Family planning and HIV service integration: potential synergies are recognized.

KEY POINTS

* Integration can enable family planning and HIV service providers to reach more people with a broader range of services.

* Many types of integration are being explored, but their impact on reproductive health is largely unknown.

* Research is needed to assess the feasibility and effectiveness of different models of integration.

In most settings throughout the world, family planning services and HIV services traditionally have been offered separately, with little or no integration. Family planning services primarily target married women of reproductive age. HIV prevention services primarily target individuals at high risk of HIV infection. But the potential benefits of integrating these services are increasingly apparent as ever more women of reproductive age become infected with HIV or are at risk of infection.

In developing countries, most HIV infection is sexually transmitted among men and women. About half of the 40 million people now living with HIV are women of reproductive age; percentages approach 60 percent in some African countries. (1) Many HIV-infected women likely need family planning services, but unmet need for these services is often greatest in countries with high HIV prevalence. (2) This need can be better met if family planning services are offered where such women access HIV or other services, in addition to being offered through family planning programs.

Meanwhile, clients accessing family planning services may well need HIV prevention, diagnosis, and treatment services. Many of these clients are married women, who are usually considered at low risk for HIV infection. But evidence from several countries suggests that marriage may offer women little protection against HIV infection since, in some settings, even married women may have little or no power to negotiate safe sexual practices with their husbands. In Kisumu, Kenya, and Ndola, Zambia, teenage brides are becoming infected with HIV at higher rates than are single, sexually active young women of the same age. (3) Forty percent of new HIV infections in Thailand occur between spouses, and 90 percent of those infections are transmitted from husband to wife. (4)

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Service integration holds the potential for helping women and others--such as men, youth, and couples--prevent unintended pregnancy and HIV infection. Experience with integrating a variety of health services, such as maternal and child health and family planning or family planning and management of sexually transmitted infections (STIs), has been mixed. But the most successful experiences suggest that integration enables providers to offer more convenient, comprehensive services. Integration is also expected to expand access to services and make them more cost-effective. (5)

Types of integration

Where services are currently integrated, some HIV services are usually provided through family planning programs (6) (see article, page 9). These services may include diagnosis and treatment of STIs, sexual risk-reduction counseling, condom promotion, and HIV voluntary counseling and testing (VCT).

Integration is also starting to move in the opposite direction. Pilot efforts have begun to add family planning counseling and services to HIV services such as VCT and prevention of mother-to-child transmission (PMTCT). (See articles, pages 12 and 21, respectively.) Such integration aims to give all VCT and PMTCT clients, regardless of their HIV status, the opportunity to avoid unintended pregnancies and space the births of their children. For HIV-infected women, ready access to family planning can help avert unintended pregnancies and thus reduce numbers of HIV-infected infants.

Also being explored is the integration of family planning into care and support for people living with HIV. An FHI study is assessing integration of family planning promotion into the services provided by volunteer caregivers in a home-based care program for people living with HIV in South Africa, and results are expected by the end of 2004. Managers of a similar program in Kenya, the HIV/AIDS Care, Support, and Prevention (COPHIA) program carried out by U.S.-based Pathfinder International, decided that it was important to train community health workers in family planning services and HIV prevention so that they could respond to the reproductive health needs of clients and family members.

Questions unanswered

The reproductive health impact of integrating HIV services into family planning programs has not been rigorously evaluated. Even less is known about the feasibility and impact of integrating family planning into HIV services. Research is essential to demonstrate not only that integration will not overburden and thus compromise the quality of existing services, but also that it will actually improve reproductive health.

Such research should assess the effects of different models of integration on service quality, adoption and continuation of family planning methods and HIV prevention strategies, acceptability and use of services, and cost-effectiveness. (7) Pilot studies with experimental designs are urgently needed to generate evidence-based recommendations for programs since, in general, "little is known about how integrated services can best be configured, and what impact they have on prevention of infection and unwanted pregnancy," caution the coauthors of an article about gaps in knowledge about STI service integration activities in sub-Saharan Africa. (8) Even when successful models of integration are identified, their expansion will require changes in government and donor policies that currently encourage vertical programs. (9)

Before attempting to integrate services, program managers need to be aware of the challenges confronting them (see chart, page 8) and consider whether integration makes sense (see article, page 6). The likelihood that combining the two kinds of services will be cost-effective depends on clients' needs, the prevalence of HIV in the area, and the strength of family planning programs. (10) The appropriate level of integration depends on a program's capacity and the costs and resources available to support and maintain integrated services, directly or through referrals. (11)

Regardless of when, where, and how family planning and HIV services are integrated, family planning remains one of the most effective ways to enhance the well-being of women and their families. By enabling women to avoid unintended pregnancies and by reducing the risks associated with age at pregnancy, too many pregnancies, or pregnancies spaced too closely together, family planning prevents about 2.7 million infant deaths and 215,000 pregnancy-related deaths in the developing world each year. (12)

These benefits of family planning may be particularly important for HIV-infected women, whose health is already compromised, and for their children.

