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...and to prevent infection among reproductive-age women are being missed, but progress is being made.
In the midst of an unrelenting AIDS epidemic, attention is increasingly being paid to the prevention of HIV infection among the world's most vulnerable individuals: its newborns.
In 2003, an alarming number of new HIV infections--about 700,000--occurred among children, the vast majority of whom were infected by their mothers. Four main approaches to reducing such infections have been promoted by the World Health Organization (WHO) and its United Nations partners. (1)
To date, funding for developing countries has primarily supported an approach of providing voluntary counseling and testing (VCT) for HIV during pregnancy and then short course of antiretroviral (ARV) drug therapy to HIV-infected pregnant women and their newborns. This is to prevent HIV transmission from mother to infant during delivery. Another approach is to provide care and support to women, infants, and families infected and affected by HIV/AIDS. But minimizing HIV-infected births will likely be best achieved through a combination of approaches that includes preventing unintended pregnancies among HIV-infected women (see article, page 22) and preventing HIV infection among reproductive-age women (see article, page 26).2
Pursuing these latter two approaches requires new thinking about how various reproductive health and HIV services can be integrated in settings where women are likely to seek health care. Such integration can contribute to the prevention of mother-to-child transmission (PMTCT) of HIV in several ways:
* Integrating HIV counseling into family planning services helps prevent infection among women of reproductive age. Integrating VCT, as well, helps identify infected women who can then receive targeted family planning counseling and services.
* Integrating family planning services into VCT services and other HIV services helps those women who test positive prevent unintended pregnancy. It also helps those who test negative (but are sexually active, of reproductive age, and at risk of infection) avoid unintended pregnancy.
* Integrating HIV counseling and VCT into antenatal care (ANC) services (the usual site of PMTCT efforts) helps prevent infection among pregnant uninfected women. It can also identify pregnant women who are HIV infected.
Integrating family planning services into ANC can help pregnant infected women avoid yet another at-risk pregnancy. In all of these scenarios, family planning services can play an essential role in achieving PMTCT goals. Yet, employing family planning services to avert HIV-infected births--particularly, offering contraceptive services to infected women--requires more than simply combining services. It involves operational challenges that, as yet, have not been explored in depth. It also requires that providers be trained to understand the special reproductive and contraceptive needs of HIV-infected women. An infected woman's decisions are likely to be shaped by many factors, including her own health and that of her partner and existing children, access to long-term ARV drug therapy, whether she can disclose her HIV status, the possible impact of HIV infection and ARV use on contraceptive method options, and the possible impact of contraceptive method use on her health and infectivity.
However, policy guidelines indicate increasing support for the integration of family planning services to achieve PMTCT goals. More than three-quarters of international guidelines, national HIV/ AIDS policies, and PMTCT and VCT policies reviewed in a recent analysis mention family planning. (3) Three recent analyses suggest that family planning services can both have a marked impact on averting HIV-infected births and be cost-effective (see article, this page). And, in May 2004, some 70 health professionals, representatives from governmental and nongovernmental organizations, and donors met in Glion, Switzerland, to consider the contributions family planning could make to PMTCT. The meeting, supported by WHO, the United Nations Population Fund, the U.S. Agency for International Development (USAID), and private donors, resulted in a "Call to Action" to strengthen linkages between family planning and PMTCT. The declaration acknowledged that all four approaches recommended by WHO and its United Nations partners are necessary to meet PMTCT goals. It also recommended strengthening family planning and PMTCT links through advocacy, policy and program development, resource mobilization, monitoring and evaluation, and research.
Challenges for family planning, ANC providers
In many settings, family planning staff will need additional training, support, and motivation to effectively serve women at risk of HIV infection and women who are already infected. Staff must be prepared to provide HIV prevention counseling for women at risk. And, they are likely to need considerably more training to counsel and serve women whose HIV infection makes reproductive and contraceptive choices far more complex than those for uninfected women (see article, page 22). Staff will need to be able to explain issues related to mother-to-child transmission of HIV. Concerns that working with HIV-infected clients will stigmatize and discredit existing family planning services must be overcome. Training about universal infection-control precautions may be necessary to quell providers' fears of being infected by HIV-infected clients. Concerns that working with HIV-infected women will increase already heavy workloads and might compromise scarce family planning funds must...
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