HIV services for family planning clients.

When the HIV epidemic emerged in the 1980s, family planning organizations responded with some of the first HIV prevention projects in the developing world. Yet, a review of the contribution of sexual and reproductive health services to HIV prevention, conducted in 2003 for the World Health Organization (WHO), found that integrating HIV prevention into family planning services had not yet been implemented effectively, except in a few cases. (1)

Still, it would be premature to conclude that integrating HIV prevention into family planning services does not work, says Dr. Ian Askew, the Population Council's representative in its office in Nairobi, Kenya, who helped conduct the review. Much has been learned, moreover, from implementing various strategies designed to achieve that goal. Such strategies include diagnosis and treatment of sexually transmitted infections (STIs) that increase the risk of acquiring HIV, sexual risk-reduction counseling, condom promotion, and voluntary counseling and testing (VCT) for HIV.

Diagnosis and treatment of STIs

STI service introduction at family planning and maternal and child health (MCH) clinics never received adequate financial support and was undertaken without strengthening the systems needed for effective service delivery. Moreover, the ability of providers in low-resource settings to detect and treat STIs in women is severely limited by the lack of simple, affordable diagnostic methods. (2) In such circumstances, WHO recommends syndromic management of STIs, which involves recognizing and treating STIs based on a group of clinical findings and patient symptoms. But most women with STIs do not have symptoms, and the syndromic approach is not effective for determining how to treat women with vaginal discharge. (3)

Nevertheless, family planning and MCH providers still have a role to play in STI management, says Dr. Irina Yacobson, an associate medical director at FHI, who worked with colleagues at WHO and the Population Council to develop a guide for STI management in family planning and MCH settings. This draft publication incorporates WHO's current recommendations on STI management, which advise providers to treat a woman who has a vaginal discharge for vaginitis (bacterial vaginosis, trichomoniasis, and possibly candidiasis), which is often caused by infections that are not sexually transmitted. However, when a woman has clinical signs of cervical infection or there are reasons to believe that she was exposed to gonorrhea or chlamydia, treatment for cervicitis should be added. (4)

Family planning and antenatal care providers with the necessary skills and supplies can also use the syndromic approach to manage genital ulcer disease in women and can screen pregnant women for syphilis. All providers should at least educate their patients about the risks and consequences of untreated STIs, adds Dr. Yacobson.

Sexual risk-reduction counseling

Incorporating STI/HIV prevention messages into family planning services has been an appealing strategy because family planning programs attract clients who generally do not access HIV program services. Family planning staff can be trained to provide basic HIV prevention information, and family planning programs can offer an infrastructure of clinics and community-based programs for service delivery. (5)

But providing STI/HIV prevention services through family planning programs is problematic because these programs usually do not reach those at greatest risk of HIV infection, including men, youth, and single women. (6) Even when married women are among those at highest risk of HIV, they often do not have the power to protect themselves by either abstaining from sex or insisting on fidelity or condom use by their husbands.

A comprehensive review commissioned by WHO found that efforts to integrate STI/HIV prevention activities with family planning and MCH services had improved providers' attitudes and counseling skills, increased user satisfaction, and, in some cases, increased condom distribution and the adoption of other contraceptive methods. 7 Little evidence exists, however, that STI/HIV prevention activities among traditional family planning clients have reduced risky sexual behavior or increased condom use. (8)

Condom promotion

Male condoms--when used consistently and correctly--are an effective way to prevent HIV infection and unintended pregnancy. (9) But promoting condom use through family planning may have limited impact because these services tend to target women, rather than the men who must agree to use condoms. Client and provider attitudes are another barrier to effective condom promotion. Condom use is rare in marriage and other steady relationships because it is often considered a sign of distrust. (10 And many family planning providers are reluctant to promote condoms) because they fear that greater use of a contraceptive method that is less effective than some methods will lead to more unintended pregnancies and abortions.

Little is known about the success of promoting the use of condoms plus another contraceptive method for dual protection against HIV and unintended pregnancy, although studies from South Africa (11) and Kenya (12) found that 13 percent to 16 percent of condom users also use another method. The addition of dual protection counseling and female condom promotion to family planning services in Ibadan, Nigeria, showed that integration of these activities is feasible but that interventions should also reach male partners to have a strong impact. (13)

In settings with high HIV prevalence, renewed emphasis on condom use alone for contraception among couples in long-term relationships might be a more effective way to encourage dual protection than is dual method use because it would allow couples to discuss condoms without accusations of infidelity. (14)

Voluntary counseling and testing

Providing VCT at family planning facilities enables providers to offer more targeted family planning counseling because clients know their HIV status, and it may motivate clients to adopt dual protection strategies. (15) Moreover, anecdotal evidence from pilot projects conducted in India, Cote d'Ivoire, and Ethiopia suggests that integrating VCT into reproductive health services can reduce the stigma associated with HIV, increase awareness of healthy sexual behavior, increase access to and use of VCT services, and reduce the cost of establishing VCT services. (16)

None of these pilot projects has been rigorously evaluated. But the Rwandan family planning association, Association Rwandaise pour le Bien-Etre Familial (ARBEF), and FHI's Implementing AIDS Prevention and Care project are assessing the impact of VCT services on clients' sexual behavior at three ARBEF clinics as part of a broader evaluation of VCT programs supported by FHI. Results are expected by the end of 2004. The Population Council's FRONTIERS in Reproductive Health program and the South African Department of Health are designing a study to compare quality of counseling, use of VCT services, sustained use of dual protection, and cost per client of direct provision of VCT with counseling and referral for HIV testing among family planning clients in South Africa's Northern Province.