Appropriate Services by Type of HIV Epidemic

HIV Epidemic Type                    Service for Type of Population

Generalized: HIV prevalence above    Integrated family planning (FP)/
1 percent among pregnant women       HIV for general population and
                                     high-risk populations

Concentrated: HIV prevalence above   * FP for general population
5 percent in at least one at-risk    * HIV (and possibly FP) for
subpopulation but below 1 percent    high-risk populations
among pregnant women

Low level: HIV prevalence below 5   * FP for general population
percent in at-risk subpopulations   * HIV for high-risk populations
and below 1 percent among
pregnant women

Source: Adapted from U.S. Agency for International Development (USAID).
Family Planning/HIV Integration: Technical Guidance for USAID-Supported
Field Programs. Washington, DC: USAID, 2003.

Potential Benefits and Challenges of Integration

Before deciding whether to integrate family planning or HIV
services, program managers need to be aware of the potential
benefits and challenges of doing so.

Type of Integration         Potential Benefits

FP [right arrow] HIV or     * More people reached with needed services
HIV [right arrow] FP        * Providers better able to meet clients'
                              various needs
                            * Cost savings through reduced duplication
                              of service delivery functions
                            * Fewer HIV infections and unintended
                              pregnancies

HIV/STI prevention [right   * Improved provider counseling skills and
arrow] FP (clinics or         greater client satisfaction
outreach), MCH, or ANC      * Increased knowledge of HIV prevention
                              strategies among women of reproductive
increasingly common           age who are at HIV risk but might not
                              otherwise receive HIV information and
                              counseling
                            * Many HIV-infected births averted by
                              preventing HIV infection among women of
                              reproductive age

VCT [right arrow] FP or     * Increased access to and use of VCT
ANC                           services
                            * Reduced stigma associated with HIV
limited, but increasing     * Increased awareness of healthy sexual
                              behavior
                            * More targeted family planning counseling
                              based on HIV serostatus
                            * Many HIV-infected births averted by
                              identifying infected women, then helping
                              those who are not pregnant avoid unin-
                              tended pregnancy or referring those who
                              are pregnant for antiretroviral drug
                              therapy

FP [right arrow] VCT or     * Expanded access to FP for all VCT
ANC (usual site of PMTCT      clients, including men and youth
services)                   * Increased knowledge of dual protection
                              strategies to prevent both unintended
limited, but increasing       pregnancy and HIV infection
                            * Greater opportunity for clients, regard-
                              less of HIV serostatus, to avoid initial
                              or subsequent unintended pregnancy
                            * Can greatly contribute to averting HIV-
                              infected births among HIV-infected women

STI care [right arrow]      * Reduced risk of HIV infection through
FP, MCH, or ANC               STI prevention, detection,and treatment
                            * Fewer cases of secondary infertility,
emphasis decreasing           pelvic inflammatory disease, and
                              negative pregnancy outcomes arising from
                              untreated reproductive tract infections/
                              STIs in women

Type of Integration         Potential Challenges

FP [right arrow] HIV or     * High initial costs of establishing
HIV [right arrow] FP          services and training staff
                            * May overburden staff and weaken
                              services, particularly if programs are
                              poorly funded
                            * FP and HIV services often implemented by
                              different programs with different
                              policies and sources of funds

HIV/STI prevention [right   * May not reach those at high risk of HIV
arrow] FP (clinics or         infection, particularly in concentrated
outreach), MCH, or ANC        or low-level epidemics
                            * Inability of many female clients to act
increasingly common           on prevention messages without a
                              partner's support
                            * Provider and client bias against condoms
                            * Difficult for many FP programs to assume
                              new tasks due to reduced funding and
                              weak systems
                            * Need to train providers to talk to
                              clients about sexual behavior and
                              relationships

