Averting HIV-infected births: integrating family planning services can help achieve goal.

KEY POINTS

* Family planning services can greatly reduce HIV-infected births.

* Family planning providers will need considerable additional training, support, and motivation to serve HIV-infected women effectively.

* Opportunities to prevent pregnancies among HIV-infected women and to prevent infection among reproductive-age women are being missed, but progress is being made.

In the midst of an unrelenting AIDS epidemic, attention is increasingly being paid to the prevention of HIV infection among the world's most vulnerable individuals: its newborns.

In 2003, an alarming number of new HIV infections--about 700,000--occurred among children, the vast majority of whom were infected by their mothers. Four main approaches to reducing such infections have been promoted by the World Health Organization (WHO) and its United Nations partners. (1)

To date, funding for developing countries has primarily supported an approach of providing voluntary counseling and testing (VCT) for HIV during pregnancy and then a short course of antiretroviral (ARV) drug therapy to HIV-infected pregnant women and their newborns. This is to prevent HIV transmission from mother to infant during delivery. Another approach is to provide care and support to women, infants, and families infected and affected by HIV/AIDS. But minimizing HIV-infected births will likely be best achieved through a combination of approaches that includes preventing unintended pregnancies among HIV-infected women (see article, page 22) and preventing HIV infection among reproductive-age women (see article, page 26).2

Pursuing these latter two approaches requires new thinking about how various reproductive health and HIV services can be integrated in settings where women are likely to seek health care. Such integration can contribute to the prevention of mother-to-child transmission (PMTCT) of HIV in several ways:

* Integrating HIV counseling into family planning services helps prevent infection among women of reproductive age. Integrating VCT, as well, helps identify infected women who can then receive targeted family planning counseling and services.

* Integrating family planning services into VCT services and other HIV services helps those women who test positive prevent unintended pregnancy. It also helps those who test negative (but are sexually active, of reproductive age, and at risk of infection) avoid unintended pregnancy.

* Integrating HIV counseling and VCT into antenatal care (ANC) services (the usual site of PMTCT efforts) helps prevent infection among pregnant uninfected women. It can also identify pregnant women who are HIV infected.

Integrating family planning services into ANC can help pregnant infected women avoid yet another at-risk pregnancy. In all of these scenarios, family planning services can play an essential role in achieving PMTCT goals. Yet, employing family planning services to avert HIV-infected births--particularly, offering contraceptive services to infected women--requires more than simply combining services. It involves operational challenges that, as yet, have not been explored in depth. It also requires that providers be trained to understand the special reproductive and contraceptive needs of HIV-infected women. An infected woman's decisions are likely to be shaped by many factors, including her own health and that of her partner and existing children, access to long-term ARV drug therapy, whether she can disclose her HIV status, the possible impact of HIV infection and ARV use on contraceptive method options, and the possible impact of contraceptive method use on her health and infectivity.

However, policy guidelines indicate increasing support for the integration of family planning services to achieve PMTCT goals. More than three-quarters of international guidelines, national HIV/ AIDS policies, and PMTCT and VCT policies reviewed in a recent analysis mention family planning. (3) Three recent analyses suggest that family planning services can both have a marked impact on averting HIV-infected births and be cost-effective (see article, this page). And, in May 2004, some 70 health professionals, representatives from governmental and nongovernmental organizations, and donors met in Glion, Switzerland, to consider the contributions family planning could make to PMTCT. The meeting, supported by WHO, the United Nations Population Fund, the U.S. Agency for International Development (USAID), and private donors, resulted in a "Call to Action" to strengthen linkages between family planning and PMTCT. The declaration acknowledged that all four approaches recommended by WHO and its United Nations partners are necessary to meet PMTCT goals. It also recommended strengthening family planning and PMTCT links through advocacy, policy and program development, resource mobilization, monitoring and evaluation, and research.

Challenges for family planning, ANC providers

In many settings, family planning staff will need additional training, support, and motivation to effectively serve women at risk of HIV infection and women who are already infected. Staff must be prepared to provide HIV prevention counseling for women at risk. And, they are likely to need considerably more training to counsel and serve women whose HIV infection makes reproductive and contraceptive choices far more complex than those for uninfected women (see article, page 22). Staff will need to be able to explain issues related to mother-to-child transmission of HIV. Concerns that working with HIV-infected clients will stigmatize and discredit existing family planning services must be overcome. Training about universal infection-control precautions may be necessary to quell providers' fears of being infected by HIV-infected clients. Concerns that working with HIV-infected women will increase already heavy workloads and might compromise scarce family planning funds must also be addressed. (4) Finally, unless they receive by referral women who have already been identified as HIV infected, family planning services face the challenge of integrating VCT services to identify infected clients (see article, page 9).

