Meeting the Contraceptive Needs of Women and Couples with HIV: Is Family Planning/HIV Integration the Answer?

Transcription

1 Meeting the Contraceptive Needs of Women and Couples with HIV: Is Family Planning/HIV Integration the Answer?

2 Session Objectives 1. Provide a global snapshot of the state of FP/HIV integration, including recent progress and current challenges 2. Present new evidence on the fertility desires and FP needs of women with HIV 3. Share findings from an evaluation of an intervention to meet the post-partum FP needs of HIV-positive women 4. Describe the health systems approach undertaken by the Kenyan government to advance FP/HIV integration

3 Improvements and Impediments to Family Planning/HIV Integration: A Global Perspective Rose Wilcher International Conference on Family Planning Dakar, Senegal December 2, 2011

4 Key Assumptions All women, including those with HIV, have a right to sexual and reproductive health Addressing the contraceptive needs of HIV+ women offers many public health benefits Historically, FP and HIV policies, programs, and services have been implemented in parallel

5 Expanded Policy Support PEPFAR is a strong supporter of linkages between HIV/AIDS and voluntary family planning programs. The need for family planning for HIV-positive women who desire to space or limit births is an important component of the preventive care package of services for people living with HIV/AIDS and for women accessing PMTCT services.

6 Expanded Policy Support There are strong reasons for strengthening linkages between gender, HIV, and sexual and reproductive health when addressing the needs of sexually active men, women, and young people services provided within HIV programs provide a potential platform for sexual and reproductive health care, such as family planning. Fact Sheet: Ensuring a Gender Sensitive Approach, 2008.

7 Expanded Policy Support Linkages between programmes to stop HIV transmission among children and maternal health, newborn and child health, and family planning programmes should be strengthened.

8 Broader Evidence Base Modeling the impact and cost-effectiveness of FP as an HIV prevention intervention Unmet need, unintended pregnancies, and fertility desires among among HIV+ women Safety and effectiveness of FP methods for HIV+ women Effectiveness of integrating FP and HIV services

9 Many Programmatic Tools

10 No More Silos? FP HIV

11 Not Exactly

12 For Example % of PMTCT clients reporting their most recent pregnancy was unintended Kenya: 50% Rwanda: 50-60% South Africa: 69% Wilcher et al, GHC 2011

13 Easier Said Than Done? Increase understanding of the benefits of FP Build capacity to routinely screen clients for unmet need for FP Build capacity to counsel on the full range of safe and effective contraceptive options Provide contraceptive method of choice either on-site or thru referral

14 Health Systems Context Policies Facilities Providers Community

15 Challenges Ahead Provider bias and misconceptions Measurement/lack of reporting requirements Commodity security Gender inequality Moving beyond the pilot & going to scale

16 It Can Be Done MOH Leadership Policy Change Technical Guidance Political Will Resource Mobilization Emerging Evidence GLOBAL National Ongoing Research

17 It Must Be Done! Advance womencentered approaches Protect reproductive rights FP/HIV Extend benefits of FP to HIV clients Strengthen health systems Enhance costeffectiveness of PMTCT Prevent new HIV infections

18 High unmet need for family planning amongst HIV positive women on antiretroviral therapy in Johannesburg Sheree Schwartz, PhD, MPH 2011 International Conference on Family Planning Meeting the Contraceptive Needs of Women and Couples with HIV: Is Family Planning/HIV Integration the Answer? December 1 st, 2011

19 Background Increased access to highly active antiretroviral therapy (HAART) across Sub-Saharan Africa HIV infected women may be at increased risk for unplanned pregnancies after initiating HAART: Returned fecundity Lower expectation of pregnancy Many women struggle to negotiate condom use Reliable access to hormonal contraception is an important component of HIV prevention of mother-tochild transmission (PMTCT) 2

20 Research Questions Expanding access to HAART means HIV-positive women are living longer How frequently are women on HAART using FP, particularly non-barrier methods of contraception? What are barriers to FP use? What is the burden of unintended pregnancy amongst women on HAART? 3

21 Methods: The Fertility Intentions & Incidence Study 18-month prospective clinical cohort study 850 women on HAART enrolled to investigate Fertility intentions Contraceptive use, method preference and barriers Incidence of planned and unplanned pregnancies Hormonal contraceptive failures Issues related to ART regimens and pregnancy Maternal and infant outcomes in women on HAART Conducted in 4 government-run HIV treatment sites in inner city Johannesburg, South Africa, September 2009 March 2011

