Family planning and HIV

Abstract

Background In 2009, AIDS published a supplement dedicated to increasing understanding of the intersection of two globally important fields: family planning and HIV. That supplement originated from the belief that more evidence was needed to compel 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. It compiled high-quality articles from a range of multidisciplinary investigations that drew attention to the ways in which the family planning and HIV fields are related and how they can be better integrated in practice [1]. The 2009 supplement came at an important time. First, advocacy was building for stronger efforts to support women living with HIV to achieve their desired fertility intentions. These efforts were driven, in part, by several compelling modeling studies that demonstrated the value and cost–effectiveness of family planning and prevention of unintended pregnancies as a prevention of mother-to-child transmission (PMTCT) intervention. Second, the President's Emergency Plan for AIDS Relief (PEPFAR) had recently endorsed linkages between its programs and family planning services following years of siloed programming. This created new opportunities to expand integrated services and better meet the reproductive health needs of HIV clients. Third, a number of international policy statements calling for stronger linkages between the fields had been issued, but a limited body of evidence was available to guide implementation. The supplement was intended to address some of the critical gaps in the family planning/HIV evidence base and foster more effective and widespread efforts to meet the dual reproductive health and HIV needs of women and couples. Four years later, family planning/HIV science and practice has continued to evolve, and the timing of the current supplement is no less important. Since the previous supplement was published, the policy environment for stronger linkages between family planning and HIV programs has grown, investments by major funders – including PEPFAR and the Bill & Melinda Gates Foundation – in research on a range of family planning/HIV-related topics have increased, and programmatic efforts have expanded. Family planning is now widely recognized as an important part of combination strategies for HIV prevention. From a variety of settings, novel approaches to integrate family planning and HIV services have been reported by Ministries and Health and implementing partners. Most importantly, evidence that integrated family planning/HIV services improve health outcomes is growing. In addition, the family planning and HIV fields each had watershed moments during the past year. At the groundbreaking London Summit on Family Planning in July 2012, funders, government leaders, and other partners committed to expanding access to contraception and rights-based family planning services to an additional 120 million women and girls. Global enthusiasm for implementing HIV treatment and prevention services to prevent new infections has spurred talk of an AIDS-free generation, illustrated well in the US government's November 2012 publication of the PEPFAR Blueprint: Creating an AIDS-free Generation. Stronger linkages between family planning and HIV programs are critical to turning these ambitious public health goals into reality. Despite improvements over the past 4 years, many women still face the dual risk of unintended pregnancy and HIV acquisition. Moreover, important gaps in knowledge and programmatic shortcomings pose obstacles to progress. Our understanding of how best to achieve and sustain integrated services at scale is limited, rates of unintended pregnancies among women living with HIV remain high, and a potential contribution of some forms of hormonal contraception to HIV risk is an unresolved and distressing question. New evidence, future directions This AIDS supplement brings to the forefront the latest advances in family planning/HIV integration research, programs, and policy. It also offers insights into strategic directions for future investments in this area. Our goal was to bring together original research, cutting-edge reviews, and opinion pieces speaking to a diversity of topics: biomedical and basic science research on the relationship between reproductive health and HIV transmission and disease, behavioral research examining contraceptive practices and fertility choices among women and couples affected by HIV, implementation science evaluating integrated service delivery innovations, and evidence-based recommendations for programming. As with the 2009 supplement, the response to the 2013 call for papers was exceptional, indicating the commitment to progress in this area remains high. The papers received and those ultimately accepted for publication not only tackle issues that have traditionally been of keen importance to this field – such as the potential association between hormonal contraception and risk of HIV acquisition and promising practices for integrating family planning and HIV services – but also expand the family planning/HIV territory to other sexual and reproductive health domains. The 14 articles presented here represent the breadth of molecular, epidemiologic, operational, and strategic lenses through which to view these two intersecting fields. Hormonal contraception and HIV Over the past 4 years, the question of whether hormonal contraception – and especially the injectable depot medroxyprogesterone acetate (DMPA) – increases the risk of HIV acquisition has come to the scientific center stage. In 2012, a WHO expert meeting concluded that the evidence was not strong enough to make major changes in the global contraceptive guidelines [2]. However, investigators have continued to wrestle with this issue from a variety of angles. In the supplement, we include five articles that address the biological and biomedical intersections of hormonal contraception and HIV. The supplement begins with a review of the evidence linking contraceptives to genital tract changes [3]. Hormonal contraception represents many different estrogen and progestin regimens, each of which has its own idiosyncrasies affecting the microbiology and immunology of the vaginal tract. Multiple molecular investigations have not identified any consistent surrogate biomarker for HIV risk. As a result, many plausible biological hypotheses exist to explain epidemiological associations between progestins and HIV acquisition. From there, we present two original research articles that seek to expand our understanding of the safety and effectiveness of hormonal contraceptive methods for women living with or at risk of HIV. The first study examines potential interactions between nevirapine-containing antiretroviral therapy (ART) and combined oral contraceptives (COCs). The results suggest that nevirapine does not interfere with COC contraceptive effectiveness as it did not affect risk of ovulation or pregnancy in women taking COCs [4]. The second study analyzes original data from discordant couples in Rakai, Uganda for evidence of an association between hormonal contraceptive use and HIV acquisition and transmission [5]. No significant risk of HIV acquisition or transmission with oral contraceptives or DMPA use occurred in the study population. However, statistical power was quite limited, and several point estimates were concerning. The last two articles addressing hormonal contraception and HIV explore methodologic issues involved with analyzing observational studies on the topic. The first reports on recommendations to improve observational evidence in women who select