Like family planning services, ANC services face the challenge of determining a woman's HIV status. The introduction of VCT provision into the antenatal setting has the potential to be quite effective. (5) For example, in a pilot study of same-day VCT in six urban antenatal clinics in Lusaka, Zambia, 84 percent of pregnant women requested testing, and a quarter of those women tested positive. (6) However, many pregnant women are reluctant to accept VCT. In a four-year study to examine the introduction of PMTCT services within maternal and child health programs in Kenya and Zambia, about two-thirds of more than 22,000 women who sought antenatal care as new clients received pretest counseling. But fewer than one-third went on to have an HIV test. (7) Reasons for disappointing VCT uptake at ANC/PMTCT sites throughout Africa may include logistical barriers (e.g., results are unavailable the same day or tests are expensive) and fears that test results will not remain confidential. (8) Even when women are tested, a substantial number do not return for their results. (9)

ANC services that attempt to integrate family planning services must confront other operational issues. For example, in Africa, adding family planning services can burden government ANC services, which are "notoriously overcrowded, understaffed, and have limited physical space for group or individual counseling," says Elizabeth Preble, an international health consultant who specializes in HIV/AIDS and reproductive health and has studied operational barriers to integrating family planning and PMTCT services in Africa and Asia. "Adding family planning services requires additional skills, space, and staff capable of dispensing contraceptives. In the African context, many ANC staff have already expressed resentment at having to take on additional PMTCT responsibilities, let alone family planning demands as well."

Training issues require considerable attention. In Africa, "at present, PMTCT and VCT curricula do not always cover family planning issues in detail, especially as they might relate to HIV-infected women," Preble says. But, at a minimum, providers should be able to offer information about the importance of family planning as a PMTCT intervention, and to explain the basics of contraception. They also need to be able to offer contraceptive methods that can be adopted immediately postpartum, or be able to refer clients for postpartum family planning services and contraceptive methods.

Family planning referrals, in themselves, can be problematic. "While many PMTCT programs now pledge to follow women, test their babies, and refer them for family planning, ARV therapy, and other AIDS-related care, this is not universally happening in African PMTCT settings," Preble says. An evaluation of a PMTCT pilot program in South Africa showed that clients referred to family planning services had poor access to health facilities. Distances were long and women lacked affordable transportation. Furthermore, poor patient records impeded continuity of care, and clients had to wait long times to be served. (10)

Another challenge is to ensure that PMTCT programs meet the family planning needs of their adolescent clients. Adolescents seen at antenatal clinics are more likely than older women to be pregnant for the first time. They may face strong social pressure to bear a child to prove their fertility and may continue childbearing--regardless of HIV status--if appropriate postpartum family planning counseling and services are unavailable to them. For this reason, FHI researchers are conducting a study in Kenya to identify and evaluate strategies for meeting adolescents' HIV and reproductive health needs within PMTCT programs. (11)

Missed opportunities, but progress continues

In a recent evaluation of pilot PMTCT projects supported by the United Nations and initiated in 11 primarily African countries in 1999-2000, all national-level program managers reported that their PMTCT programs (centered within ANC and maternal and child health care) included family planning services. Most sites offered both family planning counseling and contraceptive methods, either in the same building or next to it, as part of clients' routine care. However, PMTCT programs had made relatively little progress in addressing the prevention of HIV infection in reproductive-age women and the prevention of unintended pregnancy in infected women. (12)

The extent to which pilot PMTCT programs address family planning (and vice versa) was also evaluated as part of a four-year intervention study conducted at two sites in Kenya and one in Zambia by Horizons, the Network of AIDS Researchers in East and Southern Africa (NARESA) in Kenya, the MTCT Working Group in Zambia, and the United Nations Children's Fund (UNICEF). (13) Among its findings:

* Opportunities to counsel clients about family planning were missed. In Zambia, for example, slightly more than a third of PMTCT clients--regardless of HIV serostatus--received family planning counseling during their antenatal visit. At the two Kenyan sites, about a fifth of clients discussed family planning during their antenatal visit, and women rarely received postpartum family planning counseling. Although many women reported current use of a family planning method, they did not receive family planning counseling linked to PMTCT goals or the particular needs of HIV-infected women.

