1.2.02 Advancing the Science and Practice of Family Planning/HIV Integration




Wednesday, November 13, 2013


Ellen Starbird, USAID
Joelle Mak, London School of Hygiene & Tropical Medicine, Populations Studies Department
Daniel Grossman, Ibis Reproductive Health
Sarah Finocchario-Kessler, University of Kansas Medical Center, Department of Family Medicine
Riley Steiner, The Johns Hopkins Bloomberg School of Public Health
Isolde Birdthistle, London School of Hygiene and Tropical Medicine, Population Studies Department
Kathryn Church, London School of Hygiene & Tropical Medicine, Department for Population Studies
Natalie Friend-du Preez, LSHTM, Population Studies
Joshua Kikuvi, London School of Hygiene & Tropical Medicine
Susannah Mayhew, London School of Hygiene and Tropical Medicine
Marisiana Atieno Onono, Kenya Medical Research Insitute
Sara Jeannette Newmann, Bixby Center for Global Reproductive Health, UCSF
Cinthia Blatt, Bixby Center for Global Reproductive Health, UCSF
Elizabeth Bukusi, Kenya Medical Research Institute (KEMRI)
Starley Shade, Center for AIDS Prevention, UCSF
Rachel Steinfeld, Bixby Center for Global Reproductive Health, UCSF
Craig R. Cohen, Bixby Center for Global Reproductive Health, UCSF
Jacinda Dariotis, Johns Hopkins Bloomberg School of Public Health
Jean Anderson, Johns Hopkins Medical Institutions, Division of Gynecologic Specialties
Rachel Masuku, UNFPA

Name of Preformed Panel / Nom du Panel préformé:

Advancing the Science and Practice of Family Planning/HIV Integration

Panel Overview / Description:


This panel will advance discussion and bring new evidence to bear on how the family planning and HIV fields intersect and how they can be better integrated in practice. Objectives include:

1)      Describe new developments in the policy environment to support stronger linkages between the family planning and HIV fields

2)      Present new evidence that reflects progress in and challenges to translating policy support for family planning/HIV integration into practice

3)      Share recent findings and lessons learned from evaluations of service delivery approaches to integrating family planning and HIV services

Summary Description

In November 2013, just prior to the International Conference on Family Planning, the journal AIDS will publish a thematic supplement on family planning and HIV. Guest edited by staff from FHI 360 and the University of Washington – and with support from USAID – the supplement will compile the latest high-quality evidence from a range of multidisciplinary efforts to advance family planning/HIV science and practice.

Despite steady improvements in the linkages between family planning and HIV policies, programs, and services, many women still face the dual risk of unintended pregnancy and HIV acquisition. Moreover, our understanding of integrated service delivery best practices remains limited and the question of an association between hormonal contraception and HIV acquisition is unresolved. The supplement is intended to address many of the gaps in knowledge that pose obstacles to greater progress in meeting the contraceptive needs of women and couples living with and at risk of HIV.

This panel is comprised of four presentations drawn from articles published in the supplement. They represent a balanced set of presentations that contribute new evidence to the ways in which the two fields are related and offer guidance on future directions for integrated FP/HIV research and programming. 

Research/Program/Policy Implications

Stronger linkages between family planning and HIV programs are critical to achieving global health and development goals, including recent commitments to expand access to contraception to 120 million women and girls and create an AIDS-free generation. This panel, which will draw upon articles published in the 2013 AIDS supplement on family planning and HIV, will highlight new evidence to guide funders, policymakers, program planners and implementers to act on the synergies between the two fields and enhance the public health impact of reproductive health and HIV programs.

Presentation 1 Title / Titre de la présentation 1:

Meeting the family planning needs of women living with HIV in U.S. Government global health programs

Presenter of Presentation 1 / Auteur de la présentation 1:

Ellen Starbird, USAID Office of Population and Reproductive Health, on behalf of the U.S. Government Inter-agency Task Team on Family Planning/HIV Integration

Presentation 1/ Présentation 1:

The integration of health programs, including HIV and voluntary family planning (FP), is a priority for U.S. government foreign assistance. One critical component of FP and HIV integration that has significant positive health outcomes is ensuring that all women living with HIV have access to both a full range of contraceptives as well as safe pregnancy counseling. This presentation will outline the U.S. government global health strategy to meet the family planning needs of women living with HIV based on three key principles: (1) a focus on reproductive rights through voluntarism and informed choice, (2) quality service provision through evidence-based programming, and (3) development of partnerships.

Presentation 2 Title / Titre de la présentation 2:

Need, demand and missed opportunities for integrated RH-HIV care in Kenya & Swaziland: evidence from household surveys

Presenter of Presentation 2 / Auteur de la présentation 2:

Joelle Mak, London School of Hygiene & Tropical Medicine, Populations Studies Department

Presentation 2/ Présentation 2:

Background: Little is known about need and demand for integrated reproductive health (RH) and HIV services at the population-level. Need, demand and missed opportunities for integrated RH-HIV service provision were determined through descriptive data analysis of household surveys collected by the Integra Initiative, an evaluation of different models of providing integrated RH and HIV services in Kenya, Swaziland and Malawi. 

