Spotlight on HIV and Family Planning: After the Summit

By Julia Bunting, Director, Programme and Technical Division (IPPF Central Office)

The year 2012 saw the reinvigoration of a loud and visible global movement committed to achieving universal access to family planning, as part of a commitment to comprehensive sexual and reproductive health (SRH) services that put the rights and needs of clients at the very centre. This groundswell was catalyzed at the London Summit on Family Planning held in July 2012, which built on the foundations laid down by family planning pioneers more than half a century ago. The Summit called for political commitments, backed by increased resources, to enable an additional 120 million women and girls in the world’s poorest countries to access contraceptive information, services and supplies by 2020.

At the Summit, IPPF made an unprecedented commitment to treble the number of SRH services provided annually by our Member Associations – from a 2010 baseline of 89 million services. By offering a comprehensive and integrated package of rights-based services through the existing network of 64,000 clinics and community-based service delivery points, we estimate that our efforts will prevent 46.4 million unintended pregnancies and 12.4 million unsafe abortions by 2020. We also estimate that 54,000 deaths of some women and girls will also be averted during this period. In this renewed focus on family planning, as in all of our work, we will maintain a particular focus on services for poor and vulnerable women, men and young people.

At the Summit, IPPF also committed to develop a compendium of indicators on linkages between HIV and SRH including family planning, maternal and child health. A greater focus on integration, particularly of HIV and family planning services, provides an unparalleled opportunity to expand access to a wide range of SRH services. The rationale is indisputable: the majority of cases of HIV transmission are sexual or are associated with pregnancy, childbirth and breastfeeding; the risk of HIV transmission and acquisition can be increased by the presence of certain sexually transmitted infections (STIs); and HIV continues to be the leading cause of death among women of reproductive age.

It is vital that all women and girls have access to a full range of sexual and reproductive health options, including HIV services, family planning, contraceptive choices, and access to safe abortion services. Women living with HIV, who continue to face barriers accessing both family planning and programmes that prevent HIV transmission from mother to child, must remain at the centre of attention. Prioritizing the integration of family planning and HIV services will greatly contribute to achieving the sexual and reproductive health and rights for all.

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

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

HIV in the workplace

By Dieneke ter Huurne, HIV Officer (IPPF Central Office)

HIV is a workplace issue. According to the International Labour Organization, nine out of every ten people living with HIV will go to work each day (available here). Unfortunately, stigma and discrimination remain a reality in many workplace settings. To counter this, it is imperative that we adopt, institutionalize and internalize HIV workplace policies and programmes across the Federation.  Such policies and programmes serve to sensitize, inform and educate our staff and volunteers about HIV and AIDS. They also act as a way of challenging, and ultimately reducing, instances and acts of discrimination towards those living with or affected by HIV. 

As an employer of more than 30,000 staff around the world, and working in collaboration with more than one million volunteers, IPPF has a collective responsibility to provide a supportive and non-discriminatory work environment for all. In 2010, IPPF’s Governing Council adopted a revised HIV policy, which includes our commitment to addressing HIV in the workplace. We have institutionalised this commitment by making it a requirement for accredited Member Associations to have an HIV workplace policy. By 2011, more than 83 per cent of all Member Associations had a written HIV workplace policy; up from 56 per cent in 2009.

IPPF also actively encourages people living with HIV to work and volunteer in Member Associations and across the Secretariat. In order to support people living with HIV working in the Federation, IPPF+ was launched to ensure IPPF is recognized as an organization that not only responds to HIV issues in the communities in which we work, but also as an employer that has grappled with the workplace effects of this epidemic.

The challenge now is to bring these policies and initiatives to life and internalize HIV workplace programmes across all our offices and branches. Three key strategies to do this are included in the box below. IPPF has also developed a training guide to support staff at IPPF Regional Offices and Member Associations with planning and facilitating HIV workplace trainings. It will become available in English, French, Spanish and Arabic early in 2013 – so keep an eye out for it! 

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HIV and the politics of fear

By Matthew Weait, Professor of Law and Policy (Birkbeck College, University of London, United Kingdom)

For the past decade or so I have been privileged to participate in, and contribute to, national and international policy initiatives concerned with the criminalization of HIV transmission, exposure and non-disclosure. The people involved in this work, paid and unpaid, have been tireless in their efforts to draw the attention of those with legislative power to the negative impact that punitive responses to people living with HIV, and to those in key populations, has had and continues to have on prevention efforts and on reducing HIV-related stigma and discrimination. They could not, I think, have done more. 

