Review of field experiences: Integration of family planning and PMTCT services

The Population Council and its research partners have been addressing several key questions about prevention of mother-to-child HIV transmission (PMTCT) services and how well they function in field settings. The World Health Organization asked the Population Council to provide a review of field experiences regarding the integration of family planning and PMTCT services. This report provides conclusions and recommendations as input into a WHO/UNFPA-sponsored consultative meeting on The linkages between reproductive health and HIV/AIDS: Family planning and prevention of mother-to-child transmission

Evaluation of HIV counseling and testing in ANC settings and adherence to short course antiretroviral prophylaxis for PMTCT in Francistown, Botswana

Worldwide, it is estimated that two million children are infected with HIV (USAID 2005). The vast majority of these infections are the result of mother-to-child transmission (MTCT) of the virus during pregnancy, labor, or breastfeeding. However, there are effective methods for prevention of mother-to-child transmission (PMTCT). Botswana is one of the first countries in the developing world with a national PMTCT program that uses an efficacious and complex regimen to reduce vertical transmission. At the time of this evaluation (August - December 2005), the standard of care for prevention of MTCT of HIV in Botswana included three-drug antiretroviral therapy for HIV-infected women with a CD4 count of 200 (300 mg AZT in the morning and 300 mg AZT in the evening); four weeks of AZT for their infants; single-dose maternal and infant nevirapine (NVP); and 12 months of free infant formula. Botswana's PMTCT program also provided routine HIV testing for all pregnant women during antenatal care (ANC) to identify HIV-positive women for prophylaxis or treatment. While programs often report the number of individuals beginning AZT and receiving nevirapine for PMTCT, effectiveness is dependent on the level of adherence of individuals to these regimens. To describe adherence of pregnant women to the current PMTCT regimen, the Horizons Program of the Population Council, in collaboration with the Centers for Disease Control and Prevention (CDC) and Premiere Personnel in Botswana, conducted an evaluation to describe HIV-related services provided to women during their pregnancies, document the content of post-test counseling sessions for HIV-positive pregnant women, whether HIV-positive women remembered what had been discussed, the extent of AZT adherence based on self-reports, and the operational successes and barriers to adherence to AZT for PMTCT

Addressing the family planning needs of HIV-positive PMTCT clients: Baseline findings from an operations research study

Preventing unintended pregnancy among HIV-positive women is an effective approach to reducing pediatric HIV infection and vital to meeting HIV-positive women’s sexual and reproductive health needs. Although contraceptive services for HIV-positive women is one of the cornerstones of a comprehensive program for prevention of mother-to-child transmission of HIV (PMTCT), a review of PMTCT programs found that implementers have not prioritized family planning (FP). While there is increasing awareness about the importance of FP and HIV integration, data about FP from PMTCT clients are lacking. The Horizons Program is conducting an operations research study testing several community-based strategies to reduce mother-to-child transmission of HIV in a densely settled urban slum in Nairobi, Kenya. Strategies being piloted include moving PMTCT services closer to the population via a mobile clinic and increasing psychosocial support for HIV-positive women. This research update presents key findings about FP at PMTCT sites, including the interaction between providers and clients as well as HIV-positive women’s fertility desires and demand for contraceptives, from the baseline cross-sectional survey and qualitative interviews with postpartum women

Looking back, moving forward: Implementing PMTCT programs in resource-constrained settings, Horizons studies 1999 to 2007

In 1997, the Population Council initiated the Horizons Program—a decade-long USAID-funded collaboration with the International Center for Research on Women, the International HIV/AIDS Alliance, PATH, Tulane University, Family Health International, and Johns Hopkins University—designing, implementing, evaluating, and expanding innovative strategies for HIV prevention and care. Horizons developed and tested ways to optimize HIV prevention, care, and treatment programs; worked to reduce stigma and improve gender-biased behaviors; and greatly expanded knowledge about the best ways to support, protect, and treat children affected by HIV and AIDS. In all its projects, Horizons strengthened the capacity of local institutions by providing support and training to colleagues. This synthesis paper presents lessons learned and best practices on one of the key topics that Horizons investigated: prevention of mother-to-child transmission of HIV

The Youth Empowerment Project: Strengthening NGO Management, Research and Service Delivery Capabilities in Botswana

In an expansion of its efforts to fight a growing HIV epidemic and high teenage pregnancy rates, the Government of Botswana is encouraging nongovernmental organizations (NG0s) to be more active in providing reproductive health (RH) services, and especially HIV/AIDS education and care, to adolescents. NG0s have the potential to assume a larger role as health and education providers as well as implement pilot projects that the public health sector could learn from to increase the availability and quality of RH services for youth. The Africa OR/TA Project II designed and implemented the Youth Empowerment Project (YEP) to assist youth-oriented NG0s in taking on greater responsibility for adolescent RH and education in Botswana. YEP was part of USAID\u27s Botswana Population Sector Assistance Project that assisted the Government of Botswana in improving the accessibility and effectiveness of RH care provided by the public and NGO sectors. This report describes YEP’s focus on strengthening the management and service delivery capabilities of the participating NG0s

