Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

The intersection between migration, HIV, and contraceptive use in Uganda: a cross-sectional population-based study

BACKGROUND

Low use of modern methods of contraception has been linked to HIV seropositivity and to migration, but few studies have evaluated the intersection of both risk factors with contraceptive use.

METHODS

We analyzed cross-sectional data from sexually active female participants aged 15 to 49 years in the Rakai Community Cohort Study (RCCS) between 2011 and 2013. The RCCS is an open population-based census and individual survey in south-central Uganda. Recent in-migrants (arrival within approximately 1.5 years) into RCCS communities were identified at time of household census. The primary outcome was unsatisfied demand for a modern contraceptive method (injectable, oral pill, implant, or condom), which was defined as non-use of a modern contraceptive method among female participants who did not want to become pregnant in the next 12 months. Poisson regression models with robust variance estimators were used to identify associations and interactions between recent migration and HIV serostatus on unsatisfied contraceptive demand.

RESULTS

There were 3,417 sexually active participants with no intention of becoming pregnant in the next year. The mean age was 30 (± 8) years, and 17.3% (n = 591) were living with HIV. Overall, 43.9% (n = 1,500) were not using any modern contraceptive method. Recent in-migrants were somewhat more likely to have unsatisfied contraceptive demand as compared to long-term residents (adjusted prevalence risk ratio [adjPRR] = 1.14; 95% confidence interval [95%CI]: 1.02-1.27), whereas participants living with HIV were less likely to have unsatisfied contraceptive demand relative to HIV-seronegative participants (adjPRR = 0.80; 95%CI = 0.70-0.90). When stratifying on migration and HIV serostatus, we observed the highest levels of unsatisfied contraceptive demand among in-migrants living with HIV (48.7%); however, in regression analyses, interaction terms between migration and HIV serostatus were not statistically significant.

CONCLUSIONS

Unsatisfied contraceptive demand was high in this rural Ugandan setting. Being an in-migrant, particularly among those living with HIV, was associated with higher unsatisfied contraceptive demand.

Pre-exposure prophylaxis (PrEP) knowledge, use, and discontinuation among Lake Victoria fisherfolk in Uganda: a cross-sectional population-based study

Background

There are limited population-level data on the pre-exposure prophylaxis (PrEP) care continuum in eastern Africa. Here, we assessed the PrEP care continuum following PrEP rollout in a Ugandan community with ~40% HIV seroprevalence.

Methods

We used cross-sectional population-based data collected between September 3 and December 19, 2018 from a Lake Victoria fishing community in southern Uganda to measure levels of self-reported PrEP knowledge, ever use, and discontinuation following 2017 PrEP rollout via a U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported phased implementation program. Our analysis included HIV-seronegative persons reporting having ever received an HIV test result. We examined associations between demographic, behavioral, and health utilization factors with each outcome using age-adjusted modified Poisson regression.

Results

There were 1,401 HIV-seronegative participants, of whom 1,363 (97.3%) reported ever receiving an HIV test result. Median age was 29 years (IQR: 23-36), and 42.3% (n=577) were women. Most (85.5%; n=1,166) participants reported PrEP knowledge, but few (14.5%; n=197) reported ever using PrEP. Among 375 (47.7%) men and 169 (29.3%) women PrEP-eligible at time of survey, 18.9% (n=71) and 27.8% (n=47) reported ever using PrEP, respectively. Over half (52.3%, n=103) of those who had ever used PrEP, self-reported current use.

Conclusion

In this Lake Victoria fishing community, there were low levels of PrEP use despite high levels of PrEP awareness and eligibility, particularly among men. Efforts that enhance awareness of HIV risk and increase PrEP accessibility may help increase PrEP use among HIV-seronegative persons in African settings with high HIV burden.

Reproductive health among women living with HIV attending Melbourne Sexual Health Centre for HIV care from February 2019 to February 2020

BACKGROUND

Women living with HIV are a minority population with unique care needs. Rates of unintended pregnancy are higher among women living with HIV versus HIV negative women. However, uptake of contraception among women living with HIV including long-acting-reversible contraceptives (LARCs) remains low. This quality improvement project aimed to identify gaps in reproductive healthcare for women living with HIV attending Melbourne Sexual Health Centre (MSHC).

METHODS

We performed a retrospective review of women living with HIV attending MSHC for HIV care February 2019-February 2020. Women aged over 45years were excluded. Primary outcomes included proportion using contraception, methods used and whether a sexual or reproductive health history had been taken in the past year.

RESULTS

A total of 100 women were included, predominantly born overseas (Asia, 38%; sub-Saharan Africa, 34%). Of these, 5% were pregnant, 16% were trying to conceive and 1% were undergoing elective oocyte preservation. Of the remaining 74 women, 48.6% were using any form of contraception, including 17.6% women using less-effective methods (withdrawal and condoms), 6.8% using the combined oral contraceptive pill, 18.9% using LARCs and 5.4% using permanent methods. Sexual activity status was documented for 61% women, 1% declined to answer and not documented for 38% women.

CONCLUSIONS

Rate of contraceptive use in this study was lower than previously reported among women living with HIV in Australia; however, our findings suggest contraceptive methods may be changing in light of undetectable equals untransmittable and increased fertility desires. Discussions regarding sexual activity and reproductive health were limited. Mechanisms to increase clinician-patient discourse regarding these important issues should be explored.

Family planning integration in Ethiopia's primary health care system: a qualitative study on opportunities, challenges and best practices

BACKGROUND

Family planning (FP) service integration into primary health care (PHC) is an effective approach to realize reproductive autonomy, increase the use of contraceptives, and improve maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care (PHC). However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration.

METHODS

A qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report.

RESULTS

Family planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers' capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness.

CONCLUSIONS

Integration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

Health facility-based interventions and the uptake of contraception among people living with HIV: A systematic review & meta-analysis

BACKGROUND OBJECTIVES

The prong 2 of 4 prong strategy introduced by the World Health Organization aims at averting unintended pregnancies among people living with HIV (PLHIV). This systematic review aimed to generate evidence on the effectuality of facility-based interventions in improving uptake of modern and dual contraception, for reducing unmet family planning (FP) needs and unintended pregnancies among PLHIV.

METHODS

Articles evaluating facility-based interventions to integrate human immunodeficiency virus (HIV) and FP published in English language were included. Eligible studies were identified from electronic and lateral search from three databases (PubMed, Cochrane Library and Web of Science) and grey literature. HIV care with no/minimal focus on FP was considered a comparator. Quality was assessed using design-appropriate tools. Descriptive analysis was presented in tables. Uptake of dual methods, unmet FP needs and unintended pregnancies were included in the meta-analysis to estimate pooled odds ratio (OR) with random effect model, P and I2 values.

