Preventing HIV and

UnintendedPregnancies:

Strategic Framework

In Support of the Global Plan Towards the

Elimination of New HIV Infections among Children by 2015 and Keeping their

Mothers Alive

Lynn Collins

Global Plan Towards the

Elimination of New HIV

Infections Among

Children by 2015 and

Keeping Their Mothers Alive

22 priority countries: Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe.

Two global targets by 2015 :

• Reduce the number of new HIV infections among children by 90%.

• Reduce the number of AIDS-related maternal deaths by 50%.

Number of new HIV child infections if:

- PMTCT coverage/regimen at 2009 levels- Prong 3 (ARV/ART to 90% of HIV+ PW)- Prongs 1, 2 and 3 (50% reduction Incidence, unmet FP to Zero, and 90%

ARV/ART)- Prongs 1, 2, and 3 and limit BF to 12 months

367,000

72,000 (79%)

95,000 (73%)

138,000 (60%)

Value in 2015(% reduction)

345,000

216,000

184,000

153,000

123,00096,000

72,000

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

2009 2010 2011 2012 2013 2014 2015

Estimated New HIV infections among children: Different scenarios for 25 countries

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Guiding Principles1. Address structural determinants

of HIV & SRH2. Focus on human rights & gender3. Promote a coordinated &

coherent response (Three Ones Principle)

4. Meaningfully involve People Living with HIV (GIPA Principle)

5. Foster community participation by young people, key populations at higher risk, & the general community

6. Reduce stigma & discrimination7. Recognize the centrality of

sexuality as an essential element in human life and in the individual, family and community well-being.

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Prong 1: primary

prevention of HIV

Target: 50% reduction in HIV incidence in women of reproductive age Page 18 & 64

Why prong 1 is important

Supporting HIV-negative

women to remain HIV

negative especially during

pregnancy and

breastfeeding will:– reduce the number of

reproductive age/maternal deaths; and

– reduce the number of new HIV-positive infants, and improve child survival.

Page19

• Sero-conversion during pregnancy

• Women may be at increased risk of HIV during pregnancy & breast-feeding

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Prong 1 Package of Essential Services• Information and counselling to

reduce the risk of sexual HIV transmission

• HIV testing & counselling; referral for or on site treatment

• Treatment for prevention• STI screening and management • Condoms (female and male):

promotion, provision and building skills for negotiation & use

• Blood safety and anaemia prevention to reduce blood-related transmission

• GBV prevention and impact mitigation

Page 22 - 25

Challenges prong 1• Engaging male partners • Potentially increased risk of

infection (seroconversion) for women during pregnancy, postpartum and breastfeeding period

• Insufficient coverage & quality of HIV counselling and testing

• Inadequate condom use. • GBV and STI management• Eliminating stigma &

discrimination• Lack of access to ARV

treatment (for prevention)Page 20 - 21

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Prong 2: prevention

of unintended

pregnancies

Target: reduce unmet family planning need to zero (among all women) MDG 5B

Page 26 & 64

Why prong 2 is importantReducing unintended pregnancies will:– reduce the number of

maternal deaths and improve maternal health,

– reduce the number of new HIV-positive infants,

– improve child survival by keeping their mothers alive, &

– empower women .Page 6 & 27

Prong 2 Package of Essential Services

• Information and counselling to support reproductive rights, including preventing unintended pregnancies

• Clinical management of HIV• Rights-based family planning counselling

and services• STI screening and management• GBV prevention and impact mitigation• Stigma and discrimination eradication

Page 32 - 34

Challenges prong 2

• High level of unintended pregnancies and unmet need for family planning

• Lack of awareness of reproductive rights

• Stigma in health care settings and community

• Inadequate availability of and access to family planning services

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Specific FP needs of HIV+ women

Strengthened or additional information, counselling, & services are needed on :

• rights, including reproductive rights: respecting fertility, sexuality, and contraceptive method choices, which do not force or coerce women into abortion or sterilization;

• drug interactions: between some antiretroviral drugs and hormonal contraceptives;

• contraceptives: see WHO medical eligibility criteria for contraceptive use for HIV+ women .

• treatment for infertility: HIV+ women may be more likely to have difficulty in getting pregnant as a consequence of either her own reduced fertility or that of her partner;

.

Page 30 - 31

Specific FP needs of HIV+ women

• STIs: PLHIV may be at greater risk, specifically for:– human papillomavirus (HPV): risk

factor for cervical and anal cancers;

– syphilis: may manifest differently and require more aggressive treatment;

– genital herpes (HSV-2 or HSV-1), may be severer, as well as prolonged or atypical in presentation, particularly in those with low CD4 counts. Asymptomatic and symptomatic HSV-2 reactivation is also more frequent;

• serodiscordance: lowering the risk of HIV infection to serodiscordant partner, if intend to get pregnant (Treatment for Prevention); and

• potential risk to the woman’s health, if become pregnant. Page 30 - 31

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Preventing HIV and Unintended Pregancies: Strategic Framework

supports the Global Plan1. Implement package of services

within stigma-free integrated SRH and HIV services

2. Utilise key entry points to integrating services for HIV and sexual and reproductive health

3. Strengthen national programme implementation

4. Carry out five key strategiesPage 2

Checklists for national programme implementation

• Country implementation actions 10-point plan from Global Plan

• IATT tools and guidelines in support of Global Plan

• Checklists for prongs 1 & 2

Page 40 - 50

Five Key Strategies 1: Link SRH and HIV at

the policy, systems and service delivery levels

2: Strengthen community engagement

3: Promote greater involvement of men

4: Engage organizations of people living with HIV

5: Ensure non-discriminatory service provision in stigma-free settings Page 51

Strategy 1: Link SRH and HIV

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Rapid Assessment Tool for SRH and HIV Linkages

Assess HIV and SRH bi-directional linkages at the policy, systems, and service-delivery levels.

Identify current critical gaps in policies and programmes.

Contribute to the development of country-specific action plans to forge and strengthen these linkages.

Focus primarily on the health sector.

Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009. Page 53

Strategy 2: Engage Community

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• Fast‐tracking men/couples who come for ANC• Providing clinical services for men who come (e.g.

blood pressure screening, health check‐ups)• Peer support for men living with HIV.• Performance‐based agreement, with male

engagement as one of the reportable indices• Male champions to encourage other men to act• Letters to partners encouraging clinic visits• Transport vouchers for couples • CHWs mobilising men• Ecole de Mari

(“husband schools”)

Strategy 3: Engage Men

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The greater involvement of people living with HIV (GIPA) is recognized as a core principle of the HIV response, and is fundamental to eMTCT programming.

Strategy 4: Engage PLHIV/Key Pop.

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PeopleLiving With HIVStigma Index

Strategy 5: Eliminate Stigma & Discrimination

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Cutting Edge Issues

• Box 4: Treatment as prevention

• Box 6: Specific family planning needs of

women living with HIV

• Box 7: Hormonal contraceptives and HIV

Page 21, 29, 30

Operational Research

Gaps:

• linked services targeting men and boys;• gender-based violence (GBV) prevention;• stigma and discrimination; and• comprehensive SRH services for PLHIV,

including addressing unintended pregnancies and planning for safe, desired pregnancies.

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