Methods: Household surveys were conducted among 18-49 year-olds in Kenya (N=1752) and Swaziland (N=779) in 2009. Data on fertility intentions, contraceptive (including condom) use, sexual behaviours and HIV testing were used to determine unmet needs. Demand for integrated services was defined as wanting RH services together with HIV/STI services at the same visit. 

Results: At the population-level, FP needs (90%) were higher than HIV/STI prevention needs: 53% (women) and 75% (men). Fewer had unmet FP needs through non-use of contraceptives: 17% of women and 27% of men; versus unmet HIV/STI prevention needs through inconsistent condom use: 48% and 26% of women and 51% and 32% of men in Kenya and Swaziland respectively. Dual need was higher for men: 64% (Kenya) and 73% (Swaziland) versus women (48%) with more unmet in Kenya (43%) compared to Swaziland (25%). Missed opportunities for integrated service provision were high among women: 49% and 57% with unmet FP needs; and 55% and 32% with unmet HIV/STI prevention needs in Kenya and Swaziland respectively used services, but did not receive the needed service. Most men with unmet needs reported no RH service use in the past year. Approximately a quarter of female respondents who used a clinic for services wanted and received integrated RH-HIV/STI services in both countries. 

Conclusions: Findings indicate demand creation at the community-level and provider-initiated integrated service provision are needed using different strategies for men and women to address the unmet FP and HIV/STI prevention needs in these populations.

Presentation 3 Title / Titre de la présentation 3:

Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial

Presenter of Presentation 3 / Auteur de la présentation 3:

Daniel Grossman, Ibis Reproductive Health; Bixby Center for Global Reproductive Health, UCSF

Presentation 3 / Présentation 3:

Background: The objective of this study was to determine whether integrating family planning (FP) services into HIV care was associated with increased use of more effective contraceptive methods.

Methods: We performed a cluster randomized trial at 18 public HIV clinics in Nyanza Province, Kenya. Twelve sites were randomized to integrated FP services, while six clinics were controls where clients were referred to FP clinics at the same facility. For women age 18-45, we abstracted data on demographics, contraceptive use and pregnancy from electronic medical records.  We compared contraceptive use between the baseline period (Dec 2009-Feb 2010) and endline period (Jul 2011-Sep 2011, one year after site training) between study arms. Pregnancy rates during the follow-up year (Oct 2010-Sep 2011) were also compared. Data from clinical encounters were treated as serial cross-sections to assess change in outcomes over time. Generalized estimating equations were used to account for correlation of outcomes among patients within facilities. We assessed costs, cost-efficiency (cost per additional use of more-effective FP), and cost-effectiveness (cost per pregnancy averted) associated with the first year of integration of FP into HIV care.

Results: Data on contraceptive use were available for 5682 clinical encounters at baseline and 12531 encounters at endline. Women seen at integrated sites during the final three months of the study were significantly more likely to use more effective contraceptive methods (OR 1.81, 95% CI 1.24-2.63). No differences were observed in condom use (OR 0.64, 0.35-1.19), or dual method use (OR 1.30, 95% CI 0.77-2.17) comparing intervention to control sites. No difference was observed in incident pregnancy in the first year after training comparing intervention to control sites (IRR 0.90; 95% CI 0.68-1.20). Integration of services was associated with an average marginal cost of $841 per site and $48 per female patient.  Integration was associated with a marginal cost of $65 for each additional use of more effective FP and $1368 for each pregnancy averted.

Conclusions: Integration of FP services into HIV care and treatment in this setting increased use of more effective contraceptive methods with a non-significant reduction in condom use. Although we did not see a significant reduction in pregnancy incidence during the study, it is likely that one year is too short a period of observation for this outcome. Integration of FP and HIV services is feasible, inexpensive to implement, and cost-efficient in the Kenyan setting.

Presentation 4 Title / Titre de la présentation 4:

Preconception care for people living with HIV: recommendations for advancing implementation

Presenter of Presentation 4 / Auteur de la présentation 4:

Riley J. Steiner, Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health

Presentation 4 / Présentation 4:

Globally, research has documented high fertility desires and intentions among HIV-positive women. Improving implementation of preconception care (PCC) for people living with HIV is critical given estimates that 48-70% of HIV-positive women who want future biological children have not received reproductive counseling, largely due to a lack of provider-initiated conversations. This presentation offers initial recommendations and outlines key considerations for a research agenda to advance PCC implementation efforts globally. We consider (1) who should provide PCC; (2) where it can be effectively delivered; (3) when it should be offered; and (4) potential implementation models given various resources. We conclude with a call for PCC specific implementation science and research translation to help people living with HIV achieve their reproductive goals.


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