RESULTS

The search yielded 2112 results. After excluding duplicates and unfit articles, 17 were found eligible for review and nine for meta-analysis. The pooled OR for uptake of dual contraception was 1.69 (1.14, 2.5) ( P =0.008; I2 =90%), for unmet FP needs was 0.58 (0487, 0.69) ( P <0.00001; I2 =0%) and for unintended pregnancies was 0.6 (0.32, 1.1) ( P =0.1, I2 =38%).

INTERPRETATION CONCLUSIONS

The results of this meta-analysis suggest that health facility-based interventions to integrate HIV and FP services do result in improved uptake of dual methods and reduce unmet need for contraception along with a protective trend on incidence of unintended pregnancies. Such facility-based integration would ensure universal access to effective contraception and facilitate in achieving Sustainable Development Goals that aim at ending epidemics like HIV.

Meeting the reproductive health needs of female sex workers in Côte d'Ivoire: protecting the human right to dignified health

The sexual and reproductive health needs of female sex workers (FSW) are often understudied and underserved in the context of HIV-related research in countries across Sub-Saharan Africa and West Africa. We assessed the lived experiences of FSW across Côte d'Ivoire to characterize unmet reproductive health needs and opportunities to address them. From February-August, 2020, ENDA Santé, Côte d'Ivoire conducted 75 in-depth interviews and 15 focus group discussions with FSW and community informants in five cities in Côte d'Ivoire. Themes that emerged included the inconsistent use of contraception services, a history of unintended pregnancies, and experiences of stigma at public healthcare facilities. Opportunities to increase the impact of both SRH and HIV services included strengthening existing HIV and family planning service integration for FSW. Taken together, the results highlight the importance of addressing the unmet reproductive health needs of FSW to both optimize the HIV response and increase the delivery of human-rights affirming sexual and reproductive health services for sex workers.

An Evaluation of an Enhanced Model of Integrating Family Planning Into HIV Treatment Services in Zambia, April 2018-June 2019

BACKGROUND

We designed and implemented an enhanced model of integrating family planning (FP) into existing HIV treatment services at 6 health facilities in Lusaka, Zambia.

METHODS

The enhanced model included improving FP documentation within HIV monitoring systems, training HIV providers in FP services, offering contraceptives within the HIV clinic, and facilitated referral to community-based distributors. Independent samples of women living with HIV (WLHIV) aged ≥16 years were interviewed before and after intervention and their clinical data abstracted from medical charts. Logistic regression models were used to assess differences in key outcomes between the 2 periods.

RESULTS

A total of 629 WLHIV were interviewed preintervention and 684 postintervention. Current FP use increased from 35% to 49% comparing the pre- and postintervention periods ( P = 0.0025). Increased use was seen for injectables (15% vs. 25%, P < 0.0001) and implants (5% vs. 8%, P > 0.05) but not for pills (10% vs. 8%, P < 0.05) or intrauterine devices (1% vs. 1%, P > 0.05). Dual method use (contraceptive + barrier method) increased from 8% to 18% ( P = 0.0003), whereas unmet need for FP decreased from 59% to 46% ( P = 0.0003). Receipt of safer conception counseling increased from 27% to 39% ( P < 0.0001). The estimated total intervention cost was $83,293 (2018 USD).

CONCLUSIONS

Our model of FP/HIV integration significantly increased the number of WLHIV reporting current FP and dual method use, a met need for FP, and safer conception counseling. These results support continued efforts to integrate FP and HIV services to improve women's access to sexual and reproductive health services.

Integration of assisted partner services within Kenya's national HIV testing services program: A qualitative study

Assisted partner service (aPS) augments HIV case-finding among sex partners to individuals newly diagnosed with HIV. In 2016, aPS was incorporated into the national HIV testing services (HTS) program in Kenya. We evaluated the extent of, barriers to, and facilitators of aPS integration into HTS. We conducted semi-structured in-depth interviews (IDIs) with 32 stakeholders selected using purposive sampling at national, county, facility, and community levels. IDIs were conducted at two timepoints, at baseline from August-September 2018 in Kisumu and January-June 2019 in Homa Bay, and at follow-up from May-August 2020 to understand changes in aPS integration over time. We defined integration as the creation of linkages between the new intervention (aPS) and the existing HTS program. Data were analyzed using thematic content analysis. We found varying degrees of aPS integration, highest in procurement/logistics and lowest in HTS provider recruitment/training. At baseline, aPS integration was low and activities were at an introductory phase. At follow-up, aPS was integrated in almost the entire HTS program with the exception of low community awareness, which was noted at both baseline and follow-up. There was increasing routinization with establishment of clear aPS cycles, e.g., quarterly data review meetings, annual budget cycles and work-plans. Major barriers included limited government funding, staff constraints, and inadequate community-level sensitization, while key facilitators included increased resources for aPS, and community health volunteer (CHV) facilitated awareness of aPS. Varying degrees of aPS integration across different units of the national HTS program highlights challenges in funding, human resource, and public awareness. Policymakers will need to address these barriers to ensure optimal provision of aPS.

Access to public sector family planning services and modern contraceptive methods in South Africa: A qualitative evaluation from community and health care provider perspectives

Progress has been made to improve access to family planning services and contraceptive methods, yet many women still struggle to access contraception, increasing their risk for unintended pregnancy. This is also true for South Africa, where over fifty per cent of pregnancies are reported as unintended, even though contraception is freely available. There is also stagnation in the fertility rate indicators and contraceptive use data, indicating that there may be challenges to accessing contraception. This paper explores the evaluation of access to contraception from community and health care provider perspectives. This qualitative study explored factors affecting the uptake and use of contraception through focus group discussions (n = 14), in-depth interviews (n = 8), and drawings. Participants included male and female community members (n = 103) between 15 and 49 years of age, health care providers (n = 16), and key stakeholder informants (n = 8), with a total number of 127 participants. Thematic content analysis was used to explore the data using NVivo 10. Emergent themes were elucidated and thematically categorised. The results were categorised according to a priori access components. Overall, the results showed that the greatest obstacle to accessing contraception was the accommodation component. This included the effects of integrated care, long waiting times, and limited operational hours-all of which contributed to the discontinuation of contraception. Community members reported being satisfied with the accessibility and affordability components but less satisfied with the availability of trained providers and a variety of contraceptive methods. The accessibility and affordability themes also revealed the important role that individual agency and choice in service provider plays in accessing contraception. Data from the illustrations showed that adolescent males experienced the most geographic barriers. This study illustrated the importance of examining access as a holistic concept and to assess each component's influence on contraceptive uptake and use.

Integration of family planning into HIV services: a systematic review

BACKGROUND

The unmet need for safe and effective contraception still remains high. In 2017, about 25% of women of childbearing age who wanted to avoid pregnancy in the developing world were not using a modern contraceptive method. The biggest proportion (21%) of these women live in Sub-Saharan Africa. Little attention has been paid to the health systems factors impacting the integration of family planning into HIV services. This systematic review intends to document health systems factors constraining or facilitating the integration of family planning into HIV services.