* PMTCT services did not appear to influence uptake of contraceptive methods (except for condoms) in settings of low contraceptive prevalence, scarce resources, and high HIV prevalence. Notably, in these settings, family planning and PMTCT services are generally parallel rather than integrated. In both Zambia and Kenya, for example, postpartum family planning prevalence among women who received ANC at a PMTCT site was comparable to contraceptive prevalence reported in recent demographic and health surveys. Also, HIV-infected women were no more likely than uninfected women to be using a modern method of family planning.

* At two sites (one in Zambia and one in Kenya), 39 percent and 65 percent, respectively, of HIV-infected women reported that they had a regular sexual partner but were using no family planning method.

Further analysis by Population Council researchers of the integration of family planning and PMTCT services, reported in April of 2004 and based on field experiences in Cameroon, Kenya, Namibia, South Africa, Uganda, Brazil, the Dominican Republic, India, and Thailand, (14) found that the availability of family planning services at PMTCT sites did not ensure integration of HIV and family planning messages. Family planning was usually provided in PMTCT training but was a low priority and was given little time. Human resources were not readily available in some settings to place greater emphasis on family planning. At the national level, family planning and PMTCT services tended to be separate programs, often with separate funding. Finally, little monitoring and evaluation of family planning as a PMTCT service existed.

Of note, however, "we found strong positive views about the use of condoms by HIV-infected women for dual protection against unintended pregnancy and HIV transmission--either used alone or in combination with a more effective contraceptive method," says Dr. Naomi Rutenberg, senior program associate with the Population Council and lead author of the report summarizing findings of the analysis. "Condoms were seen as safe, cheap, easily available, promoted by PMTCT providers, and preserving the women's health by preventing infection with sexually transmitted infections and reinfection with HIV."

The researchers recommended integrating family planning support and services targeted to the needs of HIV-infected women into PMTCT services. They suggested that providers build on positive attitudes toward condoms among HIV-infected women and involve men to promote dual protection. They also recommended improving mechanisms for postnatal follow-up and offering a continuum of care for HIV-positive women.

Despite the many identified barriers to integration, the researchers concluded that many pilot activities showed promise and that "national and international leadership to integrate family planning as an essential component of PMTCT programs is bearing fruit and should be continued."

Web Resource

http://www.fhi.org/en/RH/Pubs/ bookReports/fppmtct.htm

Family Planning and the Prevention of Mother-to-Child Transmission of HIV: A Review of the Literature is a 44-page report produced by FHI with support from the World Health Organization in preparation for the meeting, "Linkages between Reproductive Health and HIV/AIDS: Family Planning and Prevention of Mother-to-Child Transmission," held in Glion, Switzerland, May 3-5, 2004. The review explores how to integrate reproductive health services to prevent mother-to-child HIV transmission among women accessing family planning, HIV voluntary counseling and testing, or antenatal care services.

References

(1) World Health Organization (WHO). Strategic Approaches to the Prevention of HIV Infection in Infants. Report of a WHO meeting. Morges, Switzerland, March 20-22, 2002. Available: http://www.who.int/hiv/pub/mtct/en/ StrategicApproachesE.pdf.

(2) O'Reilly K. Preventing HIV in infants and young children. PMTCT and integration. Reproductive Health in the Age of HIV/AIDS, San Juan, Puerto Rico, May 28-30, 2003.

(3) Strachan M, Kwateng-Addo A, Hardee K, et al. An Analysis of Family Planning Content in HIV/AIDS, VCT and PMTCT Policies in 16 Countries. POLICY Working Paper Series No. 9. Washington, DC: The Futures Group, 2004. Available: http://www.policyproject.com/ BySeries.cfm/WPS.

(4) Preble EA, Huber D, Piwoz EG. Family Planning and the Prevention of Mother-to-Child Transmission of HIV: Technical and Programmatic Issues. Arlington, VA: Advance Africa, 2003. Available: http://www.advanceafrica.org/publications_ and_presentations/Technical_Papers/TP_FP_an d_PMTCT.pdf.

