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Rationale

Donors, policy makers, and implementing organizations increasingly recognize that linking family planning and HIV (FP/HIV) services is essential to meeting the United Nations Millennium Development Goals and other international development targets. The fields of family planning and HIV intersect in many ways, and neglecting to integrate the two is an opportunity that countries with high HIV prevalence and widespread unmet need for family planning cannot afford to miss. FP/HIV integration is a valuable approach because:

There is strong international consensus and guidance on the benefits of FP/HIV integration.
Many women are simultaneously at risk of unintended pregnancy and HIV infection, and many countries with high HIV prevalence also have high levels of unmet need for family planning.
Existing HIV programs offer a means to reach men and women at risk of and living with HIV with family planning information and services; similarly, family planning programs can provide a link to HIV counseling, testing, and other services.
Male and female condoms offer dual protection against unintended pregnancy and HIV.
For women living with HIV who do not wish to become pregnant, family planning is an evidence-based, cost-effective strategy for preventing mother-to-child transmission (PMTCT) of HIV.
Women living with HIV who do wish to become pregnant can be treated with antiretroviral therapy during pregnancy for PMTCT. Postpartum family planning services can then help women with healthy timing and spacing, or limiting, of future pregnancies.
Research has linked FP/HIV integration with improved health, access to care, and service delivery outcomes. Research has also shown that integration is cost-effective and increases financial sustainability of health programs.

Despite all these benefits, family planning is still vastly underutilized as an HIV prevention strategy.

Clients seeking HIV services and those seeking reproductive health services share common needs and concerns, and integrating services will enable health care service providers to efficiently and comprehensively address them.

–National Reproductive Health and HIV and AIDS Integration Strategy, Republic of Kenya, 2009

The publications available in the Rationale section of the Family Planning and HIV Services Integration Toolkit offer evidence in support of FP/HIV integration and outline why it is a feasible, efficient, cost-effective, and often life-saving approach. Click on the links below to access materials on:

Basics of FP/HIV Integration

Contraception for Women Living with HIV

Cost-Effectiveness of Integration

Feasibility and Effectiveness of Integration

Basics of FP/HIV Integration

Family Planning and HIV Integration: An Essential Strategy for Preventing Pediatric HIV and Protecting Maternal and Child Health

2011 | Elizabeth Glaser Pediatric AIDS Foundation | 4 pp

This technical brief discusses why integration is essential to HIV prevention and maternal and child health, provides an overview of various integration models and country experiences, and explores some of the common challenges with family planning and HIV integration.

Integrating Family Planning and HIV Services

2011 | USAID's AIDSTAR-One Case Study Series | 16 pp

In regions of high fertility and HIV prevalence, integration of family planning and HIV services has emerged as a promising strategy to prevent transmission of HIV, particularly from mother to child. This case study explores different models of integration and how they have been realized in Kenya and Ethiopia, two pioneers in family planning and HIV service integration.

Family planning and HIV integration: Approaching the tipping point

2010 | FHI | 4 pp

English

Family planning and HIV integration is an important strategy for addressing the reproductive health rights and needs of women living with and at risk of HIV. Policy support for stronger linkages between family planning and HIV programs is growing, and field-based integration efforts are expanding. As policy and programmatic momentum builds, more evidence of effective integrated service delivery practices are needed to guide scale-up.

Making the case for integration: Tides Foundation's Africa family planning and HIV integration fund

2010 | Tides Foundation | 52 pp

English

This report serves as a piece in a growing body of information about FP/HIV integration in Sub-Saharan Africa. The following pages contain a summary of current research, an evaluation of difficult challenges and real solutions, in-depth profiles of organizations working on the frontlines, and insights from experts representing government and philanthropy. Together, these elements contribute to a base on which to build a more robust model of care, treatment, and prevention.

Family planning and HIV: strange bedfellows no longer

2009 | AIDS | 23(Suppl 1): S1-S6

This supplement originated from the belief that more evidence is needed to compel funders, policymakers, program planners and implementers to act on the synergies between family planning and HIV/AIDS fields and enhance the public health impact of reproductive health and HIV programs.