Meanwhile, program managers need to consider whether providing VCT services or referrals in family planning settings is necessary, feasible, or cost-effective. Some family planning clinics in areas with high HIV prevalence may be able to provide VCT, while other clinics may only be able to offer counseling and refer clients for testing services. (17) If neither option is possible, risk assessments offer a theoretical way to help clients assess whether they may be infected or at high risk of infection, and thus help them make appropriate reproductive and contraceptive choices. (18) However, such assessments may prove difficult, and their effectiveness for screening low-risk populations has not been demonstrated. More research is needed to improve these assessment tools. (19)

The way forward

Family planning program providers are often reluctant to offer HIV services. Many are concerned about the potential negative effects of new HIV responsibilities on workload, job security, allocation of scarce family planning resources, and overall quality of services. Others fear occupational exposure to HIV or worry that providing HIV services will discredit family planning programs. (20) And providers who are not trained to provide HIV services may not feel confident doing so.

Nevertheless, providers have an obligation to their clients to do what they can, says Dr. Ndugga Maggwa, regional director of FHI's Institute for Family Health in East and Southern Africa. "Wherever family planning services are offered, providers should be equipped to counsel clients about STIs and HIV and to refer them for services."

Dr. Maggwa and the Population Council's Dr. Askew advise family planning programs to reach out to men and youth, while reorienting routine consultations toward protection against both STIs/HIV and unintended pregnancies. "Strategies that seek to assess the woman's overall situation, counsel her on her risks and options, and respect her right to make the final decision concerning her behavior appear to be the most promising ways of helping her obtain the protection she needs," they recommend. (21)

References

(1) 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.

(2) Askew.

(3) Dallabetta G, Gerbase A, Holmes K. Problems, solutions and challenges in syndromic management of sexually transmitted diseases. Sex Transm Infect 1998;74(Suppl 1):1-11.

(4) World Health Organization (WHO). Guidelines for the Management of Sexually Transmitted Infections. Geneva, Switzerland: WHO, 2003.

(5) Askew.

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

(7) Dehne K, Snow R. Integrating STI Management Services into Family Planning Services: What Are the Benefits? Geneva, Switzerland: World Health Organization, 1999; O'Reilly K, Dehne KL, Snow R. Should management of sexually transmitted infections be integrated into family planning services: evidence and challenges. Reprod Health Matters 1999;7(14):49-59.

(8) O'Reilly; 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) U.S. National Institute of Allergy and Infectious Diseases (NIAID). Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention [workshop summary], NIAID, Herndon, VA, June 12-13, 2000. Available: http://www.niaid.nih.gov/dmid/stds/ condomreport.pdf; Cates W Jr. The NIH condom report: the glass is 90% full. Fam Plann Perspect 2001;33(5):231-33; U.S. Centers for Disease Control and Prevention. Fact Sheet for Public Health Personnel: Male Latex Condoms and Sexually Transmitted Diseases. Available: http://www.cdc.gov/hiv/pubs/facts/condoms.pdf.

(10) Ali MM, Cleland J, Shah IH. Condom use within marriage: a neglected HIV intervention. Bull WHO 2004;82(3):180-86.

(11) Myer L, Morroni C, Mathews C, et al. Dual method use in South Africa. Int Fam Plann Perspect 2002;28(2):119-21.

(12) Kuyoh MA, Spruyt A, Johnson L, et al. Dual method use among family planning clients in Kenya: final report. Unpublished report. Family Health International, 1999.

(13) Adeokun L, Mantell JE, Weiss E, et al. Promoting dual protection in family planning clinics in Ibadan, Nigeria. Int Fam Plann Perspect 2002; 28(2):87-95.

(14) Ali.

(15) 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.

(16) 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.

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

(18) Rutenberg N, Kalibala S, Baek C, et al. Programme Recommendations for the Prevention of Mother-to-Child Transmission of HIV. New York, NY: United Nations Children's Fund (UNICEF), 2003.

(19) Welsh M, Feldblum P, Chen S. Sexually transmitted disease risk assessment used among low-risk populations in East/Central Africa: a review. East Afr Med J 1997;74(12):765-71; Cates W Jr, Welsh MJ. Tools for assessment of STI risk in family planning settings. IPPF Med Bull 2003;37(3):1-2.

(20) 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; Preble E, 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_and_PMTCT.pdf.

(21) Askew, Maggwa.