There is widespread agreement from governments and international organizations alike that linking reproductive health – particularly family planning (FP) – and HIV policies, programs, and services is essential for addressing men and women’s reproductive health needs.  Indeed, the United States President’s Emergency Plan for AIDS Relief’s (PEPFAR) country operational plan guidance explicitly states that “Voluntary family planning should be part of comprehensive quality care for persons living with HIV” (PEPFAR, 2012). FP/HIV integration is one of the key strategies for meeting Millennium Development Goal #5 to improve maternal health and #6 to combat HIV/AIDS, malaria, and other diseases.  FP/HIV integration also supports the Global Plan Towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive (Johnson et al., 2012).  Integrating FP services into HIV prevention, treatment, and care services provides an opportunity to increase access to contraception among clients of HIV services who do not want to become pregnant, or to ensure a safe and healthy pregnancy and birth for those who desire to have a child (WHO, USAID, and FHI, 2009). Among women and men with HIV who are sexually active and do not wish a pregnancy, effective use of contraception translates into fewer unwanted pregnancies, fewer HIV-positive births and, by extension, fewer children needing HIV treatment, care, and support.

There are several entry points for FP/HIV integration, including:

• FP services
• HIV treatment, care and support services
• Antenatal care, which can incorporate HIV counseling and testing and FP counseling
• Sexually transmitted infection service delivery
• Community-based peer-oriented services

Making use of these various entry points reduces organizational “silos” and facilitates more comprehensive care (FHI 360, 2012).

Despite the well-known benefits of promoting FP to reduce mother-to-child transmission of HIV and keep women alive and healthy, efforts to address the FP needs and rights of women living with HIV need to be strengthened (FHI 360, 2012). The rate of unintended pregnancy among women living with HIV is unacceptably high, ranging from 53 percent to 84 percent in some African countries (Wanyenze et al., 2011).  And analysis of Demographic and Health Survey data found that about 14 percent of women living with HIV in six African countries have an unmet need for FP, even though they are in regular contact with the health system for their HIV care (Mahy et al., 2011).

Supporting strategies to prevent unintended pregnancies among women living with HIV is part of wider efforts to respond to the full range of sexual and reproductive health needs of women living with HIV. Meeting these needs can help women living with HIV and their partners exercise reproductive choice and attain their fertility intentions, whether that means treating infertility, assisting those who wish not to have children, or supporting pregnancy spacing (WHO, 2011).

Although there is strong justification for FP/HIV integration, on a practical level, it can be challenging to implement and monitor. Integration requires collaborative planning, management, budgeting, cross training, task shifting, and joint supervision, all translating into integrated service delivery.  When FP and HIV/AIDS services have not been organized in an integrated manner at the policy and planning level, the client level services tend to be incomplete at best.

Indicator Selection

In an effort to address this, several FP/HIV indicators were piloted in the field to test the feasibility of monitoring these integrated services.  Some of the core indicators presented here are the result of that pilot. Other indicators are from PEPFAR’s proposed Site Improvement through Monitoring Systems (SIMS) Tool.  For more information on FP/HIV indicators, see “Monitoring the Integration of Family Planning and HIV Services: A Manual to Support the Use of Indicators to Measure Progress toward PEPFAR’s 90-90-90 Targets and Protect Women’s Reproductive Rights” (MEASURE Evaluation, 2016).

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References

FHI 360, 2012. Preventing Unintended Pregnancies and HIV. https://www.fhi360.org/sites/default/files/media/documents/PMTCTbrief.pdf 

Inter-agency Task Team for Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and their Children, 2011. Preventing HIV and Unintended Pregnancies: Strategic Framework 2011-2015. Geneva: WHO. http://www.who.int/reproductivehealth/publications/linkages/HIV_and_unintended_pregnancies_SF_2011_2015.pdf  

Johnson K, Ilona V, and Paul A, 2012. Integration of HIV and Family Planning Health Services in Sub-Saharan Africa: A Review of the Literature, Current Recommendations, and Evidence from the Service Provision Assessment Health Facility Surveys. DHS Analytical Studies No. 30. Calverton, Maryland, USA: ICF International.

Mahy M, Frescura L, Alfven T, et al. “Do women with HIV received adequate family planning services? An analysis of DHS data.” Presentation at the 16th International Conference on AIDS and STIs in Africa (ICASA), 2011 December 4–8, Addis Ababa, Ethiopia.

PEPFAR, 2012, The President’s Plan for AIDS Relief (PEPFAR): FY 2013 Country Operational Plan (COP) Guidance, Version 2. Washington, DC: USAID/PEPFAR.

Wanyenze RK, Tumwesigye NM, Kindyomunda R, et al. Uptake of family planning methods and unplanned pregnancies among HIV-infected individuals: a cross-sectional survey among clients at HIV clinics in Uganda. Journal of the International AIDS Society. 2011; 14:35.

WHO, USAID, and FHI, 2009. Strategic Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, Programs, and Services. Geneva: WHO. http://www.who.int/reproductivehealth/publications/linkages/fp_hiv_strategic_considerations.pdf