Five Good Reasons to Integrate Family Planning /Reproductive Health and HIV Services

2009 | Population Reference Bureau (PRB)

This article highlights five reasons why integration is a sound investment that will pay multiple dividends for individuals, communities, societies, and health systems.

Supporting the Integration of Family Planning and HIV Services

2009 | Population Reference Bureau (PRB) | 6 pp

This policy brief highlights why service integration makes political and program sense, and describes the lessons learned from successful integration strategies in Ethiopia, Kenya, Lesotho, and Uganda. This brief also urges policymakers and program managers to make integrated services routinely and widely available.

The Astonishing Neglect of an HIV-Prevention Strategy: The Value of Integrating Family Planning and HIV Services

2009 | AIDS Support and Technical Assistance Resources [AIDSTAR-One] | 5 pp

English

Many HIV-positive women wish to control childbirth, but are unable to do so. Contraception is a powerful HIV-prevention strategy that could reach many HIV-positive women if it were a core component of HIV prevention, care, and treatment initiatives.

Glion consultation on strengthening the linkages between reproductive health and HIV/AIDS: family planning and HIV/AIDS in women and children

2006 | World Health Organization [WHO] | 4 pp

The International Conference on Population and Development established the effective prevention and treatment of sexually transmitted infections, including HIV, as an integral component of reproductive health services. There are clear interactions between reproductive health and HIV/AIDS, most HIV infections being sexually transmitted or associated with pregnancy, childbirth and breastfeeding. In addition, reproductive ill-health and HIV/AIDS share root causes, including poverty, gender inequality and social marginalization of the most vulnerable populations.

Contraception for Women Living with HIV

Reaching the Underserved: Family Planning for Women with HIV

2010 | Studies in Family Planning | 14(8):125-128

Women of reproductive age are disproportionately affected by HIV/AIDS, and women with HIV/AIDS may be more likely to have unmet need for family planning and unintended pregnancies than women in the general population. All of these data indicate that women and couples living with HIV represent an important underserved group in need of contraceptive information and services. Family planning can improve the health of HIV-positive and -negative mothers by allowing them to space pregnancies and can prevent HIV-positive births to HIV-positive mothers.

Addressing the Family Planning Needs of People Living with HIV and AIDS through Integration of Family Planning Services at an ART Center in Uganda

2009 | The ACQUIRE Project/EngenderHealth | 11 pp

English

Developed for the International Conference on Family Planning: Research and Best Practices, which took place in November 2009, Kampala, Uganda, this presentation looked at a project to provide family planning (FP)-integrated HIV services for people living with HIV (PLHIV) in Mbale, Uganda. Included are the following: a discussion of an approach to integrating FP and HIV services, the range of levels of FP integration, and examples of interventions to strengthen service delivery systems in coordination with demand creation and advocacy activities.

Determinants of contraceptive choice among women with HIV

2009 | AIDS | S47-S54

OBJECTIVE: To examine factors associated with contraceptive choice among HIV-infected women DESIGN: Data for this cross-sectional analysis were derived from baseline visits of 435 participants in an ongoing prospective study of contraception among HIV-infected women in Russia. Participants enrolled in one of four groups: combined oral contraceptives (COCs) along with condoms, depot medroxyprogesterone acetate (DMPA) along with condoms, copper intrauterine device (IUD) along with condoms, or condoms alone.

Fertility preferences and the need for contraception among women living with HIV: the basis for a joint action agenda

2009 | AIDS | S7-S17

OBJECTIVES: HIV-positive women have particular needs for contraception to avoid unwanted pregnancy, to protect their own health and to eliminate the risk of transmitting HIV to an infant. In 2004, the United Nations described a four-element strategy to preventing mother-to-child transmission of HIV; the second element is preventing unintended pregnancies among HIV-positive women. However, fertility preferences among HIV-positive women who know their status remain poorly understood.