VCT [right arrow] FP or     * May not be cost-effective if most
ANC                           clients are not at risk of HIV
                            * Possible provider reluctance to offer
limited, but increasing       HIV services due to stigma associated
                              with HIV and fears of occupational
                              exposure to the virus
                            * For VCT, special skills and equipment
                              plus strong systems for supervision,
                              monitoring, logistics management, and
                              referrals for follow-up care needed

FP [right arrow] VCT or     * For FP, special provider skills,
ANC (usual site of PMTCT      equipment, supplies, and space, as well
services)                     as strong systems for supervision,
                              monitoring, logistics management, and
limited, but increasing       referrals for follow-up care needed
                            * Unique contraceptive considerations for
                              HIV-infected women

STI care [right arrow]      * Misdiagnosis more likely since FP
FP, MCH, or ANC               clients may not be at high STI risk
                            * Current lack of simple,effective techno-
emphasis decreasing           logies to diagnose and treat STIs in
                              asymptomatic women or women with vaginal
                              discharge
                            * When diagnosis is uncertain, partner
                              notification not feasible; women treated
                              syndromically at risk of reinfection

Note: ANC = antenatal care; FP = family planning; MCH = maternal and
child health; PMTCT = prevention of mother-to-child transmission;
STI = sexually transmitted infection; VCT = voluntary counseling
and testing

References

(1) Joint United Nations Programme on HIV/AIDS (UNAIDS). Women, girls, HIV and AIDS. Strategic overview and background note. Unpublished report. UNAIDS, 2004; UNAIDS. Women in Mekong faced with higher rates of HIV than men. Mekong Leaders' Consultative Meeting on Women and HIV, Bangkok, Thailand, March 8, 2004; World Health Organization/UNAIDS. Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections (Kenya, South Africa, Zambia, Zimbabwe). Available: http://www.who.int/hiv/ pub/epidemiology/pubfacts/en/.

(2) Maggwa NB, Ominde A. Improving access to family planning and reproductive health services in the era of AIDS: challenges and opportunities in sub-Saharan Africa. ECSA Health Community 38th Regional Health Ministers' Conference, Livingstone, Zambia, November 19, 2003.

(3) Altman L. HIV risk greater for African teenage brides? New York Times, February 28, 2004.

(4) Agence France Presse. UN warns HIV infections soaring among Asian women. March 8, 2004.

(5) Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters 2003;11(22):51-73; Berer M. Integration of sexual and reproductive health services: a health sector priority. Reprod Health Matters 2003;11(21):6-15; Oliff M, Mayaud P, Brugha R, et al. Integrating reproductive health services in a reforming health sector: the case of Tanzania. Reprod Health Matters 2003; 11(21):37-48.

(6) Pruyn N, Cuca Y. Analysis of family planning/ HIV/AIDS integration activities within the USAID Population, Health and Nutrition Center. Unpublished paper. Advance Africa and The CATALYST Consortium, 2002.

(7) Askew.

(8) Askew I, Maggwa NB. Integration of STI prevention and management with family planning and antenatal care in sub-Saharan Africa--what more do we need to know? Int Fam Plann Perspect 2002;28(2):77-86.

(9) Lush L, Cleland J, Walt G, et al. Integrating reproductive health: myths and ideology. Bull WHO 1999;77(9):771-77.

(10) U.S. Agency for International Development (USAID). Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. Washington, DC: USAID, 2003.

(11) Foreit KGF, Hardee K, Agarwal K. When does it make sense to consider integrating STI and HIV services with family planning services? Int Fam Plann Perspect 2002;28(2):106-7.

(12) Singh S, Darroch JE, Vlassoff M, et al. Adding It Up: The Benefits of Sexual and Reproductive Health Care. New York, NY: Alan Guttmacher Institute and United Nations Population Fund, 2003.

RELATED ARTICLE: What is integration?

Integration in the health sector has been defined as offering two or more services at the same facility during the same operating hours, with the provider of one service actively encouraging clients to consider using the other services during the same visit, in order to make those services more convenient and efficient. (1) In practice, integrated services are not always offered under one roof, but when they are not, strong referral systems are required to ensure that clients receive the high-quality services that they deserve. (2)

Services or preventive health messages can also be integrated outside clinical settings through interventions such as behavior change communication, peer education, community outreach, youth programs, and social marketing. (3) For example, in Nigeria's Lagos State, family planning counseling and referrals are now available through an HIV/AIDS telephone hot line established in 2001 by the Health Communication Partnership (HCP), which is funded by the U.S. Agency for International Development (USAID),and the Lagos-based Youth Empowerment Foundation. After training hot line counselors in family planning counseling and referral in February 2004, HCP began promoting the new service through radio advertisements, community rallies, and a USAID-sponsored family planning program.

