In June 1981, the U.S. Center for Disease Control (CDC) Morbidity and Mortality Weekly Report described five cases of a lung infection that would later become known as Acquired Immunodeficiency Syndrome (AIDS). More than forty years later, numerous strides have been made to address what would become an epidemic around much of the world, and achievements have been hard won and significant. But as we mark the thirty-fourth World AIDS Day on December 1, 2022, more needs to be done to ensure that HIV is prevented, treated, and eventually eradicated.
Integrated family planning (FP) and HIV services are one of the most crucial ways to improve HIV and AIDS indicators.
FP2030’s webpage on FP and HIV integration outlines the many additional ways in which these two critical health areas intersect.
We spoke to four experts on the intersection of family planning services and HIV prevention and management about the current landscape, development of new technologies, and future considerations for programs. Editor’s note: Some quotes have been edited for length or clarity.
Integrating family planning and HIV services (FP/HIV integration) is widely accepted throughout the world among health professionals working in SRH and among policymakers impacting global and country guidance. Evidence supports integration and advocates have made compelling cases for it. Furthermore, the development of technologies to prevent both HIV and unplanned pregnancy have made considerable progress. Key aspects of FP/HIV integration that are not as advanced include implementation of interventions. Furthermore, changing attitudes and beliefs around integration at the client level has remained challenging in some contexts. Many people do not perceive pregnancy and HIV together when considering risk. There is often more awareness of pregnancy risk but not of HIV risk.
Rose Wilcher, Director, Director of Knowledge Management for HIV Programs, FHI 360: The Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial found high HIV incidence among women seeking family planning services and that outcome really reinvigorated the push toward integrating HIV prevention, including PrEP [pre-exposure prophylaxis], in family planning services. The idea of integrating family planning and HIV services was not a new one. There’s long been advocacy efforts toward integration of SRH and HIV services, and linkages [of] policies and programs more broadly for quite some time. But the ECHO trial result really got us focused on how we can specifically integrate HIV prevention….
That evidence, that rationale is there, and there’s lots of policy support globally and nationally for better integration of family planning and HIV services, specifically for women. [But] in practice, we’re not as far along as we should be given how long we’ve been advocating for this, and given the strength of the evidence base telling us that this is what women want, and it’s what women need and that it’s feasible and it’s acceptable.
Dr. James Kiarie, Head Contraception and Fertility Care Unit, WHO: We’ve made a lot of progress in terms of the technologies, like for dual protection. They may not be on the market already, but we have a lot which are close to market. This research is starting to pay off and soon we’ll see injectables and rings and pills that are dual prevention methods. That part has made some progress. We’ve also made good progress in terms of demonstrating the feasibility of these interventions. We’ve also done quite a good job in convincing policymakers on the need for integrated services. When you look at many national policies, you really see this need for integrated services. The perception of pregnancy and HIV infection risk is something that young girls and young women and the community should think of as one issue that often kind of happens in parallel.
We’ve not adequately changed the attitudes or beliefs in the community regarding those two risks as being something that happens at the same time. Therefore you find a lot of awareness of pregnancy risk because maybe it happens more frequently, but less awareness of HIV infection risk. Also with the service providers themselves who are at the frontline, we’ve not done as good a job to convince them that these are things which should be provided in parallel, at the same time. Many service providers still see themselves primarily as HIV prevention or primarily as family planning providers… and therefore they tend to see this as additional duties which are there when there’s somebody insisting on it, and which tends to be dropped when not under that pressure…There’s a real assumption that integration of services will just be free, that it will not have any bearing on the way you budget…You need to create budgets for integrated services.
Dr. Saumya Ramarao, Senior Associate, Population Council: The positive is that the concept [of HIV and FP/RH integration] has been accepted. We understand that it’s important and there are a lot of [reasons] which have been discussed that it is beneficial to the health consumers and the health system that you’re able to provide multiple services at kind of a one-stop shop. All of that has been done. The challenge has been in implementation. The challenge has been in how you do it right at every place.
Pre-Exposure Prophylaxis (PrEP) refers to the use of drugs taken orally or by injection to prevent HIV transmission and has been around for the last decade (oral PrEP) or the last year (injectable PrEP).
Multiple prevention technologies are methods or products that prevent not only HIV and/or other sexually transmitted infections (STI) but also an unplanned pregnancy. The only one currently available is the condom (both male and female). However, some multiple prevention methods are relatively close to entering the market in the next few years.
The dual prevention pill (DPP) is a pill taken orally every day. It combines two antiretroviral (ARV) drugs to prevent HIV (same as used in oral PrEP) with two contraceptive hormones to prevent pregnancy (same as used in oral contraceptives currently on the market).
Multiple prevention rings are made of a flexible, silicone-like polimer that is inserted into the vagina. They prevent HIV acquisition in various ways, some through ARVs used to treat HIV infection that are also used as HIV prophylaxis and some through naturally occurring algae-derived protein (QGRFT) that inhibits HIV (still in formative research stages). They also prevent pregnancy through various levels and combinations of levonorgestrel, progestin etonogestrel (ETG), and estrogen ethinyl estradiol, contraceptive hormones used in many other contraceptive methods. A ring to only prevent HIV is also in development. Each ring has different lengths of usage (from one month to three months), and only one ring should be inserted into the vagina at once.]
A large body of evidence is generated to develop and prove the safety and efficacy of new products before they enter the market. This occurs both in lab and real world settings, and due to the intensive nature of this research, product development may take decades before a product is considered “ready” to enter the market and be available to everyone who qualifies to use it.