METHODS

A search of electronic databases such as PubMed and Google Scholar was conducted using keywords. We considered peer-reviewed articles which were published in English between 1^st January 2010 and 31^st December 2020. The peer-reviewed articles which were considered focussed on identifying barriers and facilitators at the levels of the health system which influence the success or failure of integrated family planning and HIV programs, availability of integrated family planning services in HIV care, the evidence on the feasibility, effectiveness and cost-effectiveness of integrating family planning and HIV services and investigating the outcomes of programs aimed at strengthening family planning integration in HIV counselling, testing and care. Twenty-seven articles that identify factors affecting integration of family planning into HIV services met the inclusion criteria and were thematically analysed.

RESULTS

Health systems factors constraining integration of family planning and HIV services were human resource turnover and shortages, lack of policy guidance on integrated care, poor oversight, unclear service delivery guidelines, inadequate infrastructure and insufficient monitoring systems. Facilitators to the successful integration of family planning into HIV services were identified as training in family planning for service providers, the creation of a supportive policy environment to accommodate service integration, supportive supervision and a positive attitude by service providers towards service integration.

CONCLUSION

Increase in the health workforce to support integrated service delivery, skills enhancement for service providers and improvement in family planning commodity stock levels play a key role in facilitating the integration of family planning into HIV services.

Integrating services to improve quality of care for women living with HIV: A global systematic review

OBJECTIVES

The aim was to review and analyse evidence on the impact of service integration on quality of care for women living with HIV.

METHODS

Evidence search in September 2020 using the PICO format yielded 60 potential papers. Inclusion required evidence of measurement of an outcome associated with service delivery within a system showing clear integration of services exclusively for women living with HIV. In all, 60 papers were screened, 27 were excluded at the abstract stage, and 17 were excluded after full text review, leaving 20 final papers included in this review.

RESULTS

Three papers measured the impact of integrating sexual health services and all showed some measure of improved quality of care. Outcome measures considered in this paper were impact on uptake, prevention, user satisfaction, user knowledge and cost-effectiveness. Ten papers studied the impact of integrating family planning, with eight papers suggesting positive outcomes. Eleven papers studied integrated cervical cytology services with 10 able to demonstrate positive impact. Two papers assessed integrating menopause services and two looked at integration of psychological and social services. The most described positive impact was improved user knowledge and satisfaction. There were two main methods of integration demonstrated, described as 'upskilling' of staff and 'guest services'.

CONCLUSIONS

Integrating services can create opportunities to improve the quality of patient-centred care whilst promoting the sexual, reproductive and human rights of women living with HIV, with an emphasis on designing services to suit local contexts.

"…the availability of contraceptives is everywhere.": coordinated and integrated public family planning service delivery in Rwanda

Background

Contraceptive use in Rwanda tripled since 2005. This study aims to understand the role of coordinated and integrated public family planning service delivery in achieving this increase in contraceptive use in Rwanda.

Methods

This qualitative study in 2018 included eight focus group discussions with family planning providers and 32 in-depth interviews with experienced family planning users.

Results

Results indicate a well-coordinated public family planning service delivery system with community health workers and nurses filling different and complementary roles in meeting family planning client needs at the local level. In addition, integration of family planning into other maternal and child health services is the norm.

Conclusions

The coordination and integration of family planning across both providers and services may help explain the rapid increase in Rwanda’s contraceptive use and has potential applications for enhancing family planning service delivery in other settings.

Family planning use increased from 17 to 53% in Rwanda in between 2005 and 2015. The purpose of this study is to understand the roles of two types of family planning workers in providing family planning services, how those providers work together to achieve the goal to provide public services, and how the Rwandan health system includes family planning services in a variety of other types of health services. To achieve the study purpose, 32 women with experience using modern methods of contraception were interviewed. In addition, 88 providers participated in eight group discussions to discuss these topics. The results from the interviews and group discussions showed that family planning services are easy to access for Rwandans—due to two types of family planning providers filling different roles to assist Rwandans start and keep using family planning methods. Family planning services are included in services for pregnant, delivering, and postpartum mothers—as well as services for infants and children. These are all times when those adults using the services would also be in need of family planning services. The family planning service delivery team approach—as well as including family planning services in mother’s and children’s health services likely helps explain the increase in family planning use in Rwanda. Other nations might learn from Rwanda’s service delivery approach to family planning to also increase access to family planning for their citizens.

The Effect of Integration of Family Planning Into HIV Services on Contraceptive Use Among Women Accessing HIV Services in Low and Middle-Income Countries: A Systematic Review

There is substantial unmet need for family planning (FP) among women living with HIV (WLHIV), leading to unintended pregnancies and may contribute indirectly to increasing the risk of transmission of HIV. This review aims to determine whether integration of FP into HIV testing and care results in increased use of contraception, a reduction in unmet need for FP, improved use of safer conception methods and a reduction in unintended pregnancies in low and middle-income countries. A systematic review was undertaken incorporating studies from PubMed, EMBASE, CINAHL, Web of Science and Global Health, the International AIDS Society Abstract Archive, the World STI & HIV Congress Abstract Archive and the Conference on Retroviruses and Opportunistic Infections Abstract Archive published between 2016 and 2021, updating previous systematic reviews. After screening, 13 studies were included, 11 conducted in sub-Saharan Africa and 2 in India. The primary outcome of the review was contraceptive uptake and secondary outcomes included unmet need for FP, safer conception and unintended pregnancy. Integrated FP-HIV facilities were found to increase dual contraceptive use by at least 8% in five studies and modern contraceptive use by at least 8% in four studies. Findings from two studies suggested integration decreased the unmet need for contraception. Limited data prevented a conclusion from being drawn regarding whether integration increases safer conception. There was no evidence of integration reducing unintended pregnancies. The median quality score of studies was 3/9. Overall, integrated facilities have the potential of improving reproductive health of women accessing HIV services in LMICs. FP may be enhanced by including a safer conception component for WLHIV.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021251008, identifier: CRD42021251008.

Contraceptive Counseling Strategies for Women Living With Human Immunodeficiency Virus: The Role of Integrating Reproductive Health and Human Immunodeficiency Virus Services to Prevent Perinatal Transmission in Colombia

OBJECTIVES

This study aimed to evaluate the cost-effectiveness of 2 contraceptive counseling strategies in Colombia for women living with human immunodeficiency virus (HIV). The first integrates (1) reproductive health and HIV services (integrated model [IM]), and the second (2) offers these services separately (non-IM).

METHODS

Cost-effectiveness analysis from the third-party payer perspective (Colombian healthcare system). A decision analysis tree was used over a 24-month time horizon at a 3% discount rate, considering only direct costs. The outcome was the number of averted HIV perinatal transmission infections. We performed a discrete sensibility analysis and a probabilistic second-order sensitivity analysis with 10 000 iterations (Monte Carlo simulation).

RESULTS

Compared with the non-IM, the IM prevented 3% additional HIV perinatal transmission infections, with an incremental cost-effectiveness of US dollar 525 and the highest net monetary benefit at the proposed willingness to pay. In the probabilistic sensitivity analysis, we found a substantial amount of parameter uncertainty that challenges the evidence in favor of the cost-effectiveness of the IM strategy.