(5) Cartoux M, Meda N, Van de Perre P, et al. Acceptability of voluntary HIV testing by pregnant women in developing countries: an international survey. Ghent International Working Group on Mother-to-Child Transmission of HIV. AIDS 1998;12(18):2489-93.

(6) Bakari JP, McKenna S, Myrick A, et al. Rapid voluntary testing and counseling for HIV. Acceptability and feasibility in Zambian antenatal care clinics. Ann NY Acad Sci 2000; 918:64-76.

(7) Rutenberg N, Nduati R, Mbori-Nagcha D, et al. HIV Voluntary Counseling and Testing: An Essential Component in Preventing Mother-to-Child Transmission of HIV. Washington, DC: Population Council, 2003.

(8) Preble.

(9) Rutenberg N, Baek C, Kalibala S, et al. Evaluation of United Nations-Supported Pilot Projects for the Prevention of Mother-to-Child Transmission of HIV. New York, NY: United Nations Children's Fund and Population Council, 2003. Available: http://www.popcouncil. org/pdfs/horizons/pmtctunicefevalovrvw.pdf.

(10) Health Systems Trust and Department of Health, Republic of South Africa. Interim Findings on the National PMTCT Pilot Sites: Lessons and Recommendations,2002. Available: http://www.hst.org.za.

(11) Reynolds H. An Assessment of Services for Adolescents in Prevention of Mother-to-Child Transmission Programs. Research Protocol. Research Triangle Park, NC: Family Health International, 2004.

(12) Rutenberg, Baek, Kalibala, et al.; Rutenberg N, Baek C, Siwale M, et al. Family Planning and PMTCT Services: Examining Interrelationships, Strengthening Linkages. Washington, DC: Population Council, 2003. Available: http:// www.popcouncil.org/pdfs/horizons/pmtctfp.pdf.

(13) Rutenberg, Baek, Siwale, et al.

(14) Rutenberg N, Baek C. Review of Field Experiences: Integration of Family Planning and PMTCT Services. New York, NY: Population Council, 2004. Available: http://www.popcouncil. org/pdfs/horizons/fpandpmtctrprt.pdf.

RELATED ARTICLE: Preventing pregnancy among HIV-infected women.

Providing family planning counseling and services to HIV-infected women--to prevent initial or subsequent unintended pregnancy--is critical to the prevention of mother-to-child transmission (PMTCT) of HIV. Indeed, without such family planning services, achieving international goals to reduce the proportion of HIV-infected infants by 20 percent by 2005 and by 50 percent by 2010 may not be possible. (1)

HIV-infected women must be carefully counseled about the risk of transmitting HIV to their infants during pregnancy and delivery. Those women who wish to either limit or space childbearing should have access to highly effective contraception. (2) And, because all women have the right to decide the number and timing of their children, anyone counseling an HIV-infected woman should support her family planning decisions. (3)

HIV-infected women who have not ruled out childbearing need to know that pregnancy does not appear to accelerate HIV disease progression. (4) However, maternal HIV infection might affect infant health. A recent study found that miscarriage, abortion, ectopic pregnancy, and stillbirth rates among HIV-infected women--some of whom received antiretroviral (ARV) drug therapy--were no higher than those among uninfected women. (5) However, in other studies, maternal infection has been associated with adverse neonatal and obstetrical outcomes, including premature birth, low birth weight, and postpartum hemorrhage. (6)

HIV-infected women using ARV drugs may want to use family planning until the effects of these drugs on maternal and child health are better understood. Clinical trials of the effects of zidovudine show no increase in birth defects, (7) but certain ARV drugs may be toxic for pregnant women and fetuses. The drug efavirenz (EFZ), for example, is believed to be a potent early teratogen, and recent World Health Organization (WHO) draft guidelines state that "EFZ should not be given to women of childbearing potential unless effective contraception can be assured." (8) Other concerns have been raised about whether a woman's use of nucleoside reverse transcriptase inhibitors (such as zidovudine and lamivudine) could affect the mitochondrial or nuclear DNA of her child, potentially causing such side effects as lactic acidosis and anemia and increasing susceptibility to cancer. (9)