22 Background: HIV, Reproductive Health & South Africa Methods: Study Setting South Africa Nearly 1/3 women attending antenatal care HIV+ >1 million individuals on HAART Substantial reductions in MTCT.further to go High rates of maternal mortality persist 6.2 times higher in HIV positive women 776/100,000 vs. HIV negative women 124/100, DHS Black et al. Obstet Gynecol 2009;114:292 9

23 Methods: Data Collection Baseline survey Sep 09 Jan 10 Demographics Reproductive history Sexual behavior Contraceptive use Fertility intentions Patient-provider communication Longitudinal follow-up Sep 09- Mar 11 Contraceptive use Fertility intentions Pregnancy incidence Key clinical data (CD4, ART regimens, VL)

24 Results: Study Population Characteristics of the cohort (n=850) Median age, yrs [IQR] 30 [27-33] Employed, % [95% CI] 60 [57-63] Median monthly household income, USD [IQR] 270 [ ] In a relationship, % [95% CI] 93 [91-95] Median number of living children, [IQR] 1 [1-2] Currently trying to conceive, % [95% CI] 12 [10-14] Median time on HAART, months [IQR] 13 [5-24] Median CD4 count at enrollment, cells/μl [IQR] 312 [ ]

25 Results Contraceptive Use Amongst women not trying to conceive and sexually active (n=675) Hormonal Contraception: 33% Dual Use: 15% Consistent Condoms: 54% Unmet Need: 28% 8

26 Results Contraceptive Use Non-Barrier Method Use (n=243) Injectable n =67 n = 125 n = 192 Pills (COCs) n = 46 Nuristerate Implant n = 4 Depo Total IUD n = Number of Method Users 9

27 Results Unmet Contraceptive Need 10

28 Results Barriers to Hormonal Contraception (HC) Use Reasons for not using HC amongst non-users (n=509) Amongst non-users not currently trying to conceive, the most commonly reported reasons for not using HC: Already using condoms (n=184) Irregular bleeding (n=61) General side effects (n=53) Trying to get pregnant in the future (n=35) Not currently sexually active (n=30) Don t think can conceive (n=11) No time to see another doctor (n=9) Experiences reported amongst users (n=243) Median time on HC was 12 months [IQR 5-24] Of the 243 women using HC, 82 (33%) reported problems with their method 79% of problems reported were related to bleeding Amenorrhea (n=31) Any Irregular bleeding (n=20) Heavy bleeding (n=14)

29 Results Discussions with providers about FP Nearly all women (93%) reported that a provider had discussed condom use with them Conversations with HIV providers about non-barrier contraception, however, were less frequent Only 48% of women reported that an HIV provider had discussed non-barrier methods The majority of women experiencing problems with their method had not discussed these with providers and the majority quitting a method in the last 6 months had not told providers HC method use was higher in women whose HIV providers had initiated discussions over methods with them (37% vs. 21%, p<0.01) Amongst HC users, 55% informed FP providers of their HIV status

30 Results Predictors of Using HC & Condoms amongst those not currently trying to conceive Predictors Adj. PR for HC Use* Adj. PR for Condom Use Age (per 5 yr increase) 0.84 [ ] 1.15 [ ] Income, USD ($) $0-200 REF REF $ [ ] 1.20 [ ] > $ [ ] 1.23 [ ] Employed (Yes vs. No) 0.82 [ ] 1.09 [ ] Married /Cohabitating (Yes vs. No) 1.21 [ ] -- Number of living children 1.33 [ ] 0.94 [ ] Time on HAART ( 1 yr vs. >1 yr) 0.93 [ ] 0.89 [ ] CD4 Category, cells/μl [ ] 0.90 [ ] [ ] 1.09 [ ] [ ] 1.05 [ ] >500 REF REF *Results control for sexual behavior during the past three months

31 Results Consequences of Unmet Need (and undermet need!) 170 pregnancies detected in the cohort amongst 161 women 62% (105/170) unplanned >60% among self-described condom users Of unplanned pregnancies: 59/105 (56%) were not carried to term 38/105 (36%) ended in termination of pregnancy

32 Conclusions Around 3/10 women on HAART have an unmet need for FP High undermet need & high incidence of unplanned pregnancies in the cohort Irregular bleeding is a barrier to HC use and should be addressed as part of FP counseling and method use determination HIV providers promote condoms, but <50% had discussed other FP methods Fear that women will substitute other FP for condoms Our data provide further evidence that condom usage is an empowerment issue and condoms are not regularly substituted for FP (or vice versa!) Integration of service provision within HIV treatment clinics would provide an opportunity to decrease unplanned pregnancies and eliminate barriers to FP amongst HIV-positive women Initiation of ART in the past year is the strongest predictor of an unmet need for family planning FP integration efforts must address HIV providers concerns over product substitution

