Spoilt for choice

By Nienke Blauw, Advocacy Officer UAFC Joint Programme (Rutgers WPF, The Netherlands) and Saku Mapa, HIV Officer: Prevention, Treatment and Care (IPPF Central Office)

Like male condoms, female condoms (FCs) provide protection against unintended pregnancy and most sexually transmitted infections (STIs), including HIV. However, unlike their male counterparts, female condoms remain a relatively unknown and underfunded dual protection method. For a long time, the success of the product has been affected by a combination of frequent stock-outs, skepticism, myths and prejudices, high prices, and lack of variety.

In 2008, the Universal Access to Female Condoms (UAFC) Joint Programme was formed by four organizations (Netherlands Ministry of Foreign Affairs, I+solutions, Rutgers WPF and Oxfam Novib) to address the bottlenecks around availability and access to female condoms. As part of its holistic approach (combination of advocacy, large scale female condom programming, and manufacturing support and regulatory issues), UAFC commissioned a clinical study in China and South Africa to compare the functional performance of and preferences for three new female condom designs (Cupid, Women’s Condom and VA w.o.w.) compared to a ‘control’ design, called Female Condom 2 (FC2).  In each country, around 300 people took part in the study who were primarily urban women aged 18-45 who were either novice or experienced users of female condoms.       

"The female condom is gaining ground as it should do, I myself used throughout my life six different methods for family planning and protection, not even counting abstinence, this shows that variety is key." Marijke Wijnroks, Director for Social Development / HIV and SRHR ambassador for the Netherlands

The primary goal of the study was to look into the device functioning (clinical and non-clinical breakage, total breakage, slippage, misdirection, and invagination), while the study also looked into safety and acceptability. It was found, both in China and South Africa, that most women preferred the Women’s Condom. Overall, the study concluded that the three new condoms are non-inferior to the FCS, and recommended them as worthwhile products to add to the market alongside the FC2 (report available here).

The data gathered during this study will be used to secure regulatory approvals for the female condoms, including UNFPA/WHO prequalification. The Cupid female condom, as well as its manufacturer Cupid Ltd, was the first to fulfill all requirements and was prequalified by UNFPA/WHO in July 2012, thereby introducing more variety to the  female condom market.

At a recent meeting in The Hague, The Netherlands, some experts spoke out in support of this development as an important step in the right direction as variety of designs will increase competition leading to lower prices for procurers and eventually also for users, thus providing better access and more choice.

For more information about the UAFC Joint Programme visit: www.condoms4all.org.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

Integrating postnatal care, family planning, and HIV services

By Dr James Kimani, Senior Analyst (Population Council, Nairobi, Kenya)

Addressing the postpartum needs of new mothers, including new mothers who are living with HIV, and new mothers living in settings with a high HIV prevalence, is a neglected area of care throughout sub-Saharan Africa and other resource-limited settings. Few developing countries have mechanisms in place to ensure that mothers and their newborns are assessed early and monitored during the initial six-week postpartum period.

Some of the challenges include lack of clearly defined standards, including the content and timing of both postpartum and postnatal services, and a discontinuity of services limiting linkages to other key postpartum services for new mothers, including family planning and HIV care services for women living with HIV.

According to the World Health Organization, over 60 per cent of maternal deaths occur within the first 48 hours after childbirth [2], while newborn morbidity and mortality, including postnatal transmission of HIV to infants, are more likely to happen soon after birth [3, 4]. In high HIV prevalence settings, there is also evidence that women living with HIV are at 1.5–2 times greater risk of maternal mortality than women who are HIV-negative [5]. Providing adequate and effective services to meet the needs of mothers and their infants during this postpartum period can substantially reduce maternal and infant morbidity and mortality.

It is often assumed that women who deliver in a facility will have received adequate care prior to discharge and do not need further attention until the six-week consultation. Women giving birth at home are least likely to receive any care, especially within the first two days, when they are most susceptible to postpartum hemorrhage and hypertensive disorders [6].

However, our research has supported other studies that have found that regardless of where a woman gives birth, she is unlikely to receive the comprehensive care she needs. Two critical issues need further attention – the first, to promote family planning and prevent future unintended pregnancies, and the second, to prevent vertical transmission of HIV during the postpartum period.

