Family planning and HIV: expanding the evidence base.
Subject: HIV infection (Prevention)
Family planning services (Usage)
Family planning services (Influence)
Pub Date: 05/01/2010
Publication: Name: Reproductive Health Matters Publisher: Reproductive Health Matters Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2010 Reproductive Health Matters ISSN: 0968-8080
Issue: Date: May, 2010 Source Volume: 18 Source Issue: 35
Product: Product Code: 8000188 Family Planning; 9105262 Family Planning NAICS Code: 62141 Family Planning Centers; 92312 Administration of Public Health Programs SIC Code: 8099 Health and allied services, not elsewhere classified; 8322 Individual and family services
Accession Number: 236247763
Full Text: A 2009 supplement to the journal AIDS (1) greatly expands the evidence base regarding how the family planning and HIV fields are related and how they can be better integrated in practice. A few of the articles included are summarised below:

This study used Demographic and Health Surveys from Zambia, Swaziland, Zimbabwe and Lesotho and found that HIV-positive women who know their serostatus exhibit fertility desires and contraceptive behaviours that are different from other women: they are more likely to use condoms and more likely to want to limit childbearing by using contraception. The findings support efforts to scale up prevention of motherto-child transmission of HIV. (2)

This cross-sectional survey interviewed 236 HIV-positive and 162 HIV-negative post-partum women within 12 months of their expected delivery date in 12 randomly selected public sector health facilities providing PMTCT services in Rwanda. HIV-negative women were 16 times more likely to report wanting additional children (p<0.001) and nearly 85% less likely to use modern family planning (p<0.001), although modern family planning use was low in both groups. Condoms were the most commonly used method among HIV-positive women (31%) compared to withdrawal among HIV-negative women (19%). These results highlight success in provision of family planning counselling in PMTCT services. (3) 5,284 pregnant women were interviewed and tested for HIV in 15 antenatal clinics in Mwanza region, Tanzania in 2007-2008. HIV prevalence was 8.9% overall, and family planning ever-use was 26%. HIV-positive and HIV-negative women differed with respect to age, parity, length of last birth interval, child survival, childbearing intentions and intention to breastfeed, with HIV-positive women both desiring and having fewer children. HIV-positive women were more likely to have used family planning, particularly hormonal methods. Family planning services must be tailored to the specific needs of HIV-positive and HIV-negative women. (4)

This cross-sectional survey of 421 men and women recently tested for HIV in rural western Uganda found that HIV-positive individuals were more than six rimes as likely to want to stop childbearing (p<0.001) than HIV-negative individuals. Use of dual protection against HIV/sexually transmitted infection and unwanted pregnancy was rare in both groups, and the unmet need for a highly effective family planning method, which was high in both groups, was higher in HIV-positive participants compared with HIV-negative ones (90% vs. 78%). Barriers to utilising family planning services must be jointly addressed by HIV and family planning programmes. (5)

This systematic review aimed to determine whether HIV-positive women who use hormonal or intrauterine contraception are at increased risk of HIV disease progression, other adverse health outcomes, or HIV transmission to sexual partners. Evidence is limited, but generally reassuring. Eight observational studies reported no increased risk of disease progression with hormonal or intrauterine contraceptive use, whereas one randomised controlled trial found increased risks of declining CD4 count and death for hormonal contraceptive users compared with intrauterine device users. Women with HIV who used hormonal contraception had increased risks of acquiring STIs compared with women not using hormonal contraception. Findings from nine studies examining contraceptive use and HIV transmission to partners were inconsistent. Preventing unintended pregnancy among women with HIV remains a high priority. (6)

This study compared HIV disease progression among 4,109 antiretroviral therapy-naive women with and without exposure to hormonal contraception at 13 sites in Africa and Asia. 20% used implants/injectables and 5% used oral contraceptives. The study provides some reassurance as neither implants/injectables nor oral contraceptive pills were associated with disease progression, even when contraceptive method was treated as a time-varying exposure. (7)

This systematic review examined the effectiveness, optimal circumstances, and best practices for strengthening links between family planning and HIV interventions. Sixteen studies evaluating interventions linking family planning anal HIV were included and interventions were categorised into six types. Interventions were generally considered feasible and effective, with most studies reporting positive or mixed results for key outcomes, and no negative results reported. Overall evaluation rigour was low (3.25 out of 9). (8)

This study interviewed 4,019 people attending eight Ethiopian HIV voluntary counselling and testing (VCT) clinics and 4,027 patients 18 months after introducing family planning in those facilities, to determine whether VCT counsellors could offer acceptable family planning. Despite the lower risk this population had for unwanted pregnancy than expected, family planning counselling in VCT increased from 2% to 41% for women and from 3% to 29% for men (p<0.01). 6% of patients received contraceptive methods, and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher patient loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower patient loads. Patients whose counsellors perceived contraceptive availability to be adequate were significantly more likely to receive contraceptive methods than those counselled by providers who felt supplies were inadequate (p<0.01). Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted. (9)

(1.) Family planning and HIV. AIDS 2009; 23 (Supplement 1):S1-S130.

(2.) Johnson K, Akwara P, Rutstein S, et al. Fertility preferences and the need for contraception among women living with HIV: the basis for a joint action agenda. S7-S17.

(3.) Elul B, Delvaux T, Munyana E. Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda. S19-S26.

(4.) Keogh S, Urassa M, Kumogola Y, et al. Reproductive behaviour and HIV status of antenatal clients in northern Tanzania: opportunities for family planning and preventing mother-to-child transmission integration. S27-S35.

(5.) Heys J, Kipp W, Jhangri G, et al. Fertility desires and infection with HIV: results from a survey in rural Uganda. S37-S45.

(6.) Curthis K, Nanda K, Kapp N. Safety of hormonal and intrauterine methods of contraception for women with HIV/AIDS: a systematic review. S55-S67.

(7.) Stringer E, Giganti M, Rosalind C, et al. Hormonal contraception and HIV disease progression: a multicountry cohort analysis of the MTCT-Plus Initiative. S69-S77.

(8.) Spaulding A, Brickley D, Kennedy C, et al. Linking family planning with HIV/AIDS interventions:

a systematic review of the evidence. S79-S88. 9. Bradley H, Gillespie D, Kidanu A, et al. Providing family planning in Ethiopian voluntary HIV counselling and testing facilities: client, counselor and facility-level considerations. S 105-S114.
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