Hormonal contraception and HIV disease progression: A multicountry cohort analysis of the MTCT-Plus Initiative

2009 | AIDS | S69-S77

HIV-infected women need access to safe and effective contraception. Recent animal and human data suggest that hormonal contraception may accelerate HIV disease progression. Neither implants/injectables nor oral contraceptive were associated with disease progression. Treating contraceptive method as a time varying exposure did not change this negative finding. This multi-country cohort analysis provides some reassurance that hormonal contraception is not associated with HIV disease progression. Further research is needed to address the contraceptive needs of HIV-infected women.

Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi

2009 | AIDS | 1565-1573

Researchers found that in 2003-2005, a majority of PLWHAs in Kenya and Malawi were unaware of their HIV status and were sexually active, especially those who were married or cohabiting. Few reported using a condom at last intercourse. Of HIV-infected women not wanting more children, few used contraception. Researchers recommended that HIV testing should be expanded, and prevention programs should target married or cohabiting couples. After determining a significant unmet need for family planning among PLWHA, researchers also recommended integrating family planning servi

Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda

2009 | AIDS | S19-S26

The objective of this study was to understand pregnancy intentions and contraception knowledge and use among HIV-positive and negative women in the national prevention of mother-to-child transmission (PMTCT) program in Rwanda. HIV-positive women were less likely to report wanting additional children than HIV-negative women, and although a majority of women reported discussing family planning with a health worker during their last pregnancy, modern family planning use remained low in both groups.

Safety of hormonal and intrauterine methods of contraception for women with HIV/AIDS: a systematic review

2009 | AIDS | S55-S67

The objective of this study was to determine from the literature whether HIV-infected women who use hormonal or intrauterine contraception are at increased risk of HIV disease progression, other adverse health outcomes, or HIV transmission to uninfected sexual partners.

Successful increase in contraceptive uptake among Kenyan HIV-1-serodiscordant couples enrolled in an HIV-1 prevention trial

2009 | AIDS | S89-S95

The objective of this study was to evaluate a multipronged approach to promote dual contraceptive use by women within heterosexual HIV-1-serodiscordant partnerships. Nonbarrier contraceptive use increased after implementation of the intervention. Self-reported condom use remained high during follow-up, and pregnancy incidence decreased. A multipronged family planning intervention can lead to high nonbarrier contraceptive uptake and reduced pregnancy incidence among women in HIV-1-serodiscordant partnerships.

Contraception’s proved potential to fight HIV

2005 | Sexually Transmitted Infections | 81:184-185

This letter discusses the results of a study on contraception in sub-Saharan Africa.

Cost-Effectiveness of Integration

Benefits and costs of expanding access to family planning programs to women living with HIV

2009 | AIDS | 23(Suppl 1):S123-S13

This analysis models the potential benefits and costs of adding family planning to national strategies for achieving universal access to programs to prevent mother-to-child HIV transmission. Programs to prevent perinatal HIV transmission would, if accessed by all women in need with the most efficacious antiretroviral regimen available, prevent over 240 000 infant HIV infections in the top 14 countries (over 300 000 globally) at an estimated cost of over $131 million ($208 million globally).

Contraception to prevent HIV-positive births: current contribution and potential cost savings in PEPFAR countries

2008 | Sexually Transmitted Infections | 84 Suppl 2:ii49-53

OBJECTIVES: To estimate the number of HIV-positive births currently prevented by contraceptive use in the focus countries of the President’s Emergency Plan for AIDS Relief (PEPFAR) and to estimate the first-year cost savings to each country if unintended and unwanted HIV-positive births were prevented by means of contraceptive use rather than by providing antiretroviral prophylaxis for HIV-positive pregnant women ("PMTCT services").

Cost-effectiveness of integrating HIV prevention in maternal health programmes

2006 | EngenderHealth | 12 pp

This is a PowerPoint presentation on the cost-effectiveness of integrating HIV prevention in maternal health programs.