33 Acknowledgements Wits Reproductive Health & HIV Institute Vivian Black Helen Rees Francois Venter Study Team & Participants Johns Hopkins Bloomberg School of Public Health Taha E. Taha Shruti Mehta Global Field Experience Fund U.S. Centers for Disease Control Dissertation grant 1R36PS

34 Family Planning/HIV Integration Success Hinges on Strength of Health System Lessons learned from an intervention trial: Serving the Family Planning Needs of PMTCT Clients in South Africa Theresa Hoke Tricia Petruney Jane Harries Sarah Crede Jennifer Moodley

35 Presentation Overview Study Context Objectives Study design Results overview Integration Intervention: Lessons Learned Reflections on study intervention challenges Conclusions about improving integration interventions through a health systems framework

36 Study Goal and Outcome Indicators Goal: Produce evidence about potential strategy to help postpartum PMTCT clients avoid unintended pregnancy through an expanded range of contraceptive choices that include long acting and permanent methods Outcome indicators of primary interest: Knowledge and attitudes regarding IUD and sterilization among postpartum women Method uptake Service providers knowledge and attitudes regarding IUD and sterilization promotion

37 Study Design O X O INTERVENTION Pre-intervention interviews 265 HIV+ CHS clients 273 HIV- CHS clients Training: PMTCT-FP integration Training: IUD insertion Supplies & equipment IEC materials Coaching Referral reinforcement Post-intervention interviews 266 HIV+ CHS clients 273 HIV- CHS clients In-depth Interviews with 16 providers Feb-Apr Apr 09-Mar 10. Apr-Sep 10

38 RESULTS: HIGHLIGHTS

39 Use of contraception, fertility intentions, and exposure to messages CHARACTERISTIC PMTCT (n=265) Pre-intervention Non-PMTCT (n=273) Most recent pregnancy intended 38% 37% Currently using family planning 90% 89% Desire future pregnancy 11% 27% CURRENT METHOD AMONG FP USERS IUD 0 0 Sterilization (F) 7% 6% Condoms (M/F) 6% 2% Injectables 86% 89% DO YOU THINK IN THE FUTURE YOU WILL TRY. IUD 77% 74% Female sterilization 68% 62% PROVIDER HAS TALKED TO YOU ABOUT IUD 4% 6% Female sterilization 28% 27%

40 Use of contraception, fertility intentions, and exposure to messages CHARACTERISTIC PMTCT (n=265) Pre-intervention Post-intervention (%) Non-PMTCT (n=273) PMTCT (n=266) Non-PMTCT (n=273) Most recent pregnancy intended 38% 37% 41% 53% Currently using family planning 90% 89% 83% 75% Desire future pregnancy 11% 27% 15% 25% CURRENT METHOD AMONG FP USERS IUD 0 0 <1% 0 Sterilization (F) 7% 6% 9% 9% Condoms (M/F) 6% 2% 12% 14% Injectables 86% 89% 86% 82% DO YOU THINK IN THE FUTURE YOU WILL TRY. IUD 77% 74% 53% 47% Female sterilization 68% 62% 56% 44% PROVIDER HAS TALKED TO YOU ABOUT IUD 4% 6% 13% 26% Female sterilization 28% 27% 36% 49%

41 Awareness that IUD & sterilization are safe and effective for HIV+ women SURVEY QUESTION IUD A woman who is HIV positive can use the IUD IUD not recommended for women who are taking drugs for AIDS and are doing well Why IUD good: very effective in preventing pregnancy FEMALE STERILIZATION A woman who is HIV positive can undergo sterilization Women doing well on ARVs can safely be sterilized Why sterilization good: very effective in preventing pregnancy Correct response PMTCT (n=265) Pre-Intervention Agree 55% 56% Disagree 23% 20% Mention 55% 59% Agree 76% 68% Agree 58% 54% Mention 43% 51% Non-PMTCT (n=273)

42 Awareness that IUD & sterilization are safe and effective for HIV+ women SURVEY QUESTION IUD A woman who is HIV positive can use the IUD IUD not recommended for women who are taking drugs for AIDS and are doing well Why IUD good: very effective in preventing pregnancy FEMALE STERILIZATION A woman who is HIV positive can undergo sterilization Women doing well on ARVs can safely be sterilized Why sterilization good: very effective in preventing pregnancy Correct response PMTCT (n=265) Pre-Intervention Non-PMTCT (n=273) PMTCT (n=266) Post-Intervention Agree 55% 56% 45% 48% Disagree 23% 20% 23% 27% Mention 55% 59% 36% 38% Agree 76% 68% 84% 79% Agree 58% 54% 73% 75% Mention 43% 51% 53% 63% Non-PMTCT (n=273)