Expanding men\u27s participation in reproductive health in Kenya

To increase men’s participation in family planning (FP) and reproductive health (RH) both for their own well-being and as gatekeepers to women’s health, the African Population Policy Research Center and the Population Council’s OR/TA Project II launched a study designed to explore best practices for delivering services to men. The study examined men’s knowledge, perceptions, and concerns about RH issues, including FP, and the social context of their knowledge. In sub-Saharan Africa, FP and reproductive health-care research and interventions place a disproportionate emphasis on women and largely ignore the role of men. As a result, male participation in FP and RH has been low. The study’s goals, as detailed in this document, were to collect information on men’s views and perspectives on RH, including FP, in order to expand services to encompass men as FP users and supportive partners. The study looked at men’s perceptions of FP and their knowledge and attitudes about existing and preferred FP and STD services

Building evidence to guide PrEP introduction for adolescent girls and young women

This document was developed by the Population Council, with support from the Bill & Melinda Gates Foundation, to provide DREAMS country teams with practical guidance on building evidence to guide pre-exposure prophylaxis (PrEP) introduction for adolescent girls and young women (AGYW). The primary audiences for this document are health policymakers and program planners who will be making decisions about how PrEP is introduced and the researchers who will assess AGYW’s specific needs and experiences. Our aim is to complement emerging global guidance on PrEP and ongoing work regarding delivery platforms, marketing, and policy and regulatory frameworks for PrEP introduction more generally. We focus on examining the factors that influence informed choice, demand, and use of PREP by young women and that influence client–provider interactions. Further, this document can serve as a useful guide to gather data on user, community, and provider perspectives as countries move from introduction to broad-based implementation of PrEP

Youth talk about sexuality: A participatory assessment of adolescent sexual and reproductive health in Lusaka, Zambia

Thirty-six percent of Zambia’s 9 million inhabitants are between 10 and 19 years of age, and most adolescents are sexually active by their mid-teens. Pregnant teenagers have an elevated risk of maternal mortality and complications related to birth. In 1990, at Lusaka’s University Teaching Hospital, self-induced abortion accounted for up to 30 percent of maternal mortality, and one-quarter of these deaths occurred in women under 18 years. Sexually transmitted infections (STIs) are a major health problem for adolescents, yet only a small proportion protect themselves from pregnancy and STIs. There are many barriers to improving the situation, including opposition by parents and teachers to the use of modern contraceptive methods. CARE Zambia is conducting a study to test community-based strategies that increase knowledge of, demand for, and use of barrier methods to reduce unprotected intercourse among out-of-school adolescents in peri-urban Lusaka. As noted in this report, adolescent behavior change will be measured as the prevalence of barrier method use, number of sexual partners, FP attitudes, and measures of self-esteem and responsibility among participants

Evidence for the importance of community involvement: Implications for initiatives to prevent mother-to-child transmission of HIV

This paper offers lessons learned from a literature review of community involvement in biomedical and other technologies that can guide appropriate and effective introduction of services for prevention of mother-to-child transmission of HIV. A companion paper discusses research in Botswana and Zambia that showed gaps in community knowledge about HIV transmission, particularly from mother to child, and yielded insights into community perspectives about barriers to using voluntary counseling and testing services; stigma and fear associated with HIV; traditional norms on breastfeeding; and the role of family and community members in women’s decisions to participate in programs to prevent mother-to-child transmission of HIV. A separate publication (“Community involvement in the prevention of mother-to-child transmission of HIV: Insights and recommendations”) offers recommendations for community involvement strategies. Placed within the framework of community involvement, an intervention that addresses mother-to-child transmission of HIV offers an enormous opportunity to improve HIV prevention and care. Successful interventions can influence how AIDS is perceived by the community, reduce stigma, and have an effect beyond the immediate prevention of perinatal transmission

Pregnant or positive: Adolescent childbearing and HIV risk in South Africa

In communities where early age of childbearing is common and HIV prevalence is high, adolescent boys and girls may place themselves at risk of HIV to realize their childbearing preferences. In this paper, we analyze survey data from Kwa-Zulu-Natal province that explores whether an association exists between pregnancy preferences and behavioral and perceptual measures of HIV risk among adolescents in South Africa. Our analysis is based on data from 1,426 sexually active respondents aged 14-22 who participated in wave 1 of the “Transitions to Adulthood in the Context of AIDS in South Africa” study. We use logistic regression to model the probability of reporting that pregnancy would be a problem, using measures of HIV risk together with controls for individual and community measures that are also likely to affect pregnancy preferences. We find that educational and employment opportunities affect fertility preferences but also that the HIV pandemic, specifically adults’ perception of HIV risk for the young in the community and peer opinions about HIV risk, affect fertility preferences. Some significant differences by sex emerge concerning the influence of the perceptions of HIV risk. The analysis suggests that although individual and structural factors remain important, for some adolescents-and for girls more than for boys-the danger of HIV infection is becoming part of their calculus of the desirability of pregnancy. For both boys and girls, the unprotected sex required for conception puts them at danger of HIV transmission. For girls, the environment of risk may be particularly influential because the double threat of pregnancy and HIV infection carries an additional risk of HIV transmission to the infant, as well as the possibility of learning one’s serostatus at an antenatal clinic during pregnancy