CONCLUSIONS

This study opens the possibility of integrating reproductive health and HIV services for women living with HIV in Colombia. In addition, it raises the necessity to produce additional good quality local empirical evidence to inform better and support the estimation of the economic efficiency of such a model in the country.

Attitudes Toward Pregnancy Among Women Enrolled in Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services in Moshi, Tanzania

For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.

Quality of care in public sector family planning services in KwaZulu-Natal, South Africa: a qualitative evaluation from community and health care provider perspectives

BACKGROUND

Quality of care is a multidimensional concept that forms an integral part of the uptake and use of modern contraceptive methods. Satisfaction with services is a significant factor in the continued use of services. While much is known about quality of care in the general public health care service, little is known about family planning specific quality of care in South Africa. This paper aims to fill the gap in the research by using the Bruce-Jain family planning quality of care framework.

METHODS

This formative qualitative study was conducted in South Africa, Zambia, and Kenya to explore the uptake of family planning and contraception. The results presented in this paper are from the South African data. Fourteen focus group discussions, twelve with community members and two with health care providers, were conducted along with eight in-depth interviews with key informants. Thematic content analysis using the Bruce-Jain Quality of Care framework was conducted to analyse this data using NVIVO 10.

RESULTS

Family planning quality of care was defined by participants as the quality of contraceptive methods, attitudes of health care providers, and outcomes of contraceptive use. The data showed that women have limited autonomy in their choice to either use contraception or the method that they might prefer. Important elements that relate to quality of care were identified and described by participants and grouped according to the structural or process components of the framework. Structure-related sub-themes identified included the lack of technically trained providers; integration of services that contributed to long waiting times and mixing of a variety of clients; and poor infrastructure. Sub-themes raised under the process category included poor interpersonal relations; lack of counselling/information exchange, fear; and time constraints. Neither providers nor users discussed follow up mechanisms which is a key aspect to ensure continuity of contraceptive use.

CONCLUSION

Using a qualitative methodology and applying the Bruce-Jain Quality of Care framework provided key insights into perceptions and challenges about family planning quality of care. Identifying which components are specific to family planning is important for improving contraceptive outcomes. In particular, autonomy in user choice of contraceptive method, integration of services, and the acceptability of overall family planning care was raised as areas of concern.

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.

Integrating Sexual and Reproductive Health Services Within HIV Services: WHO Guidance

Among the 1.9 billion women of reproductive age worldwide in 2019, 1.1 billion need family planning and 270 million have an unmet need for contraception. For women and adolescent girls living with human immunodeficiency virus (HIV), using effective contraception reduces the mother-to-child transmission of HIV by preventing unintended pregnancies and enabling the planning and safer conception of desired pregnancies with optimal maternal and child health outcomes. The World Health Organization (WHO) recommends that sexual and reproductive health services, including contraception, may be integrated within HIV services. Integration is associated with increased offers and uptake of sexual and reproductive health services, including contraception, which is likely to result in improved downstream clinical outcomes. Integrating HIV and sexual and reproductive health services has been found to improve access, the quality of antenatal care and nurse productivity while reducing stigma and without compromising uptake of care. Research is encouraged to identify approaches to integration that lead to better uptake of sexual and reproductive health services, including contraception. Implementation research is encouraged to evaluate different strategies of integration in different health systems and social contexts; such research should include providing contraception, including long-acting contraception, in the context of less frequent clinical and ART refill visits.

Future directions for HIV service delivery research: Research gaps identified through WHO guideline development

Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.

Integration of family planning services into HIV services in Nigeria: Evidence from the Performance Monitoring and Accountability 2020 survey in seven states

Despite global calls for stronger linkages between family planning and HIV, a growing body of evidence in sub-Saharan Africa suggests that the integration of family planning and HIV service delivery is suboptimal in some countries. In this study, we assess the integration and quality of family planning services in health facilities that provide HIV-related services in Nigeria. This study analysed secondary data from the Performance Monitoring and Accountability 2020 cross-sectional survey conducted between May and July 2016 in seven states in Nigeria. Our study sample was restricted to 290 health facilities providing HIV services. We performed descriptive statistics and binary logistic regression analyses. Ninety-five per cent of the health facilities reported offering family planning counselling, provision of family planning methods, and/or referral for family planning methods to clients accessing HIV services. About 84% of these health facilities with integrated family planning and HIV services reported that they discussed the preferred method, dual methods, instructions and side effects of the chosen method, and the reproductive intentions with clients during an HIV consultation. None of the health facilities' characteristics was significantly associated with the integration of family planning services into HIV services. Private health facilities (aOR 0.3, 95% CI 0.07-0.92), urban health facilities (aOR 3.8, 95% CI 1.64-8.76), and provision of postnatal care (aOR 3.9, 95% CI 1.10-13.74) were statistically associated with the quality of family planning services provided to clients accessing HIV services. Family planning services were integrated into HIV services in a majority of the health facilities in our study. However, our findings indicate the need for improvement in the quality of family planning services provided to clients accessing HIV services.

Contraceptive Method Mix and HIV Risk Behaviors Among Kenyan Adolescent Girls and Young Women Seeking Family Planning Services: Implications for Integrating HIV Prevention

Background: Understanding HIV risk behaviors among adolescent girls and young women (AGYW) seeking contraception could help inform integrating HIV prevention services within family planning (FP) clinics. Methods: From 10/2018 to 04/2019, we conducted a survey at 4 FP clinics in Kisumu, Kenya to evaluate risk behaviors among AGYW without HIV infection seeking contraception. All AGYW aged 15-24 were invited to participate following receipt of FP services. Adolescent girls and young women initiating or refilling contraception were included in this analysis. Long-acting reversible contraceptives (LARC) included intrauterine devices, implants, or injectables. Non-LARC methods included oral contraceptive pills (OCP) or condoms. We used an empiric risk score to assess HIV risk behaviors; HIV risk scores of ≥5 (corresponding to 5-15% HIV incidence) defined "high" HIV risk. Results: Overall, 555 AGYW seeking FP were included. Median age was 22 years [interquartile range (IQR) 20-23], median completed education was 12 years (IQR 10-12); 23% of AGYW had HIV risk scores of ≥5. The most frequent form of contraception was injectables (43%), followed by implants (39%). After adjustment for education, prior pregnancy, and marital status, LARC users more frequently engaged in transactional sex than non-LARC users [6 vs. 0%, adjusted prevalence ratio (PR) = 1.17, 95% CI 1.09-1.29, p < 0.001]; LARC use was not associated with HIV risk scores ≥5. Among LARC users, AGYW using injectables more frequently had condomless sex compared to AGYW using other LARC methods (85 vs. 75%, adjusted PR = 1.52, 95% CI 1.09-2.10, p = 0.012); injectable use was not associated with HIV risk scores ≥5. Conclusions: Adolescent girls and young women seeking contraception frequently had high HIV risk, emphasizing the importance of integrating HIV prevention within FP. Multipurpose technologies for contraception and HIV prevention could particularly benefit AGYW.

