preventing hiv and unintended pregnancies: strategic framework in support of the global plan towards...
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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
Page 7
Page 6
Page 6
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.
Page 17
Page 9
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
Page 19
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
Page 36
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
Page 27
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
Page 38
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
Page 52
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
Page 57
• 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
Page 57
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.
Page 60
PeopleLiving With HIVStigma Index
Strategy 5: Eliminate Stigma & Discrimination
Page 62
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.
Page 66
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