(December 2009) Integrating family planning and reproductive health and HIV services is an important strategy to reduce new HIV infections and unintended pregnancies and promote gender equality and human rights. Integrating family planning/reproductive health and HIV services will broaden the reach of both, essential at a time when, despite a massive increase in resources devoted to fighting HIV/AIDS, only a negligible reduction in new HIV infections has been achieved.1 Furthermore, more than 200 million women have an unmet need for contraception to prevent an unintended pregnancy.2 Because more than 80 percent of new HIV infections are sexually transmitted and women are vulnerable to both HIV infections and unintended pregnancies, addressing these two problems simultaneously is more necessary now than ever before.
Counteracting Gender Inequality and Stigma
UNAIDS has identified gender inequality and stigma against AIDS as the leading factors contributing to HIV risk.3 The fear of stigma and discrimination impedes socially marginalized people and adolescents from accessing HIV prevention, care, and treatment. Illiterate, socially restricted women and girls have severely limited opportunities to learn how to protect themselves. Integrating services responds to their strategic gender needs, promoting greater equality with men in their use of time and access to information.4 In many societies, including the United States, women have less unscheduled time; and girls have less leisure time than boys.5 If individuals—mothers, working adults, in-school and out-of-school youth—are able to address two or more health issues in a single visit to a health center, they save time and travel expense and do not forfeit other opportunities. It is not surprising therefore that the ability of clients to do "one-stop shopping" has resulted in improved health outcomes. Benefits also accrue to the economic sector and to households when girls and women are able to spend their time earning income, studying, caring for their children and families, or participating in community life.
Integration also helps reduce the stigma associated with free-standing clinics that treat HIV and sexually transmitted infections. When women (and men) can take advantage of provider-initiated testing and counseling as part of routine care, more people will be aware of their HIV status. Coupled with the savings that integration can mean for scare health system resources, linking services is a win-win situation. Yet, more than a decade after integration of HIV and reproductive health services was proposed, widespread integration remain an unrealized goal.6
Knowledge Fundamental to Women's Empowerment
Quality services for family planning or HIV prevention, care, and treatment empower sexually active individuals to make safe and responsible decisions about their intimate lives. Women are empowered with lifesaving information when HIV prevention is discussed in the context of maternal health and family planning services, and the availability of family planning information and contraceptives within HIV services settings allows a woman to exercise her rights to plan and space her births, to conceive more safely if she chooses to become pregnant, and to negotiate safer sex with a partner.
Clients' Need for Comprehensive Services
Clients who seek HIV and reproductive health services share similar needs and concerns. Tens of millions of women want to delay their next pregnancy for at least two years or stop having children altogether, but for a variety of reasons, are not using a modern method of contraception. Women with an unmet need for contraception also need information on how to avoid contracting HIV. Women represent nearly half of the 33 million people living with HIV, and several studies suggest that a majority of them also have an unmet need for family planning.7 Because of the dual burden of high unmet need for contraception and high regional prevalence of HIV, women in sub-Saharan Africa have the greatest risk of unintended pregnancy and HIV. While many of these women may wish to have a child at some point, studies in Côte d'Ivoire, South Africa, and Uganda have found that more than half of HIV-positive respondents had an unintended pregnancy.8 Integration gives providers an opportunity to educate clients about the strategies for preventing HIV, sexually transmitted infections, and unintended pregnancies.
Preventing Mother-to-Child Transmission of HIV
Nearly all of the 370,000 new HIV infections that occurred among infants and children in 2007 were preventable.9 The risk of transmitting HIV from mother to child during birth or through breastfeeding can be greatly reduced through providing antiretroviral treatment, but services to prevent mother-to-child transmission (PMTCT) of HIV currently reach only a third of HIV-positive expectant mothers. Clearly, it is in the interests of parents, children, and societies to prevent new infections by ensuring universal access to PMTCT services. Many women fail to be tested or to accept treatment because they fear they will be discriminated against or abandoned if identified as HIV-positive. Access could be greatly expanded through integration of PMTCT services with existing maternal and reproductive care.
Safer Pregnancies for Women With HIV
Many HIV-positive women hope to safely conceive a child at a future time. In Ghana, researchers found that 56 percent of women with HIV wanted to have a child in the future, and 22 percent wanted a child within the next two years.10 HIV-positive women who desire a pregnancy can conceive more safely if the severity of their infection is reduced through antiretroviral therapy prior to conception. Providers of integrated services can help by starting them on this therapy prior to conception and encouraging consistent condom use until their level of infection (viral load) is as low as possible.11 Many women are in a relationship where one partner is not infected. When pregnancy is desired, couples also need counseling on low-cost strategies to help them conceive safely while minimizing the risk for the uninfected partner.12 In addition, women who have recently given birth need family planning services to prevent a subsequent birth that is too closely spaced. Most PMTCT services do not include family planning counseling or referral, but making this information and referral universally available in HIV counseling, testing, and PMTCT treatment centers is a route to better health for women and infants.