different methods of contraception [6]. Such topics as careful definition of exposure groups; handling potential confounders, mediators, and effect modifiers; estimating and addressing the magnitude of measurement error; using multiple methods to account for incidence of pregnancy; and exploring the potential for differential exposure to HIV-infected partners are discussed. The second article raises important issues regarding the etiologic consequences of misreported and/or differential condom use by hormonal and nonhormonal contraceptive users [7]. Depending on the direction of underreporting or overreporting, spurious associations with HIV acquisition would result. In the future, biologic assessments of unprotected intercourse (PSA, Y-chromosome) may help minimize this potential for confounding. Behavioral and programmatic research The next five articles in the supplement move us into the world of integrating family planning and HIV programs. We include a review article of 12 recent evaluations of interventions integrating family planning into HIV service delivery settings [8]; two companion articles from a randomized controlled trial of an integrated family planning/HIV service delivery intervention in Western Kenya [9,10]; an analysis of household survey data on need and demand for integrated services from the Integra Initiative in Kenya and Swaziland [11]; and a study from Lusaka, Zambia that examines contraception initiative, discontinuation, and switching among HIV positive couples exposed to a family planning intervention in HIV counseling and testing services [12]. The review article synthesizes evidence and lessons learned from recently published evaluations of family planning/HIV integration interventions [8]. The review reveals that integrated family planning/HIV services can increase use of contraception by women and couples who do not wish to become pregnant, although the quality of the evidence is still less than ideal. However, rather than calling for more rigorous studies, the authors recommend moving on to invest in health system reinforcements and meaningful evaluations that will foster our ability and understanding of how to take integrated service delivery innovations to scale. The two articles from the trial in Western Kenya provide important contributions to gaps identified in the review article – namely, impact data from a rigorously designed study and data on the cost–effectiveness of integrated family planning/HIV services [9,10]. Although the results indicate that the family planning/HIV integration intervention tested was effective at increasing access to contraception, the intervention was not associated with a reduction in unintended pregnancies. The Integra Initiative is 5-year, multicountry research project designed to contribute evidence on the benefits and costs of delivering integrated reproductive health and HIV services. We include an article from this project that analyzes population-level data from household surveys in Kenya and Swaziland, revealing high levels of unmet need for both family planning and HIV prevention services and missed opportunities for addressing those needs at the service delivery level [11]. Finally, we include an evaluation of a family planning intervention delivered to HIV-positive couples receiving HIV counseling and testing services [12]. The study documents the types of contraceptives chosen and their continuation rates, an aspect of family planning use that has been largely unexamined in family planning/HIV integration evaluations to date. Although encouraging progress was made on offering WHO tier one longer acting contraceptive methods, the results also suggest that more work remains to increase uptake and continuation of these effective methods. Broadening the family planning/HIV landscape We round out this supplement by stretching our traditional borders of family planning and HIV. We have included one original article that provides an additional perspective – maternal mortality – for why we must continue to bolster efforts to meet the contraceptive needs of women with HIV who do not wish to become pregnant [13]. We also offer three commentaries with insights into future directions for the ever-evolving field of family planning/HIV integration. These articles expand the conversation about family planning and HIV intersections into areas that have been underrepresented in the global dialogue on this technical area to date. The cohort study with HIV-positive women initiating ART in Uganda found that these women experienced increased mortality during pregnancy and the postpartum period [13]. The data provide further rationale for integrating rights-based family planning services into HIV care and treatment settings to reduce the risk of unintended pregnancies. A related commentary emphasizes the importance of preconception care for women with HIV [14]. As reproductive rights are at the core of family planning, high-quality preconception services for any HIV-positive woman who wishes to become pregnant is an essential part of her reproductive health spectrum. Implementing preconception services in HIV clinical care is another way to address reproductive goals while minimizing the risk of HIV transmission to infants and partners. One of the most encouraging developments over the past 4 years has been the increasing commitment of the US Government to meeting the fertility intentions of people living with HIV [15]. An article coauthored by representatives from US Government foreign assistance agencies articulates the collaborative vision of PEPFAR and United States Agency for International Development for ensuring women living with HIV have access to a full range of contraceptive options and safe pregnancy counseling. The priority placed on enhancing the integration of US Government-supported family planning and HIV services offers exciting new opportunities for HIV programs to offer the full spectrum of reproductive health services to its clients. Finally, the supplement closes with a commentary on the importance of a framework focused on sexual health, as opposed to sexual disease, to advancing reproductive rights and HIV prevention [16]. This aspirational vision forms an underpinning to the types of health-oriented semantics and services, which could be added to the current HIV care infrastructure. Moving in a sexual health direction would both empower sexual decision-making by those living with HIV and strengthen the entire health system by considering broader client participation. Conclusion To capitalize on the opportunities that currently exist to advance reproductive health and HIV outcomes, we must apply what we have learned about how to address the reproductive rights and needs of women and couples living with and at risk of HIV. This supplement reflects the ‘two steps forward’ recent progress in the many different facets of family planning and HIV intersections. We hope it provides a springboard for scientists, policymakers, and program leaders alike to build on this momentum. Despite many unresolved issues within both of these two fields, the benefits in operational efficiencies and client convenience make family planning and HIV natural allies. Acknowledgements Conflicts of interest The authors declare they have no conflicts of interest. Support for this manuscript was provided by FHI 360 with funds from the United States Agency for International Development (USAID), Cooperative Agreement Number GHO-A-00–09-00016-00, although the views expressed in this publication do not necessarily reflect those of USAID or the United States Government.