Uptake of Contraception Among Adolescent Girls and Young Women PrEP Clients: Leveraging the Opportunity to Strengthen HIV and Sexual and Reproductive Health Integration

The introduction of oral pre-exposure prophylaxis (PrEP) for HIV prevention was a major breakthrough in South Africa (SA). While the initial introduction focused on issues such as the development and implementation of new guidelines, supply, and the development of demand creation strategies, the need to integrate PrEP services with sexual and reproductive health (SRH) services has gained traction both globally and locally. Project PrEP was implemented in eight healthcare facilities and four mobile clinics in three provinces in SA. Using monitoring data from across the four project clusters, and 4,949 clients, over a 21-month period, we conducted an analysis of baseline routine monitoring data to examine contraceptive uptake in adolescent girls and young women (AGYW) initiating PrEP at project sites. Two-thirds of women (62.3%, n = 3,083) reported the current use of contraception at baseline, with the most commonly used methods being hormonal injectables (61.9%, n = 1,829) and male condoms (19.4%, n = 575). A third (32.3%, n = 603) of the non-contraceptive users accepted a method at PrEP initiation. From a total of 1,007 (32.7%) current contraceptive users at baseline, 865 (85.9%) chose the same or a different method at this visit. The method uptake at PrEP initiation increased the overall contraceptive prevalence by 12.2 to 74.5%. Data indicated that over a third (38.8%, n = 725) who were not using a method at baseline described themselves as consistent condom users. Although a major focus of the project was on PrEP service provision, all women were counseled and offered contraceptive services. The acceptance of a method by a third of non-users was promising; however, more understanding of those who did not take up a method is required. The need to leverage opportunities for the promotion of the integration of HIV and family planning at all levels of PrEP provision was highlighted.

Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming

BACKGROUND

Female sex workers in sub-Saharan Africa face high unmet need for family planning and higher risk for unintended pregnancy. Community empowerment HIV prevention approaches have the potential to increase family planning uptake and present an opportunity to integrate HIV, reproductive health, and contraception. This article describes family planning use and pregnancy among female sex workers in Iringa, Tanzania and evaluates whether engagement in a community empowerment HIV prevention program is associated with contraceptive use.

METHODS

This study consists of secondary analysis from a two-community randomized controlled trial following a longitudinal cohort over 18 months. We implemented a year-long community empowerment intervention consisting of 1) a community-led drop-in-center; 2) venue-based peer education, condom distribution, and HIV testing; 3) peer service navigation; 4) sensitivity trainings for providers and police; and 5) text messages to promote engagement. Additionally, monthly seminars were held at the drop-in-center, one of which focused on family planning. Modified Poisson regression models were used to estimate the association between program exposure and family planning use in the intervention arm. (Trials Registration NCT02281578, Nov 2, 2014.) RESULTS: Among the 339 participants with follow-up data on family planning, 60% reported current family planning use; 6% reported dual use of modern contraception and condoms; over 90% had living children; and 85% sought antenatal care at their most recent pregnancy. Among the 185 participants in the intervention arm, the adjusted relative risk (aRR) of family planning use among female sex workers who reported ever attending the Shikamana drop-in-center and among female sex workers who reported attending a family planning-related workshop was respectively 26% (aRR 1.26 [95% Confidence Interval (CI): 1.02-1.56]) and 36% (aRR 1.36 [95%CI: 1.13-1.64) higher than among those who had not attended.

CONCLUSION

There is a clear need for family planning among this population. General program exposure and exposure to a family planning workshop were associated with higher family planning use, which suggests that community empowerment models have potential to increase family planning uptake for this vulnerable group.

The Promise of the Dual Prevention Pill: A Framework for Development and Introduction

Women of reproductive age need multipurpose prevention technology (MPT) products to address two overlapping health risks: unintended pregnancy and HIV. Currently, condoms are the only available MPT, however male condoms are not within the control of a woman, and the use of female condoms has been limited by low acceptability and cost. Oral pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet uptake and adherence among women have been low to date. Women globally need more options for HIV and pregnancy prevention. Several MPTs for simultaneous HIV and pregnancy prevention are in various stages of development and clinical testing, although most are many years away from market launch. A dual prevention pill (DPP), a daily oral pill combining oral contraceptives and PrEP, both of which are licensed, approved products in many low- and middle-income countries (LMIC), is likely to be the fastest route to getting an MPT product into the hands of women. The DPP is one option that could enhance method choice, particularly for women who are already using oral contraceptives. By leveraging the oral contraceptive market and reaching women currently using condoms or with an unmet need for contraception, the DPP has the potential to increase the uptake of PrEP. The successful rollout of the DPP will require careful consideration of user-, provider-, and product-centered factors during product development and introduction. Early attention to these interrelated factors can help ensure that the DPP has the ideal characteristics for maximum product acceptability, that effective and quality services are designed and implemented, and that users can make informed choices, demand the product, and use it effectively. The proposed framework outlines key considerations for the effective development and introduction of the DPP, which could also facilitate integration models for future MPTs.

Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

Fertility desires of people living with HIV: does the implementation of a sexual and reproductive health and HIV integration model change healthcare providers' attitudes and clients' desires?

Background

There is a need for information and healthcare support for the fertility desires and contraceptive needs of people living with HIV (PLHIV) in order to provide safer conception support for sero-discordant couples wanting to safely conceive. A model to integrate sexual and reproductive health and HIV services was developed and implemented in a district hospital and six clinics in the eThekwini District, South Africa.

Methods

To evaluate the model’s success, a cross-sectional survey was conducted before and after implementation of the model. As part of this evaluation, fertility desires of PLHIV (both male and female), and providers’ perspectives thereof were explored. Changes in desires and attitudes after integration of services were investigated.

Results

Forty-six healthcare providers and 269 clients (48 male, 221 female) were surveyed at baseline, and 44 providers and 300 clients (70 male, 230 female) at endline. Various factors including relationship status, parity and antiretroviral treatment (ART) access influenced PLHIVs’ desires for children. Concerns for their own and their child’s health negatively impacted on PLHIV’s fertility desires. These concerns declined after integration of services. Similarly, providers’ concerns about PLHIV having children decreased after the implementation of the model.

Conclusions

Integrated services are important to facilitate provision of information on contraceptive options as well as safer conception information for PLHIV who want to have children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06487-0.

Improving public health service delivery response to address contraceptive needs of socio-economically disadvantaged HIV positive people in Maharashtra, India

Background

People living with HIV (PLHIV) receive free antiretroviral treatment (ART) in public health facilities of India. With improved life expectancy, unmet sexual and reproductive health needs of PLHIV have to be addressed through a converged programmatic response strategy. Evidence shows that socioeconomically disadvantaged women are most vulnerable to high reproductive morbidities, especially HIV positive women with an unmet need of contraception.