Yet punitive responses remain – a stubborn stain that refuse to be shifted (except for a few notable exceptions). Why is this so? Why, in an era in which effective treatment (where it is accessible and available) means that people living with HIV with an early diagnosis have a similar life expectancy to those without HIV, should people be so afraid of infection that they want to punish and imprison? And why is this even more apparent in countries where that treatment is indeed accessible and available (North America, Australasia and Europe)? It seems to me that the answer lies in an increasingly obsessive focus on the value of security and in a perversion of that value during the last twenty years.

There was a time when we accepted that our bodies were fragile, porous, weak – open to disease and infection. To be human was to be a much more vulnerable organism, more susceptible during accidents, childbirth, and illness. As biological, medical, and pharmaceutical sciences have developed, as we have come increasingly to believe that we are able to regulate, manage and master the pathological agents that threaten our physiological integrity. 

It is thus completely explicable that HIV – despite being a manageable, if serious, chronic illness – should be stigmatized to the point of criminalization. Explicable because it is a reminder – an embodied reminder – that we are mortal; that the fantasy we entertain about our bodies is merely that – a fantasy.  Any threat to this – including the person who fails to let us know that they are a potential source of infection, and the person whose virus might (but doesn’t) escape – is, quite literally, intolerable. 

HIV is an environmental fact. It coexists with humans. The humans in whom it is embodied suffer criminalization, stigma, and discrimination not because of HIV itself – it’s a virus (!) – but because HIV confounds us, challenges us, frightens us, forces us to acknowledge what being human really means. And these negative effects of HIV can, and will, only be eradicated (for as long as there is neither vaccine nor cure) if we learn from the experience and practice of those who have organized so hard to counter them: if we (re)learn the value of, and progressive political opportunities that come from, working together and with a certain degree of humility in the face of nature. 

If there is one legacy from HIV that we might wish to remember, I hope that it is the reaffirmation of what can be achieved – for ourselves and for others – through a politics that acknowledges the value of community rather than one that thrives on the fear of difference.

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HIV Update: Rights in Action

By Kevin Osborne (IPPF)

Since the beginning of the epidemic, HIV has been at the crossroads of science, rights and moral values. All too often human-rights, tolerance, and acceptance are seen as ‘nice-to-haves’ but not ‘must haves’ as part of national and international responses to HIV. Yet studies have shown that failure to respect human rights undermines the return on investment. There is a financial as well as moral imperative to ensure that the efforts, attention and hard-earned currency invested in responding to HIV are as effective as possible.

There is an unconscionable economic, human and social cost of inaction on human rights. In my home country South Africa, a study by the Harvard School of Public Health found that the political inaction during the AIDS denialism of Thabo Mbeki’s government equated to 365,000 premature deaths. This included 330,000 South Africans who died for lack of treatment and the 35,000 babies who perished because of ineffective, incomplete or absent efforts to prevent the transmission of HIV from their mothers. In total, the economists found this was at least 3.8 million years of life, lost.

On a global scale, a recent study has also quantified the cost of inaction. A new investment framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for the prevention of HIV transmission.  The framework differentiates between (i) basic programme activities that aim to directly reduce HIV transmission, morbidity, and mortality; (ii) activities that are necessary to support the effectiveness and efficiency of these programmes (critical enablers); and (iii) investments in other sectors that can have a positive effect on HIV outcomes (synergies with development sectors). Human rights, tolerance and social inclusion are core principles at the heart of creating such an enabling environment. Scaling up and implementing   the new investment framework, would avert 12.2 million new HIV infections and 7.4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches.

The significance of human rights in the response to HIV has been integral from the very beginning. Due to the link between HIV and traditionally sensitive issues, the epidemic has brought into the open differing values and attitudes related to human sexuality and behaviour. As the spotlight shines away from HIV and specific sources of funding are opened up to incorporate other diseases and health systems strengthening, there is a risk that addressing these rights could falter. With an ever-increasing focus on numbers and scales (which are both important) it is imperative that rights – which are often difficult to quantify – are not jeopardized, forgotten, or simply taken for granted.

For IPPF, putting rights into action by upholding the sexual rights of all and addressing HIV-related stigma are key priorities for our work. Practical measures such as ensuring that our workplace is a stigma-free environment and providing stigma-free services in all of our clinics, go a long way in maintaining a rights-based approach in everything we do.

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