Contraceptive options for HIV-infected women

WHO also provides guidance as to the suitability of each major contraceptive method (including sterilization) for family planning clients in three HIV/ AIDS categories: high risk of HIV, HIV-infected, and AIDS. Women in all categories are eligible for most major methods. Of note, based on the latest clinical and epidemiological data, recent revisions to the guidelines (see brief, page 2) have removed some barriers to intrauterine device (IUD) use. Initiation usually not recommended for a woman with AIDS who either is not receiving ARV therapy or has not clinically improved while on it. (This is because such a woman may have a suppressed immune system and thus be more vulnerable at the time of IUD insertion to infections, such as other sexually transmitted diseases [STIs] that could lead to pelvic inflammatory disease.) Otherwise, all other HIV-infected women, including those with AIDS, are now eligible to initiate or continue IUD use. (10)

Hormonal contraceptives may also be a good choice for many HIV-infected women. For long-lasting contraception, the Norplant implant has been found to be safe, efficacious, and well tolerated in the immediate postpartum period among asymptomatic HIV-infected women. (11) However, there is some concern that nevirapine and EFZ can alter the metabolism of oral contraceptives, thus requiring an adjustment in contraceptive dosage or change to another contraceptive method.12 Due to concerns about drug interactions, WHO guidelines state that the use of oral contraceptives and hormonal patches, rings, and implants is usually not recommended for women taking rifampicin, an antibiotic used to treat tuberculosis. Meanwhile, use of hormonal methods may be associated with increased risks of cervical HIV shedding (and thus HIV transmission), transmission), (13) as well as HIV disease progression. (14) More data on these possible associations will be forthcoming this year.

For HIV-infected women who have decided against childbearing, female sterilization is a good option. The procedure should be delayed, however, if a woman has an AIDS-related illness. (15) The use of diaphragms (with spermicide) or cervical caps is usually not recommended for HIV-infected women and those with AIDS, according to WHO's 2003 recommendations.

Finally, an HIV-infected woman should be counseled about dual method protection--using a condom for disease prevention (HIV transmission to her partner or the woman's reinfection with other HIV strains or STIs) and another, more effective method for contraception (see figure, page 22).

[FIGURE OMITTED]

Family planning providers also should be aware that the contraceptive behavior of HIV-infected women may differ from that of uninfected women. Numerous studies suggest that contraceptive use by HIV-infected women can be surprisingly low. Many become pregnant. One reason is that infected women may very much want to have children, particularly in cultures that are pronatalist. (16) The increasing availability of ARV drugs may also make pregnancy more appealing, since treatment offers hope for better health, better quality of life, and survival. (17) Fears of the health effects of contraceptive use may also play a role. This suggests the need to provide ample information about contraceptive options and reliable follow-up to reduce method discontinuation related to side effects. (18)

Contraceptive needs of postpartum HIV-infected women are the same as those of nonpregnant infected women, with two exceptions. An infected woman's risk of transmitting HIV to her infant may grow with subsequent pregnancies, since the risk of such transmission increases as maternal infection progresses. (19) Also, an infected woman may be less likely than an uninfected woman to breastfeed, since breastfeeding can transmit HIV to infants. But nonbreastfeeding women miss the contraceptive benefits of lactational amenorrhea.

As is the case for nonpregnant HIV-infected women, contraceptive uptake may be low for postpartum infected women. (20) Why this is so remains poorly understood. However, many infected women are reluctant to share their HIV status with their partners and thus are unable to argue for family planning. For example, in Zaire, a study of fertility rates among 238 HIV-infected women followed for three years postpartum found that the women's nearly uniform unwillingness to inform partners of their HIV status largely accounted for the "disappointingly high fertility rates in women who had been provided with a comprehensive program of HIV counseling and birth control." (21) Thus, men's involvement in family planning may be a key to preventing subsequent pregnancies among infected women. (22)

* Kim Best

References

(1) United Nations General Assembly (UNGASS). Global crisis--global action: Declaration of commitment on HIV/AIDS. 26th Special Session. Adopted June 27, 2001. New York, NY: United Nations, 2001. Available: http://www. un.org/ga/aids/coverage/FinalDeclarationHIVA IDS.html; World Health Organization. Strategic Approaches to the Prevention of HIV Infection in Infants. Report of a WHO meeting. Morges, Switzerland, March 20-22, 2002. Geneva, Switzerland: WHO, 2003. Available: http://www.who.int/hiv/pub/mtct/en/ StrategicApproachesE.pdf.