To promote family planning, research has shown that during the extended postpartum period (12 months after birth), women may want to delay or avoid future pregnancies, but do not have access to a modern contraceptive method. A review of data from Demographic and Health Surveys (DHS) in 27 developing countries found that 67 per cent of women who gave birth within the previous year had an unmet need for family planning [7]. Although unmet need for family planning during the postpartum period is widespread among all women, evidence from recent studies has shown that substantial proportions of women living with HIV also have an unmet need. Studies in Zambia and Kenya found that 39 per cent and 65 per cent of postpartum women living with HIV reported that they were not using any contraceptive method with their regular sexual partner [8].

To prevent vertical transmission of HIV, there is evidence that even if counseling and information on family planning is available within programmes for the prevention of mother-to-child transmission of HIV (PMTCT), this does not necessarily translate into the initiation of contraception [9].

Evidence has shown that providing a continuum of care from antenatal, delivery, postnatal services and beyond results in improved maternal and neonatal health outcomes [10-12].  For example, in Swaziland, integration of PMTCT into postnatal care led to considerable improvements in follow-up visits during the first three days postpartum, a significant increase in the proportion of postpartum women and their partners who got tested for HIV, an increase in the proportion of women and infants who received HIV treatment and care, and significant improvements in the proportion of mothers practicing exclusive breastfeeding [11].

However, there is still a paucity of evidence from southern and eastern Africa (where HIV prevalence is highest) focused on measuring the benefits of integrated HIV and sexual and reproductive health services, particularly, postnatal care services.

As part of the Integra Initiative, our study in Kenya has contributed to filling this gap and aimed to build the evidence base by assessing the effect of integrating HIV and postnatal care services on the uptake of provider-initiated HIV testing and counseling and family planning services among women attending postnatal care in public health facilities. Preliminary results indicate that an integrated delivery approach of postnatal services is beneficial in increasing the uptake of HIV testing and family planning services among postpartum women, including the uptake of long-term family planning methods. However, there are important gaps in the uptake of these services based on facility-type and socio-demographic characteristics. This has important implications in addressing the sexual and reproductive health and HIV needs of women, including prevention of unintended pregnancies.

References listed in the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

HIV Update: Family planning and HIV integration

From words to action

By Lucy Stackpool-Moore (IPPF)

One of the many things that the response to HIV has shown the world over the last 30 years, is that communities can stand up, demand access to better quality services, defend their sexual and reproductive rights, and ultimately make a difference to policies and programmes. The growing movement for women, girls and their partners to demand sexual and reproductive health and rights, including family planning, can learn from these successes.

One of the key messages from the session on sexual and reproductive health (SRH) and HIV linkages at the London Summit on Family Planning Summit in July 2012 was that: “family planning needs to take a holistic approach to women’s health including their direct engagement in the prioritization of what is needed, what works and what is the appropriate method mix." (full session report) To be effective, this ‘holistic approach’ needs to engage communities not only as clients and end-users of services alone, but also as active participants in demanding the range and quality of services that meet their needs.

Internationally, different ‘communities’ have been speaking out to galvanize attention, energy and action on family planning and HIV integration. This past month has seen action on the commitments made during the Summit and a renewed focus on the potential health and economic benefits of integrating HIV and family planning services.

From the research community, the results from the five-year Integra operations research Initiative - launched at the UK Houses of Parliament - indicated that integrating SRH and HIV services can reduce unmet need for family planning, especially for women living with HIV. Several of the study components showed an unmet need for SRH services among women living with HIV, and suggest that integrated services can help realize their fertility intentions and meet their contraceptive needs. New technologies, such as different varieties of the female condom, have also been developed and evaluated that could contribute to the range and accessibility of family planning methods.

From the donor community, building on the London Family Planning Summit it was announced that the UK government will provide additional support for Malawi’s HIV response as well as support for wider healthcare – an additional £21 million pounds was provided specifically for family planning and HIV. In Malawi, this was welcomed as direct action following on from their first national family planning conference (held in May 2012) and owes much to sustained political leadership on maternal and child health by President Joyce Banda.

From our IPPF community, we remain committed to scaling up family planning and HIV service delivery particularly for poor and vulnerable women, men and young people. We also celebrate the vast contribution that Kevin Osborne has made to the HIV community - within IPPF and beyond - through his vision and leadership over the last 10 years.

Different communities are speaking out and demanding action. All of us – clients, providers, managers, advocates and ambassadors defending sexual rights – need to make sure that we listen and continue to drive the actions (and not only the words in declarations of commitments) forward.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April