Cost-effectiveness of nevirapine to prevent mother-to-child HIV transmission in eight African countries

2004 | AIDS | 18 (12):1661-1671

BACKGROUND: A comprehensive approach to preventing HIV infection in infants has been recommended, including: (a) preventing HIV in young women, (b) reducing unintended pregnancies among HIV-infected women, (c) preventing vertical transmission (PMTCT), and (d) providing care, treatment, and support to HIV-infected women and their families. Most attention has been given to preventing vertical transmission based on analysis showing nevirapine to be inexpensive and cost-effective.

Costs and benefits of adding family planning to services to prevent mother-to-child transmission of HIV (PMTCT)

2003 | Futures Group | 16 pp

English

High levels of HIV prevalence among women of childbearing age in many parts of the world carry a triple tragedy. Not only do HIV-positive women face the prospect of discrimination, illness and early death, but they may also pass the HIV infection to their children or leave their children behind as orphans when they die. Efforts are underway to rapidly expand programs to prevent adult HIV infections (through behavior change communications programs, voluntary counseling and testing and other prevention programs) and to improve treatment for those already infected.

Feasibility and Effectiveness of Integration

Study of family planning and HIV integrated services in five countries: Final report

2010 | FHI | 54 pp; 2 pp

This study was undertaken to provide a “snapshot” of early integration efforts, in order to provide the U.S. Agency for International Development (USAID) and national programs with information needed to improve integrated services. Three models of integrated HIV and FP services were included in this study: family planning in counseling and HIV testing (FP-CT), family planning in HIV care and treatment services (FP-C&Tx), and HIV services (particularly counseling and testing) into family planning (HIV-FP).

Feasibility and effectiveness of integrating provider-initiated testing and counselling within family planning services in Kenya

2009 | AIDS | 23(Suppl 1):115-121

The objective of this study was to assess an intervention for increasing access to and use of HIV testing among family planning clients through provider-initiated testing and counselling for HIV. Following the intervention, the proportion of consultations in which HIV prevention counselling was provided and HIV testing offered increased significantly. The proportion of clients requesting an HIV test increased from 1 to 26%; approximately one third of these had never been tested previously.

Integration of STI and HIV prevention, care, and treatment into family planning services: A review of the literature

2009 | Studies in Family Planning | 40(3):171-186

English

The last comprehensive literature review to examine the effectiveness of family planning (FP) services in delivering STI and HIV prevention and care was published in 2000. This review updates that report by examining evidence of the impact of integrating any components of STI or HIV prevention, care, and treatment into a family planning setting in developing countries.

Linking family planning with HIV/AIDS interventions: A systematic review of the evidence

2009 | AIDS | 23(Suppl 1):S79-S88

The objective of this study was to conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Researchers used a systematic review of peer-reviewed articles and unpublished program reports ('promising practices') evaluating interventions linking family planning and HIV services. Most studies reported generally positive or mixed results for key outcomes; no negative results were reported.

Feasibility, acceptability, effect and cost of integrating counseling and testing for HIV within family planning services in Kenya

2008 | FRONTIERS Population Council | 50 pp

This report examines the integration of counseling and testing for HIV within family planning services in Kenya from a variety of perspectives, including cost effectiveness.

Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations

2008 | IPPF | 8 pp

The importance of linking sexual and reproductive health (SRH) and HIV is widely recognized. The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to SRH and HIV prevention, treatment, care, and support. In order to gain a clearer understanding of the effectiveness, optimal circumstances, and best practices for strengthening SRH and HIV linkages, a systematic review of the literature was conducted.

Quick Links

To browse the materials in this toolkit by topic, click on the links below:

Antiretroviral Therapy (ART)

HIV Counseling and Testing

Prevention of Mother-to-Child Transmission (PMTCT) of HIV

For more information about family planning and reproductive health for people living with HIV, take the Global Health eLearning course (registration required).

To learn about various family planning options, visit K4Health's Contraceptive Method Toolkits:

Lactational Amenorrhea Method (LAM)

Oral Contraceptives

Standard Days Method