Research has shown that community-based distribution (CBD) programs can successfully promote and deliver condoms to both men and women. (4) The impact of integrating HIV prevention messages and voluntary counseling and testing referrals into a CBD program is being evaluated in Zimbabwe (see article, page 18).Meanwhile, condom social marketing programs, which use commercial sales outlets and marketing techniques to sell condoms at subsidized prices,have been more successful than other family planning programs in reaching men. (5)

* Kathleen Henry Shears 

References

(1) Foreit KGF, Hardee K, Agarwal K. When does it make sense to consider integrating STI and HIV services with family planning services? Int Fam Plann Perspect 2002;28(2):106-7.

(2) Myaya M. Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health Settings: Stepwise Guidelines for Programme Planners, Managers and Service Providers. London, England: International Planned Parenthood Federation South Asia Regional Office and United Nations Population Fund, 2004.

(3) Shelton JD. Prevention first: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. Int Fam Plann Perspect 1999;25(3): 147-52; Shelton J, Fuchs N. Opportunities and pitfalls in integration of family planning and HIV prevention efforts in developing countries. Public Health Rep 2004;119(1):12-15.

(4) Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters 2003;11(22):51-73.

(5) Shelton, Fuchs.

RELATED ARTICLE: To integrate or not to integrate.

When does integrating family planning and HIV services make sense? New technical guidelines from the U.S. Agency for International Development (USAID) state that such integration is most appropriate in countries where the epidemic has moved beyond groups at highest risk of infection and HIV prevalence has climbed above 1 percent among pregnant women receiving antenatal care. In these countries with "generalized" (see chart, this page) epidemics, the number of people who need both family planning and HIV services is likely to be high. (1)

Family planning and HIV service needs intersect in a growing number of countries. In 2000, 55 countries had generalized epidemics, up from 25 countries in 1990.2

In contrast, in countries where the epidemic is "low level" or "concentrated" among people at highest risk of infection, HIV services specifically targeting those individuals are needed. Integrating services in such settings is unlikely to be cost-effective. (3)

An exception to these general rules is Mali, which has an epidemic that fits the definition of a generalized epidemic, with HIV prevalence estimated at 1.7 percent among pregnant women. (4) But Malian women have an average of seven children, and only 8 percent of married women use any contraceptive method. (5) In Mali and other countries where unintended pregnancies still represent a greater threat to health and survival than does HIV, represent a greater threat to health and survival than does HIV, strengthening the family planning program--rather than integrating family planning and HIV services--should be the priority, USAID advises. (6)

Even in countries where HIV primarily affects high-risk groups, good opportunities may exist to reach people in need of HIV or family planning services through service integration. Some family planning programs, for example, may be able to tailor their services to reach those at highest risk, such as men, young people, and sex workers. (7)

Moreover, though a country's epidemic is low level or concentrated nationally, it may be generalized in some geographic areas. "Epidemics in Asia are very local, so planning has to occur on that level," says Steve Mills, associate director for technical support in FHI's Asia and Pacific Division Office in Bangkok, Thailand. "What makes sense in one district may not make sense in another, since a high-prevalence area may be right next to a very low-prevalence area."

* Kathleen Henry Shears

References

(1) U.S. Agency for International Development (USAID). Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. Washington, DC: USAID, 2003.

(2) Walker N, Garcia-Calleja JM, Heaton L, et al. Epidemiological analysis of the quality of HIV serosurveillance in the world: how well do we track the epidemic? AIDS 2001;15(12):1545-54.

(3) USAID.

(4) World Health Organization/Joint United Nations Programme on HIV/AIDS. Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections (Mali). Available: http://www.who.int/hiv/pub/ epidemiology/pubfacts/en/.

(5) Demographic and Health Surveys. Country statistics: Mali. Calverton, MD: ORC Macro, 2004. Available: http://www.measuredhs.com/ countries/country.cfm.

(6) USAID.

(7) Shelton JD. Prevention first: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. Int Fam Plann Perspect 1999; 25(3):147-52; Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters 2003;11(22):51-73.