(2) Cates W Jr. Use of contraception by HIV-infected women. IPPF Med Bull 2001;35(1):1-2.

(3) Chervenak FA, McCullough LB. Common ethical dilemmas encountered in the management of HIV-infected women and newborns. Clin Obstet Gynecol 1996;39(2):411-19.

(4) Minkoff H, Hershow R, Watts DH, et al. The relationship of pregnancy to human immunodeficiency virus disease progression. Am J Obstet Gynecol 2003;189(2):552-59; Bessinger R, Clark R, Kissinger P, et al. Pregnancy is not associated with the progression of HIV disease in women attending an HIV outpatient program. Am J Epidemiol 1998;147(5):434-40; Vimercati A, Greco P, Lopalco PL, et al. Immunological markers in HIV-infected pregnant and non-pregnant women. Eur J Obstet Gynecol Reprod Biol 2000;90(1):37-41.

(5) Massad LS, Springer G, Jacobson L, et al. Pregnancy rates and predictors of conception, miscarriage and abortion in U.S. women with HIV. AIDS 2004;18(2):281-86.

(6) Leroy V, Ladner J, Nyiraziraje M, et al. Effect of HIV-1 infection on pregnancy outcome in women in Kigali, Rwanda, 1992-1994. Pregnancy and HIV Study Group. AIDS 1998;12(6):643-50; Brocklehurst P, French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol 1998;105(8):836-48.

(7) Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Intervention to Reduce Perinatal HIV-1 Transmission in the United States. Rockville, MD: U.S. Department of Health and Human Services, 2003; Sperling RS, Shapiro DE, McSherry GD, et al. Safety of the maternal-infant zidovudine regimen utilized in the Pediatric AIDS Clinical Trial Group 076 Study. AIDS 1998;12(14):1805-13.

(8) World Health Organization (WHO). Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Treatment Guidelines for a Public Health Approach. Geneva, Switzerland: WHO, 2003. Available: http://www.who.int/3by5/publications/ documents/arv_guidelines/en/print.html.

(9) Cossarizza A, Moyle G. Antiretroviral nucleoside and nucleotide analogues and mitochondria. AIDS 2004;18(2):137-51; Blanche S, Tardieu M, Rustin P, et al. Persistent mitochondrial dysfunction and perinatal exposure to anti-retroviral nucleoside analogues. Lancet 1999; 353(9184):1084-89; Poirier MC, Divi RL, Al-Harthi L, et al. Long-term mitochondrial toxicity in HIV-infected infants born to HIV-infected mothers. J Acquir Immune Defic Syndr 2003; 33(2):175-83; Olivero OA, Fernandez JJ, Antiochos BB, et al. Transplacental genotoxicity of combined antiretroviral nucleoside analogue therapy in Erythrocebus patas monkeys. J Acquir Immune Defic Syndr 2002;29(4):323-29.

(10) World Health Organization (WHO). Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Second Edition. Geneva, Switzerland: WHO, 2000; WHO. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva, Switzerland: WHO, 2004. Available: http://www.who.int/reproductive-health/publications/ RHR_00_2_medical_eligibility_criteria_3rd/index.htm.

(11) Taneepanichskul S, Tanprasertkul C. Use of Norplant implants in the immediate postpartum period among asymptomatic HIV-1 positive mothers. Contraception 2001;64(1):39-41.

(12) Leitz G, Mildvan D, McDonough M, et al. Nevirapine (VIRAMUNE, NCP) and ethinyl estradiol/norethindrone (ORTHO-NOVUM 1/35 [21 pack] EE/NET) interaction study in HIV-1 infected women. The 7th Conference on Retroviruses and Opportunistic Infections. San Francisco, CA, January 30-February 2, 2000; Piscitelli S, Flexner C, Minor J, et al. Drug interactions in patients infected with human immunodeficiency virus. Clin Infect Dis 1996;23(4):685-93.

(13) Stephenson JM. Systematic review of hormonal contraception and risk of HIV transmission: when to resist meta-analysis. AIDS 1998; 12(6):545-53; Mostad SB, Overbaugh J, DeVange DM, et al. Hormonal contraception, vitamin A deficiency and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997;350(9082):922- 27; Wang C, McClelland R, Overbaugh J, et al. The effect of hormonal contraception on genital tract shedding of HIV-1. AIDS 2004; 18(2):205-9.