Methods

Programmatic convergence by linking ART and family planning services were strengthened at two public health facilities (district hospitals) generally accessed by disadvantaged socio-economic sections of the society. Barriers to linking services including stigma and discrimination were addressed through analysis of existing linkage situation, sensitization and training of healthcare providers and system-level interventions. This facilitated provider-initiated assessment of contraceptive needs of PLHIV, counseling about dual contraception using a couple approach, linkage to family planning centers and maintaining data about these indicators. Six hundred eligible PLHIV seeking care at ART centers were enrolled and followed up for a duration of 6 months. Acceptance of family planning services as a result of the intervention, use of dual contraception methods and their determinants were assessed.

Results

Eighty-seven percent HIV couples reached FP centers and 44.6% accepted dual methods at the end of the study period. Dual methods such as oral contraceptive pills (56.2%), IUCDs (19.4%), female sterilization (11.6%), injectable contraception (9.9%) and vasectomy (2.9%) in addition to condoms were the most commonly accepted methods. Condom use remained regular and consistently high throughout. The study witnessed seven unintended pregnancies, all among exclusive condom users. These women availed medical abortion services and accepted dual methods after counseling. Female index participants, concordant couples, counseling by doctors and women with CD4 count above 741 had higher odds of accepting dual contraception methods. Standard operating procedures (SOP) were developed in consultation with key stakeholders to address operational linkage of HIV and family programs.

Conclusion

The study saw significant improvement in acceptance of dual contraception by PLHIV couples as a result of the intervention. Implementation of SOPs with supportive supervision can ensure efficient linkage of programs and provide holistic sexual and reproductive healthcare for PLHIV in India.

Sexual and reproductive health among adolescent girls and young women in Mombasa, Kenya

This secondary data analysis of a cross-sectional survey conducted in Mombasa, Kenya characterises sexual and reproductive health (SRH) indicators among adolescent girls and young women (AGYW) engaged in casual and transactional sexual relationships as well as sex work. It describes the association between awareness of local HIV programmes and SRH services uptake for AGYW engaged in sex work. Thirty-eight percent of the participants reported a history of pregnancy. Among participants not trying to get pregnant, 27% stated that they were not currently using any form of contraception. Of the participants who had an abortion, 59% were completed under unsafe conditions. For AGYW engaged in sex work, awareness of local HIV prevention programmes was associated with increased STI testing within the last year (29%) as well as at least one HIV test (99%) compared to those who were not aware of local programming (18% and 92%, respectively); however, only 26% of participants engaged in sex work had heard of local HIV prevention programmes. There were no associations between awareness of local HIV programming and rates of dual contraception use, safe abortion, most recent birth attended by a skilled health professional or testing for HIV during pregnancy. Our study found high need for SRH services, particularly, access to contraception and safe abortion. Continued efforts are required to improve access to the full spectrum of SRH interventions, including family planning services and access to safe abortion in addition to HIV prevention to promote health equity.

The role of contraception in preventing HIV-positive births: global estimates and projections

BACKGROUND

Meeting the contraceptive needs of women living with HIV (WLHIV) has primary health benefits for women, in addition to being a key element to prevent mother-to-child HIV transmission. This analysis will estimate the current number of infant HIV infections prevented by contraception in the era of increased HIV treatment coverage and; 2) model the additional HIV benefits of preventing unintended births to WLHIV.

METHODS

Secondary data analysis was conducted using publicly available data from the United Nations Programme on HIV/AIDS (UNAIDS) and Population Division, Demographic Health Surveys, and peer-review literature. National data from 70 countries, that had a UNAIDS estimate for the number of WLHIV nationally, were combined into country-level models. Models estimated the current number of infant HIV infections averted by contraception annually and potentially averted if unintended births to WLHIV were prevented. Estimates take into account pregnancy and live birth rates, contraceptive coverage, contraceptive method mix and failure rates, and HIV treatment coverage during pregnancy to prevent mother to child transmission.

RESULTS

Contraception use among WLHIV prevents an estimated 43,559 new infant HIV infections annually across 70 countries. Countries with the largest number of infant infections averted by contraception included South Africa (9441), Nigeria (4195), Kenya (3508), Zimbabwe (2586), and India (2145). Preventing unintended births to WLHIV could avert an additional 43,768 new infant infections per year, with the greatest potential gains to be made in South Africa (12,036), Nigeria (2770), Uganda (2552), and the Democratic Republic of the Congo (2324).

CONCLUSIONS

Contraception continues to play an integral role in global HIV prevention efforts in the era of increasing HIV treatment coverage, especially in sub-Saharan Africa. Broad contraceptive availability, increased contraceptive voluntarism and method mix are key components to preventing unintended births and ending new infant HIV infections worldwide.

Integration of family planning services into health care for HIV-positive women in Botswana

OBJECTIVE

To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV.

METHODS

We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18-45 years and using antiretrovirals.

RESULTS

At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception.

CONCLUSIONS

Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC.

Integrating HIV and Family Planning Services: The Pros and Cons

Background

The integration of HIV and family planning services as a one-stop service is a cost-effective way of service delivery, but it has advantages and disadvantages.

Methods

A cross-sectional study design was applied to conduct this research in Ethiopia from June 2015 to November 2018. Two-stage sampling was applied: 1) a simple random sampling method was used to select 31 public health centers, and 2) 403 clients and 305 service providers were selected by using a stratified simple random sampling. A self-administrator questionnaire was developed to collect the data from service providers, and an interview questionnaire was used to collect data from clients. The data were statistically computed using bi-variate and multivariate logistic regression.

Results

Integrated HIV and family planning services allow for the enhancement of the competencies of healthcare workers, client satisfaction, mobilization of fiscal resources, provision of infrastructures, and adequate numbers of human resources available. It can also mobilize additional resources for health education and improve awareness on HIV and family planning services. Despite the mentioned advantages, shortages of human resources, HIV drugs and contraceptives, funding and long waiting times were identified as the disadvantages of HIV and family planning service integration. There was a risk of nine times lower chance of intention to use an integrated HIV and family planning services, if a client waited for more than 1 hour and 6 times risk waited for 30-60 minutes.

Conclusion

The advantages of offering an integrated service at a one-stop facility by far outweighing the disadvantages. It might be relevant to develop a strategic action plan for stakeholders to facilitate the integration of HIV and family planning services with the aim to improve service utilization and to reduce maternal and child morbidity and mortality.

Health systems software factors and their effect on the integration of sexual and reproductive health and HIV services

Despite a large and growing body of literature on sexual and reproductive health (SRH) and HIV integration, the drivers of integration of SRH and HIV services, from a health systems perspective, are not well understood. These drivers include complex so-called hardware (structural and resource) and software (values and norms, and human relations and interactions) factors. Two groups of software factors emerge as essential enablers of effective integration of SRH and HIV services that often interact with systems hardware: (1) leadership, management, and governance processes and (2) provider motivation, agency, and relationships. Evidence suggests the potential for software elements that are essential enablers to overcome some of the obstacles posed by the non-integration of health system hardware elements (eg, financing, guidelines, and commodity supplies). These enabling factors include flexible decision making, inclusive management, and support in motivating frontline staff who can work with agency as a team. Improved software, even within constrained hardware (especially in low-income and middle-income countries), can directly contribute to improved SRH and HIV service delivery.