43 Integration Intervention: Lessons Learned

44 WHO Health System Building Blocks Service Delivery Health Workforce Medical Products Information Leadership and Governance Financing

45 Study Intervention Challenges: PMTCT-FP Training Intended design: With PEPFAR support and in collaboration with the Provincial Department of Health, train PMTCT providers in contraception for HIV+ women Reality: Sub-district, not province, directly responsible for health service management Training content not translated into service delivery expectations

46 Study Intervention Challenges: IUD Insertion Training Intended design: 5-day training on IUD insertion and removal provided to at least one provider from each of the 5 target sites Reality: Sub-district manager wary of training duration due to staff shortage Pitfalls with alternative training approach: Incomplete participation in theoretical sessions Low client recruitment for on-the-job practicum Lack of basic family planning training

47 Study Intervention Challenges: Supply and Equipment Reinforcement Intended design: Co-located family planning services that are equipped to offer IUD service provision Reality: Delays in ordering insertion equipment and IUDs Outdated supply ordering form

48 Study Intervention Challenges: Referral Mechanisms Intended design: All family planning providers communicate general information about sterilization and refer interested clients to NGO service provider Reality: Lack of confidence to provide sterilization counseling Inadequate communication between health facilities and NGO sterilization provider Poor understanding of referral/booking processes

49 Study Intervention Challenges: Coaching Intended design: Consultant provides on-the-job coaching to support FP service provision and referrals Reality: She, she was encouraging, like she was visible all the time although shame, it just failed because they were not really participating, they were not willing to do it, they will make the appointments, she will see the book, the appointment is there, the list is there for the people who will come, then they will not book doctor to come for supervision. Senior Professional Nurse

50 Conclusion: A Systems Approach to HIV-FP Integration Service Delivery Health Workforce Medical Products Information Leadership and Governance Financing

51 Conclusion: A Systems Approach to HIV-FP Integration Service Delivery Health Workforce Medical Products Information Leadership and Governance Financing Clarify service procedures Motivate providers Partner with commodity managers Track performance Engage managers who set performance expectations Produce evidence to influence decision makers

52 Taking RH/HIV Integration to Scale: Experience and Lessons from Kenya Margaret Gitau, 1 Shiphrah Kuria, 2 Marsden Solomon, 3 Wilson Liambila, 4 Jennifer Liku International Conference on Family Planning Dakar, Senegal Nov. 29-Dec.2 1. RH HIV Integration Programme Coordinator, National AIDS and STI Control Program, Ministry of Health Kenya 2. Division of Reproductive Health, Ministry of Health 3. FHI 360/Kenya 4. Population Council/Kenya

53 Presentation Outline The Process The Experience Implementation Challenges Critical factors for Success Next Steps Lessons Learnt

54 The Process Assessment (June 2002) * RH HIV Integration Strategy Strategy Development Curriculum development Assessments and Piloting Models Advocacy/ sensitization M&E TOT and provider training

55 The Experience: National Commitment RH HIV Interagency Committee Review and development of policies and strategies Advocacy Leveraging of resources by MOH and partners Evidence Informed Integration Models Development of materials

56 The Experience: Interventions Stakeholder engagement Capacity building o Training o Orientations o CMEs o OJT o Mentorship Reorganization / renovation of clinics Social mobilization o Outreach o Health talks Supplies o FP methods o HIV commodities Linkages and referrals M&E o Registers o Tools

57 The Experience: Results Health Care Levels - Facility, Community Types of Integration Models- HTC FP;MCH FP; CCC FP, STI TB HIV FP CA Cervix screening Different skills set, Knowledge

58 Implementation Challenges Infrastructure-space, equipment Commodities Staff- shortage, deployment, attitude, skills Weak referral/linkages systems Inadequate collaboration among implementing partners Poor private sector involvement

59 Critical Factors for Success o Ensure Commodity Security o Provide resources o Ensure private sector involvement o Strengthen Facility and Community linkages o Address Cultural, religious beliefs and practices o Increase male involvement

60 Next Steps Implement RH/HIV minimum package o Ensure commodity security o Reorganise current health systems o Ensure required skills set o M&E Revise/Update pre- and in-service curricula

61 Lessons Learnt Ministry of Health leadership /ownership RH/HIV Interagency committee crucial Advocacy a continuous process Tailor Interventions to specific contexts One size does not fit all

62 Where there s a will there s a way!