Dr. Saumya Ramarao, Senior Associate, Population Council: You first start off with an idea about what drugs or what hormones could work towards addressing the indication you’re trying to address, in our case pregnancy prevention or HIV prevention or any other STI prevention. That’s the phase where it’s still very early on lab work. Then they’ll go through a period of testing in animals to show yes indeed it works, not just outside, but within a living body. Once it passes that, that’s when it goes into the clinical trial phases and there are three levels of clinical trials…After these three phases are done, then it will go into post-marketing [also known as phase IV trials]. The product is registered and available and you still want to know, with even more thousands and thousands of people, what happens in real life. What’s really happening? Is it still as effective, are people using the product as intended or what are the real life hurdles to use.
Regulatory bodies such as the WHO and in-country agencies are involved to ensure guidance is provided and the product is included in key policies such as essential medicines lists and in state budgets. Enabling environments that facilitate smooth product introduction consider aspects related to service delivery counseling and generating demand among potential users. Previous FP/HIV integration programs can provide important best practices and key considerations to address real world constraints and challenges. For example, a project in Kenya that introduced PrEP into existing family planning services in three clinics worked with key stakeholders to design and implement the program, and utilized a core implementation team to innovatively address challenges such as high staff turnover and ensuring clients are retained throughout the referral process.
Rose Wilcher, Director of Knowledge Management for HIV Programs, FHI 360: …[W]e took a quality improvement [QI] approach to integrating oral PrEP in three clinics [in Kenya]. What we did was we actually brought people together from the Kenyan Ministry of Health at the National Level, at the county level in Nairobi, at the sub-county level where the three facilities were based, and from the facilities themselves. We had really meaningful stakeholder engagement at the outset to say ‘this is what we’re hoping to do. We really want to strengthen the integration of oral PrEP delivery in family planning services to better meet the dual needs of adolescent girls and young women [to prevent unwanted pregancy and HIV transmission] in Nairobi County… The feeling was, if the family planning provider can begin the conversation with her clients about PrEP, do some initial screening about their risk of HIV and about their eligibility for PrEP, and if the client was interested then refer them, within the facility, to HIV testing and further PrEP assessment, and then to actually obtain PrEP from the HIV provider within the facility, that that model would really work best for them.
Rose Wilcher, Director of Knowledge Management for HIV Programs, FHI 360: [When we think about creating an enabling environment for PrEP product introduction], we talk a lot about the product introduction pathway. And that requires planning and coordination and preparing for implementation on multiple fronts—on the policy and planning front, supporting ministries of health to develop national strategies, national implementation plans for product introduction, getting the new product integrated into existing national strategies and plans. It’s working with existing supply chain mechanisms and preparing the market for the new product by conducting analysis to understand what the demand for the product might be. Looking at various opportunities within the market, beyond the government supported facilities, but perhaps through the private sector where the product might be able to be introduced. It’s preparing the service delivery environment to integrate the new product. That means building the capacity of providers to counsel on the new product and to integrate it into the existing service delivery infrastructure. It’s about generating demand for the new product, raising awareness in the community among both potential users and their influencers and other community members and [avoiding stigmatization of the product]…
One of the things that [the] MOSAIC [project] is charged with doing is really building and strengthening the collaborations across the ecosystem…but it’s a lot of moving parts.
Dr. Tafadzwa Chakare, Technical Director, Jhpiego/Lesotho: Once WHO has made a recommendation [for a new PrEP product], countries with resource limitations like Lesotho then consider if they think they’re ready for the product depending on their epidemic. WHO prequalifies. From there it’s pretty straightforward and the next step is to have the Ministry of Health have that product included on its essential medicines list, included in all technical guidelines. The final point is to have Ministries of Health procuring the drug for themselves, and having it on the shelf. That is one of the more difficult ones, because now you have to wait for the next national budget. But if you’re lucky, that’s where donor funding may come in. There’s more flexibility on that end. The advocacy process usually includes a question of efficacy…
Dr. Saumya Ramarao, Senior Associate, Population Council: We have a lot of experience with introducing contraceptives. Many, many contraceptives have come on to the market, and we have over 40-50 years of experience with that. What we could do with that experience is leverage it for all sets of new products that are coming in the HIV field, and especially for those that are for both FP and HIV [prevention]… There’s no need for confusion, but we have to prepare for that eventuality. As it is, if you just look at oral contraception, some people say there are so many brands of oral contraception. There’s a tendency for not knowing what’s a brand and what’s a product category.
A second thing is vaginal rings. There are contraceptive vaginal rings, and now there’s the dapivirine ring, which is an HIV prevention ring, and then there’s probably in the future, let’s hope there’s an MPT [multiple prevention technologies] ring. People have to start understanding a ring doesn’t only mean one thing. A ring can be multiple things. A ring is only a drug delivery system. You can put different drugs into it for different reasons. Just like we take pills. We take vitamin pills, we take Tylenol, we take Tums, they’re all pills. But we know what the difference is. That kind of understanding should be more broad-based especially when the drug delivery format becomes different.
The third piece that is important would be to understand how the counseling process works, especially if some of these products are meant to be self-use products to give more autonomy to the individual user, especially women and adolescents. If they want to use these products discreetly without the knowledge of a partner, what type of counseling would you provide such that she knows how to talk about the product that she’s using if she were found out? One of the rationales for work on DPP and other MPTs is that colleagues have noted that it’s easier for a woman to use a contraceptive than be seen as taking an HIV prevention or treatment product alone. If you can combine both into an MPT then she can say, ‘oh this is a contraceptive.’ She need not talk about the HIV prevention piece of it at all. That’s why some of these MPTs have been developed to not only give her autonomy and power over her own sexual and reproductive health but also to…[protect] her privacy and [give] her a little bit of cover.”