Alignment of PrEP use and effective contraceptive use among East African women in HIV serodiscordant partnerships

Women who have a prevention mindset may opt for concurrent use of oral pre-exposure prophylaxis (PrEP) and all forms of contraception; we therefore assessed how contraception may influence PrEP use or vice versa. We analyzed data from Kenyan and Ugandan HIV-uninfected non-pregnant women in sero-discordant partnerships who were participating in the Partners Demonstration Project. Using multivariable generalized estimating equation models, we estimated the associations between effective contraceptive use and 1) PrEP dispensation 2) high effective PrEP use. Among the 311 women (93.1% of all those followed in the Partners Demonstration Project) median age was 29 years (interquartile range [IQR] 24.0-35.0) and 115 (37.0%) reported using effective contraception at baseline. All the women initiated PrEP during the study and moderately high PrEP adherence was recorded at 73.1% of visits over an average 7.5 months following PrEP dispensation. Women (14.8%) consistently used an effective contraceptive throughout study follow-up. PrEP dispensation was more frequent among those concurrently using effective contraception, (adjusted relative risk [aRR] = 1.19; 95% confidence interval [CI] = 1.08-1.32) and contraceptive use was more common among those on PrEP (aRR = 1.63; 95% CI = 1.18-2.25). Among East African women at high risk of HIV infection, PrEP dispensation was more frequent among women using effective contraception, indicating that family planning outlets may be efficient locations to deliver PrEP.

Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples

OBJECTIVE

To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services.

DESIGN

Implementation and modelling.

SETTING

Fifty-five government health facilities in Zambia.

SUBJECTS

Patients in government health facilities.

INTERVENTION

Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015.

MAIN OUTCOME MEASURES

We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year.

RESULTS

Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use.

CONCLUSION

Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.

Capacity assessment for provision of quality sexual reproductive health and HIV-integrated services in Karamoja, Uganda

INTRODUCTION

Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS.

METHODS

A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions.

RESULTS

64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored "excellent", followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%.

CONCLUSION

HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.

Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services

Background

With the advent of effective treatment, women living with HIV can plan for pregnancy while minimizing risk of transmission to infants and seronegative partners. Family planning (FP) services tend to focus solely on addressing contraceptive need, but HIV-positive women—including female sex workers—often plan to have children someday. Various “safer conception” strategies are now available to support women living with HIV achieve fertility intentions, and integrated HIV/FP services may be a promising platform to offer these services.

Methods

At integrated community-based HIV/FP service delivery sites operated by Jhpiego’s Sauti project in Dar es Salaam, we conducted exit interviews with 300 HIV-positive female sex workers. Descriptive analyses were conducted to describe their desire for children, use of condoms and other modern contraceptive methods, self-reported viral suppression, and knowledge of and interest in safer conception strategies. We conducted bivariate and multivariate logistic regression analysis to examine correlates of fertility desire among respondents.

Results

Median age of participants was 32. Nearly one-third wished to have a child within two years. Seventy-two percent had heard of having the HIV-positive partner taking ART to reduce sexual transmission during pregnancy attempts. Thirty-one percent felt the amount of FP content covered in the consultation was “too little.” Factors significantly associated with desire for children were having a nonpaying partner (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI]1.13–4.20) and having fewer children (AOR 0.65, 95% CI 0.48–0.87). Viral suppression was not associated with fertility desire.

Conclusions

Sex workers living with HIV attending integrated HIV/FP services have need for both contraception as well as safer conception counseling. This integrated service delivery modality is a promising platform for providing safer conception services. FP counseling for HIV-positive women should be broadened to broach the topic of safer pregnancy, as well as explicit counseling on strategies to minimize risk of sexual transmission to partners.

Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa

Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.

Higher contraceptive uptake in HIV treatment centers offering integrated family planning services: A national survey in Kenya

OBJECTIVES

Integrating family planning (FP) into routine HIV care and treatment are recommended by WHO guidelines to improve FP access among HIV-infected individuals in sub-Saharan Africa. This study sought to assess factors that influence the delivery of integrated FP services and the impact of facility-level integration of FP on contraceptive uptake among women living with HIV (WLWH).

STUDY DESIGN

A national cross-sectional study was conducted among WLWH at HIV Care and Treatment centers with >1000 antiretroviral treatment (ART) clients per year. A mobile team visited 108 HIV Care and Treatment centers and administered surveys to key informants regarding facility attributes and WLWH regarding FP at these centers between June and September 2016. We classified facilities offering FP services within the same facility as 'integrated' facilities.

RESULTS

4805 WLWH were enrolled at 108 facilities throughout Kenya. The majority (73%) of facilities offered integrated FP services. They were more likely to be offered in public than private facilities (Prevalence Ratio [PR]: 1.86, 95% Confidence Interval [CI]: 1.11-3.11; p = 0.02] and were more common in the Nyanza region than the Nairobi region (77% vs 35% respectively, p = 0.06). Any contraceptive use (89% vs 80%), use of modern contraception (88% vs 80%), dual method use (40% vs 30%), long-acting reversible contraception (LARC) (28% vs 20%), and non-barrier short-term methods (34% vs 27%) were all significantly higher in facilities with integrated FP services (p < 0.001).

CONCLUSIONS

The majority of high volume facilities integrated FP services into HIV care. Integrating FP services may increase modern contraceptive use among WLWH.

IMPLICATIONS

Integration of FP services was associated with higher modern contraceptive use, lower unmet need for modern methods and higher use of long-acting, reversible contraception (LARC), and non-barrier short-term methods among women living with HIV. Despite high prevalence of integration of FP services, organizational challenges remain at integrated clinics.

A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia

BACKGROUND

Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia.

OBJECTIVE

The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples.

STUDY DESIGN

A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted.

RESULTS

A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%).

CONCLUSION

Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs.

Background:

Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods:

From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results:

Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions:

Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

HIV pre-exposure prophylaxis for female sex workers: ensuring women's family planning needs are not left behind

INTRODUCTION

Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs.

DISCUSSION

FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed.

CONCLUSIONS

As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.

Long-acting reversible contraception knowledge, attitudes and use among HIV-infected and -uninfected women and their providers

OBJECTIVE(S)

To describe differences in contraceptive knowledge, attitudes and use among HIV-infected and HIV-uninfected women served by an academic medical center in New York City and to describe gaps in knowledge and practice of gynecologic and HIV clinicians providing care at the same clinic sites where patients completed surveys.