(14) Sagar M, Lavreys L, Baeten J, et al. Identification of modifiable factors that affect the genetic diversity of the transmitted HIV-1 population. AIDS 2004;18(4):615-19; Sagar M, Lavreys L, Baeten J, et al. Infection with multiple human immunodeficiency virus type 1 variants is associated with faster disease progression. J Virol 2003;77(23):12921-26; Lavreys L, Baeten J, Kreiss J, et al. Injectable contraceptive use and genital ulcer disease during the early phase of HIV-1 infection increase plasma virus load in women. J Infect Dis 2004;189(2):303-11.

(15) WHO, 2000.

(16) Rutenberg N, Baek C, Siwale M, et al. Family Planning and PMTCT Services: Examining Interrelationships, Strengthening Linkages. Washington, DC: Population Council, 2003. Available: http://www.popcouncil.org/ pdfs/horizons/pmtctfp.pdf.

(17) Massad.

(18) King R, Estey J, Allen S, et al. A family planning intervention to reduce vertical transmission of HIV in Rwanda. AIDS 1995;9(Suppl 1): 45-51.

(19) Joint United Nations Programme on HIV/AIDS (UNAIDS). Counselling and Voluntary HIV Testing for Pregnant Women in High HIV Prevalence Countries: Guidance for Service Providers. Geneva, Switzerland: UNAIDS, 1999.

(20) Wilson TE, Koenig L, Ickovics J, et al. Contraception use, family planning, and unprotected sex: few differences among HIV-infected and uninfected postpartum women in four U.S. states. J Acquir Immune Defic Syndr 2003; 33(5):608-13; Nebie Y, Meda N, Leroy V, et al. Sexual and reproductive life of women informed of their HIV seropositivity: a prospective cohort study in Burkina Faso. J Acquir Immune Defic Syndr 2001;28(4):367-72; Desgrees-du-Lou A, Msellati P, Viho I, et al. Contraceptive use, protected sexual intercourse and incidence of pregnancies among African HIV-infected women. DITRAME ANRS 049 Project, Abidjan 1995-2000. Int J STD AIDS 2002;13(7):462-68.

(21) Ryder RW, Batter VL, Nsuami M, et al. Fertility rates in 238 HIV-1-seropositive women in Zaire followed for 3 years post-partum. AIDS 1991; 5(12):1521-27.

(22) Angulo JE. Social-anthropological issues in prevention of mother-to-child transmission in Uganda. Abstract: F11953. XIV International AIDS Conference, Barcelona, Spain, July 7-12, 2002; U.S. Agency for International Development (USAID)/Synergy. Women's Experiences with HIV Serodisclosure in Africa: Implications for VCT and PMTCT. Meeting Report. Washington, DC: USAID, 2004.

RELATED ARTICLE: Family planning: considerable impact at relatively low cost.

Preventing pregnancy through family planning services has the potential to be an effective, economical contribution to the prevention of mother-to-child transmission (PMTCT) of HIV, as illustrated by three recent analyses:

* An analysis funded the U.S. Agency for International Development (USAID) of the costs and benefits of adding family planning services to PMTCT programs in 14 high-HIV-prevalence countries suggested that adding the services could double the impact of PMTCT programs in reducing HIV-infected births by 2007. Access to PMTCT services (i.e., voluntary counseling and testing and antiretroviral drug therapy) by half of pregnant women using antenatal care would avert 5 percent (39,000) of expected infections, at a cost of U.S. $1,300 per HIV infection averted. The addition of family planning services to prevent future births to infected women would avert another 32,000 infections, at a cost of U.S. $660 per HIV infection averted. (1)

* An FHI modeling exercise found that, for the same costs, increasing contraceptive use to prevent unintended pregnancies in the general population averts more HIV-positive births than does increasing services that promote and provide nevirapine (antiretroviral drug therapy) in antenatal care programs. For example, spending U.S. $45,000 to increase contraceptive services would avert 88 HIV-infected births. Spending the same amount to promote and provide nevirapine in antenatal care would avert 68 such births. (2)

* An analysis of the estimated impact of various PMTCT approaches in eight African countries with severe HIV epidemics (Botswana, Cote d'Ivoire, Kenya, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe) indicated that preventing just 1,000 to 8,000 pregnancies among HIV-infected women or slightly decreasing adult HIV prevalence were both as effective in reducing HIV-infected births as was treating infected mothers with nevirapine. (3)

* Kim Best

References

(1) Stover J, Fuchs N, Halperin D, et al. Costs and benefits of adding family planning to services to prevent mother-to-child transmission of HIV (PMTCT). Unpublished paper. The Futures Group, 2003.

