This article explores recent research on the extent that family planning has been incorporated into HIV services in Malawi and discusses implementation challenges throughout the world.
The HIV epidemic is staggering, and it continues to affect communities all over the world. In 2019, there were 37.9 million people living with HIV worldwide, and 24.5 million people accessing antiretroviral therapy (ART). Present treatment allows people living with HIV to lead long and healthy lives. But getting people on treatment—and keeping them on treatment—remains challenging. In addition, a high number of women, girls, and couples living with HIV have unmet family planning needs, leading to unwanted or mistimed pregnancies. In recent years, the integration of HIV and family planning has become a critical intersection for those working in both fields to get and keep more people on treatment and to address unmet family planning needs.
In 2019, the ECHO trial results found that while injectable contraceptives, IUDs, or implants do not pose a higher risk for acquiring HIV, the incidence of HIV acquisition among women seeking contraceptive services (regardless of the method) was high, and more work needs to be done to integrate both services. That same year, the WHO released updated guidance on contraceptive eligibility for women living with HIV, and hosted a recent webinar training diving into these guidelines in detail.
One of the ways in which integration is implemented is through Provider-Initiated Family Planning (PIFP).
Provider-Initiated Family Planning (PIFP) encourages providers to routinely ask their clients about their reproductive health needs and desires, even if they have come for other health services (such as HIV services).
Many countries have created policies around the integration of services. In 2011, the government in Malawi issued guidelines on this integration for providers and health facilities that require PIFP. Using a variety of methods including facility audits, interviews with providers and clients, and mystery clients, a recent study evaluated the extent that family planning has been incorporated into HIV services among 41 health facilities in Malawi.
The study conducted in Malawi consisted of several key data collection methods that provided a more holistic measurement approach to the integration of family planning in HIV services.
Highlighted below are several significant findings on the extent to which services are integrated including client support, provider training, and supply chain management.
The short answer is no. Policies are important and signal government commitments to addressing key public health areas. Policies on integrated services are now common in many countries around the world. However, integrated services are often implemented unevenly. A study looking at the implementation of integrated HIV and family planning services across ten countries in Sub-Saharan Africa found that implementation is challenging. The median availability of integrated on-site services among countries was low. Most countries had oral contraceptive pills, male condoms, and injectable contraceptives available but most lacked long-acting methods (implants and IUDs). Furthermore, there were relatively few sites that had family planning guidelines and trained staff.
HIV treatment appointments are crucial points of care in which to provide family planning services and ensure that a client is not lost to follow-up. When clients receive HIV services, providing family planning services at the same visit can ensure that clients’ family planning needs are met and prevent unwanted or mistimed pregnancies. In addition, providing family planning services can also ensure that clients are empowered and equipped to prevent mother-to-child transmission of HIV.
Implementing integrated services requires more focus on training providers in PIFP and all family planning methods, quality improvement systems based on monitoring data, and more research on the challenges facing implementation including supply chain management.