STUDY DESIGN

We conducted a survey comparing contraceptive knowledge, attitudes, reproductive histories and long-acting reversible contraception (LARC) use in HIV-infected and -uninfected women. We also conducted a survey to elicit clinician demographic characteristics and education, contraceptive practice patterns and their knowledge of current contraceptive guidelines. We surveyed clinicians and patients at five ambulatory sites.

RESULTS

We screened 90% of patients approached. All 257 women who were eligible completed a survey. These included 107 (42%) HIV-infected women and 150 (58%) HIV-uninfected women. HIV-infected women were older, were more likely to be black/African-American, were less likely to be Latina, were more likely to receive public assistance and had lower educational attainment. HIV-infected women reported lower lifetime LARC use (12% vs. 28%) and higher recent condom use (58% vs. 25%) than HIV-uninfected women. Both groups reported similar attitudes toward intrauterine devices (IUDs) and implants. HIV clinicians were less likely to have had training in or discuss LARC methods with their patients.

CONCLUSIONS

HIV-infected women were less likely to be current (last 30 days) or ever LARC users, despite having similar attitudes toward IUDs and implants, compared to HIV-uninfected women. HIV providers had lower levels of knowledge of HIV-specific contraceptive guidelines compared with gynecology practitioners.

IMPLICATIONS

HIV-infected women and their providers share a knowledge gap regarding LARC. Increased interdisciplinary collaboration may help mitigate the resulting disparities in access to highly effective contraception in HIV-infected women. Knowledge of HIV-specific contraceptive guidelines and ability to place contraceptive implants were low among all surveyed providers, suggesting need for additional training.

Strengthening integration of family planning with HIV/AIDS and other services: experience from three Kenyan cities

Background

Kenya has made remarkable progress in integrating a range of reproductive health services with HIV/AIDS services over the past decade. This study describes a sub-set of outcomes from the Bill & Melinda Gates Foundation (BMGF)-funded Jhpiego-led Kenya Urban Reproductive Health Initiative (Tupange) Project (2010–2015), specifically addressing strengthening family planning (FP) integration with a range of primary care services including HIV testing and counselling, HIV care services, and maternal, newborn and child care.

Methods

A cross-sectional study was conducted between August and October 2013 in the cities of Mombasa, Nairobi and Kisumu in Kenya to assess the level of FP integration across six other service delivery areas (antenatal care clinic, maternity wards, postnatal care clinic, child welfare clinic, HIV testing and counseling (HTC) clinics, HIV/AIDS services in comprehensive care clinics). The variables of interest were level of integration, provider knowledge, and provider skills. Routine program monitoring data on workload was utilized for sampling, with additional data collected and analyzed from twenty health facilities selected for this study, along with client exit interviews. Descriptive analysis and Chi-square/ Fishers Exact tests were done to explore relationships between variables of interest.

Results

Integration of FP occurred in all the five service areas to varying degrees. Service provider FP knowledge in four service delivery areas (HTC clinic, antenatal clinic, postnatal clinic, and child welfare clinic) increased with increasing levels of integration. Forty-seven percent of the clients reported that time spent accessing FP services in the HTC clinic was reasonable. However, no FP knowledge was reported from service providers in HIV/AIDS comprehensive care clinics in all levels of integration despite observed provision of counseling and referral for FP services.

Conclusions

Integration of FP services in other primary care service areas including HTC clinic can be enhanced through targeted interventions at the facility. A holistic approach to address service providers’ capacity and attitudes, ensuring FP commodity security, and creating a supportive environment to accommodate service integration is necessary and recommended. Additional studies are necessary to identify ways of enhancing FP integration, particularly with HIV/AIDS care services.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0715-8) contains supplementary material, which is available to authorized users.

Availability of integrated family planning services in HIV care and support sites in sub-Saharan Africa: a secondary analysis of national health facility surveys

Background

Integrating family planning (FP) with HIV care and treatment programs is a strategy to expand FP service delivery and prevent unintended pregnancies among women living with HIV. However, little is known about the extent to which FP services are available in health facilities providing HIV services across sub-Saharan Africa. In this study, we assessed the availability of integrated FP services and the associated factors in HIV care and support sites across sub-Saharan Africa.

Methods

We conducted a secondary analysis of nationally representative facility-level data from Service Availability and Readiness Assessments (SARA) and Service Provision Assessments (SPA) conducted in 10 sub-Saharan African countries between 2012 and 2015. We used six indicators that reflect the structure and process of care essential for FP service delivery in HIV care and support facilities to define the outcome of interest - onsite availability of integrated FP services. Multivariate logistic regression was used to explore facility-level characteristics associated with the outcome.

Results

Among the 3161 health facilities offering HIV care and support services, most reported also offering FP services at the same location. The availability of three FP methods was higher than the availability of FP guidelines and trained staff. Onsite availability of integrated FP services ranged from 10 to 61%. Results of multivariate logistic regression indicated that the odds of having onsite integrated FP services available was higher in HIV care and support sites that were operated by the government, classified as a tertiary level care facility, and provided services for PMTCT, antenatal care and basic surgery.

Conclusions

Our findings indicate critical shortcomings in the preparedness of HIV care and support sites to deliver onsite integrated FP services. Renewed efforts are needed to address these supply-side barriers and ensure that integrated FP and HIV services meet the unique needs of HIV clients.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0713-x) contains supplementary material, which is available to authorized users.

Integration of HIV testing services into family planning services: a systematic review

BACKGROUND

Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously.

METHODS

We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017.

RESULTS

Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes.

CONCLUSIONS

Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.

Provider understandings of and attitudes towards integration: Implementing an HIV and sexual and reproductive health service integration model, South Africa

In South Africa, a lack of integration between sexual and reproductive health (SRH) and HIV services has led to lost opportunities in the treatment cascade. In a context of high HIV, tuberculosis (TB) and unplanned pregnancies, a model for integrating SRH and HIV services was implemented in a hospital and six feeder clinics in KwaZulu-Natal, South Africa. Changes in healthcare provider knowledge, attitudes and understandings were explored following model implementation. Baseline data were collected via focus group discussions (FGDs) and a cross-sectional survey, and were used to inform the development of a model for integrating SRH and HIV services. Following the implementation of the model, an endline survey was conducted to explore any changes. Four FGDs were conducted with healthcare providers at study facilities. A total of 46 providers participated in the baseline survey, and 44 in the endline survey. Qualitative data were thematically analysed using NVivo 11, and quantitative data were descriptively analysed using SPSS 24. The understanding of integration improved by endline. Integration of services was considered important for reducing stigma and increasing access to and improving quality of care. Concerns raised were that integration would increase workload and time per client. Physical structure of facilities was not always conducive to referral or integration. Perceived benefits of integration and actual integration of services improved between baseline and endline. Enhanced understanding of integration and increased levels of reported integration over time imply that providers are more aware, suggesting that the model was effective. Provider perspectives and understandings are important for the successful integration of services. This integration model is relevant and useful to inform training and mentoring of providers, as well as to provide recommendations for policy implementation.