(2) Reynolds H, Janowitz B, Homan R, et al. Cost-effectiveness of two interventions to avert HIV-positive births. Unpublished paper. Family Health International, 2004.

(3) Sweat M. Cost-effectiveness of PMTCT: what can we learn from Africa? Reproductive Health in the Age of HIV/AIDS, San Juan, Puerto Rico, May 28-30, 2003.

RELATED ARTICLE: Preventing HIV infection among pregnant women.

Antenatal care (ANC) services present excellent opportunities to help pregnant women who are uninfected or of unknown HIV status avoid infection that they could transmit to their fetuses. The risk that a woman will transmit HIV to her fetus during pregnancy is 5 percent to 10 percent. (1) This risk may be even greater if a woman becomes infected while pregnant, since her HIV virus level may be especially high immediately after infection. (2)

ANC services also present opportunities to help women protect themselves from infection postpartum and possible subsequent transmission to their infants during breastfeeding. Infection rates in the postpartum period are high in many countries. In Southern Africa, 5 percent to 10 percent of HIV-uninfected women become infected in the year after they give birth. (3)

Interventions to prevent HIV infection in pregnant women, as in nonpregnant women, focus on counseling about reducing potentially risky behaviors by the woman or her partner. Also, any pregnant woman who is unaware of her partner's HIV status or feels that she may be at risk of infection should encourage her partner to use condoms. (4) A woman may have little control over her partner's behavior. But involving men in counseling, when possible, can be a key to raising awareness of the need to practice safe sex to prevent infection during pregnancy. In fact, to reflect men's role in transmitting HIV to children, the term "parent-to-child transmission" sometimes is preferred to the biologically precise term of "mother-to-child transmission." (5)

Although research is needed to demonstrate the impact of male involvement on reproductive health outcomes, efforts to reach out to partners of pregnant women at risk of HIV infection are proceeding.

In Rwanda, IntraHealth is attempting to involve men at its six sites that offer services for the prevention of mother-to-child transmission of HIV. There, women are encouraged to take home a letter inviting their partners to visit the centers for voluntary counseling and testing (VCT) and HIV prevention counseling. Results have been encouraging: Although acceptance rates vary among facilities, nearly 20 percent of some 7,400 male partners who were sent letters between March 2002 and February 2004 have accepted testing.

"This male involvement is vitally important," says Sosthene Bucyana, IntraHealth/Rwanda deputy director. "Not only does it reduce the perception that women are always the cause of HIV infection, but it helps increase awareness among men, regardless of their HIV status, of the need to practice safe sexual behaviors to prevent the acquisition or transmission of HIV."

* Kim Best

References

(1) DeCock K, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries. JAMA 2000;283(9):1175-82.

(2) World Health Organization (WHO). HIV in Pregnancy: A Review. Occasional Paper No. 2. Geneva, Switzerland: WHO/Joint United Nations Programme on HIV/AIDS, 1999. Available: http:// www.who.int/reproductive-health/publications/ rhr_99_15/rhr99-15.pdf.

(3) Rutenberg N, Kalibala S, Mwai C, et al. Integrating HIV Prevention and Care into Maternal and Child Health Care Settings: Lessons Learned from Horizons Studies. Consultation Report. July 23-27, 2001. Maasai Mara and Nairobi, Kenya: Population Council, 2002.

(4) World Health Organization (WHO). Voluntary Counseling and Testing for HIV Infection in Antenatal Care: Practical Considerations for Implementation. Geneva, Switzerland: WHO, 2000. Available: http://hivinsite.ucsf.edu/ InSite?page=kbr-07-01-04&doc=2098.46dd.

(5) Preble EA, Piwoz EG. Prevention of Mother-to-Child Transmission of HIV in Africa: Practical Guidance for Programs. Washington, DC: Academy for Educational Development, 2001. Available in English at http://www.dec.org/pdf_docs/PNACM052. pdf and in French at http://www.dec.org/ pdf_docs/PNACP214.pdf.