Gender Equity and Human Rights
Integrated programs providing a variety of services offer a greater potential of reaching underserved or vulnerable groups, particularly youth, who now represent 45 percent of all those newly infected with HIV. Young women are three times as likely as young men of the same age to become infected.13 They are especially in need of information and services they can access with confidence that their personal information will be kept confidential and that providers will treat them with respect.14
Integration enhances gender equity and fosters human rights—another important rationale for moving forward with the rollout of high-quality, convenient, one-stop comprehensive health care services. When policymakers, program staff, and other key stakeholders, including people living with HIV, work together to advance the field of reproductive health and HIV/AIDS integration, millions, particularly women and girls, will benefit.
Karin Ringheim is a senior policy adviser at the Population Reference Bureau.
- UNAIDS reports a decline in new HIV infections from 3.0 million (ranging from 2.6 to 3.5 million) in 2001 to 2.7 million (ranging from 2.2 to 3.2 million) in 2007. The estimated reduction is within the margin of error.
- Susheela Singh et al., Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care (New York: UNFPA and Guttmacher Institute, 2009).
- UNAIDS, Report on the Global AIDS Epidemic 2008 (Geneva: UNAIDS, 2008).
- Caroline Moser, Gender Planning and Development: Theory, Practice and Training (London: Routledge, 1993).
- Cynthia B. Lloyd, ed., Panel on Transitions to Adulthood in Developing Countries (Washington, DC: National Research Council, 2005); and Amanda Ritchie, Cynthia Lloyd, and Monica Grant Gender, "Differences in Time Use Among Adolescents in Developing Countries: Implications of Rising School Enrollment Rates," Population Council Working Paper (New York: Population Council, 2004).
- World Health Organization and UNAIDS, Guidance on Provider-Initiated HIV Testing and Counseling in Health Facilities (Geneva: WHO/UNAIDS, 2007); Rose Wilcher et al., "From Effectiveness to Impact: Contraception as an HIV Prevention Intervention," Sexually Transmitted Infections 84, suppl. (2008): 1154-60; Rumeli Das et al., Strengthening Financial Sustainability Through Integration of VCT and Other RH Services (Washington, DC: Population Council, 2007); Rick Homan et al., "Cost of Introducing Two Different Models of Integrating VCT for HIV Within Family Planning Clinics in South Africa," presentation at the International Conference on Linking Reproductive Health, Family Planning, and HIV/AIDS Programs in Africa, 2006; Jim Shelton, "Prevention First: A Three-Pronged Strategy To Integrate Family Planning Program Efforts Against HIV and Sexually Transmitted Infections," International Family Planning Perspectives 25, no. 3 (1999): 147-52; and Marge Berer, "HIV/AIDS, Sexual and Reproductive Health: Intersections and Implications for National Programs," Health Policy and Planning 19, suppl. 1 (2004): i62-70.
- Tamsen J. Rochat et al., "Depression Among Pregnant Rural South African Women Undergoing HIV Testing," Journal of the American Medical Association 295, no. 12 (2006): 1376-78; and Theo Smart, "PEPFAR: Unexpected and Unwanted Pregnancies in Women on ART Highlights Family Planning Gap," accessed online at www.aidsmap.com, on Dec. 2, 2009.
- Annabel Desgrées-du-Loû et al., "Contraceptive Use, Protected Sexual Intercourse and Incidence of Pregnancies Among African HIV-Infected Women, DITRAME ANRS 049 Project, Abidjan 1995-2000," International Journal of STD & AIDS 13, no. 7 (2002): 462-68.
- Expanded Inter-Agency Task Team (IATT) on Prevention of HIV in Pregnant Women, Scale-Up of HIV-Related Prevention, Diagnosis, Care and Treatment for Infants and Children, A Programming Framework (Geneva: World Health Organization, 2008).
- Susan Adamchak et al., Introducing Family Planning Services Into Antiretroviral Programs in Ghana: An Evaluation of a Pilot Intervention (Research Triangle Park, NC: Family Health International, 2007).
- The risk of mother-to-child transmission of HIV is directly related to viral load, a measure of level of infection. A lower viral load lessens the risk of transmission from mother to child and from infected partner to uninfected partner. Treatment is therefore also an important prevention strategy.
- Sylvia Nakayiwa et al., "Desire for Children and Pregnancy Risk Behavior Among HIV-Infected Men and Women in Uganda," AIDS and Behavior 10, suppl. 1 (2006): 95-104; and Landon Myer et al., "Reproductive Decisions in HIV-Infected Individuals," The Lancet 366, no. 9487 (2005): 698-700.
- UNAIDS, Report on the Global AIDS Epidemic 2008.
- Karin Ringheim, "Ethical and Human Rights Perspectives on Providers' Obligation to Ensure Adolescents' Rights to Privacy," Studies in Family Planning 38, no. 4 (2007): 245-52.