutional arrangements /community involvement & participation

11. Types of integration High integration –Services in the same physical location Medium integration –Services in the same institution but different physical locations Low integration –Services in different institutions but linked by arranged mechanism

12. Integrating FP to HIV services; What do we know? Integrating FP into VCT services Integrating FP into care & support services Integrating FP into PMTCT services

13. Integrating FP to VCT services; Challenge Add family Planning information, referral or method provision to VCT services Re-position condom for family health Concept of dual protection

14. What to do? Development of strategy Advocacy for integration Needs assessment of sites Participatory planning Capacity building Supervision M&E

15. Method Mix by HIV status in 3 service delivery sites

16. Integrating FP into PMTCT FP as standard component of most PMTCT services FP counseling and education provided during antenatal care; FP counseling and methods offered postpartum Stronger emphasis on FP within PMTCT programs where tubal ligation is common Because most PMTCT programs have no/weak postnatal component, where methods are adopted later in postnatal period, PMTCT programs mainly refer to general FP services Limited FP services at sites supported by some faith-based organizations

17. % of pregnant women with at least one antenatal care visit WHO 1996

18. PMTCT sites miss opportunities to provide FP counseling Percent who receive FP counseling, Lusaka, Zambia n=981 Antenatal visit n=90 n=256 3 mths postpartum n=68 n=218 6mths postpartum

19. Percent using modern FP by HIV Status at 6 months postpartum PillInjectableLong term Condom Lusaka, Zambia HIV+ (n = 63) 8 5 025* HIV – (n = 92) 1611 110* Karatina, Kenya HIV+ (n = 37) 2449 311* HIV- (n = 237) 174711 1*

20. HIV-positive women view condoms favorably Offer protection against re-infection, STIs and unwanted pregnancy Safe (particularly in low contraceptive prevalence areas, women had many fears of side effects of other contraceptive methods) Cheap Readily available Promoted by PMTCT sites

21. High sterilization rates in DR, Thailand and India Almost all PMTCT clients are sterilized in DR, where HIV+ women are offered tubal ligation either in conjunction with a caesarean or following a vaginal birth A study of HIV+ women from 37 hospital sites in Thailand found that 56% were sterilized at 6 weeks postpartum (Lallemant et al. 2004) Providers in India report that sterilization is most popular method among HIV+ women

22. Making family planning decisions IF you know your HIV status This is a big IF –< 5% of adults know their HIV status Many women still choose to get pregnant again

23. Powerful motivations to have children; balance between family size having HIV-free children Cement the marriage Financial security Expectations/norms of a pro-natalist society Caring for children provides reason for living Want to leave offspring to carry on name Avoid partner’s suspicion of HIV infection—fear of abandonment Hide HIV status from community, prevent stigma Denial

24. PMTCT program gives hope for having healthy children “Previously they used to fear producing because they knew it would lower their immunity and the child may be infected. But now with PMTCT awareness, that fear is gone. They now know there is a way of preventing mother-to-child transmission.” (Provider in Uganda)

25. Integrating FP into PMTCT services Advocacy with providers sought to clarify the concept of integration Participatory planning to create consensus and prepare for the implementation of integration Reorganization of services and reallocation and distribution of resources Community component crucial

26. Conclusion Integrating FP/RH and HIV/AIDS programs have great benefits to providers and clients Political will, commitment and change in orientation is required to ensure that integration happens Challenges are inevitable but can be overcome Integrating FP/RH and HIV/AIDS services is feasible in spite of HR and financial constraints.

27. Publications of studies Documents available on our website: http:// www.popcouncil.org/horizonsfinalrpts.html or by e-mailL horizons@pcdc.org http:// www.popcouncil.org/Frontiersfinalrpts.html or by e-mail: frontiers@pcdc.org http://advanceafrica.org