** **

**FAMILY PLANNING/HIV INTEGRATION**

**TECHNICAL GUIDANCE FOR USAID-SUPPORTED FIELD PROGRAMS**

This guidance is an update of USAID\'s *Integration of Family
Planning/MCH with HIV/STD Prevention: Programmatic Technical Guidance*,
1998. The previous guidance focused on limitations and appropriate use
of syndromic management of STIs, counseling approaches for behavior
change and reaching men as a key population for both pregnancy and HIV
prevention.  This guidance builds on those issues and is expanded to
include new evidence about effective integration of family planning into
HIV programs and HIV counseling and services into family planning
programs.  Intended for USAID field officers, cooperating agencies and
other partners, the guidance is a technical tool to help program
managers make sound choices in integrating HIV/AIDS and family planning
programs.  It does not address issues concerning earmarks and use of
funds that are fully outlined in the *Guidance on the Definition and Use
of the Child Survival and Health Programs Fund*, *FY 2002 Update*. 

It is important to note that FP/HIV integration is an area of thinking
in which the evidence base is rapidly growing.[^1]  However, important
knowledge gaps remain that need to be addressed. Thus, this guidance
will be periodically reviewed and updated as new evidence emerges. The
process for developing these guidelines was undertaken in collaboration
with USAID/Washington, field missions and other donors and partners with
the intention that the concepts expressed will be broadly supported by
UNAIDS, WHO and other multilateral and bilateral donors.

**GUIDING PRINCIPLES**

**Synergy (1+1 = 3). ** The central tenant of this guidance is to
emphasize approaches which are most likely to have a broad health impact
and to increase the efficiency and effectiveness of prevention. The
guidance does not preclude the need for separate programs and
interventions, but rather, in appropriate settings, aims to assure there
are no missed good (value added) opportunities for HIV prevention and
family planning promotion.[^2]  

**Evidence-based. ** Recognizing that development work is
situation-specific, we draw on the best current programmatic evidence to
determine priority interventions. For example, emerging epidemiological
evidence suggests that a multi-pronged, behavior change approach
(Abstain, Be faithful/partner reduction and/or use a Condom - ABC) is
more effective for HIV prevention than condom promotion alone.[^3] A
multi-pronged behavior change approach is more effective in generalized
epidemics and especially for young people. All three of these behavior
change messages have potential applications to pregnancy prevention
programs as well.

**Program for impact within each country situation. ** This guidance
underscores that \"one size does not fit all\" and there is an important
need to use data to identify the areas where integrating FP and HIV
programs and interventions makes the most sense. USAID Missions and
other partners will need to consider the specifics of their country
situations to help determine whether vertical or integrated approaches
will have greater impact. Issues of cost and sustainability are other
factors that are important to identify the most effective program
approaches. Other considerations include but may not be limited to:

-   *What is the epidemiology of HIV?*  Is the epidemic *low level* (HIV
    prevalence has not consistently exceeded five percent in any defined
    at-risk sub-population); *concentrated* (HIV prevalence consistently
    over five percent in at least one defined sub-population but below
    one percent in pregnant women nationwide); or *generalized* (HIV
    prevalence consistently over one percent in pregnant women
    nationwide)?[^4] If the epidemic is still confined to high-risk
    groups, targeted HIV programming will have more impact.  For example
    in Cambodia, where the epidemic has been largely fueled by sex work,
    interventions focused on decreasing visits to commercial sex worker
    (CSW) and promoting condom use in brothels, have been successful in
    reducing the spread of HIV.[^5]  In this context, investments to
    integrate HIV activities, such as treatment of sexually transmitted
    diseases, in family planning venues did not make sense.  On the
    other hand, there may have been opportunities to consider
    integrating some family planning concepts into HIV activities, for
    example in counseling sex workers. When considering the status of
    the HIV epidemic relative to FP integration, it is important to
    understand that the epidemic is not static and, over time, evolves,
    affecting different populations. 

-   *How mature is the family planning program?* How significant and
    where is the unmet need for contraception? In Mali HIV prevalence in
    the general population is 1.7%, while total fertility is 7.0 and
    modern method contraceptive use is very low at 5%.[^6] Here the need
    for basic family planning services for the general population
    remains critical. Thus, strengthening family planning programs
    should be the priority intervention. The greatest impact on the
    spread of the HIV epidemic would be achieved through interventions
    targeted towards core transmitters and groups who move between core
    transmitters and the general population, such as married men who
    visit commercial sex workers.

-   *What is the interplay between HIV and FP programs, and does the
    overall program environment support or hinder integration?* For
    example, in Zimbabwe, where HIV prevalence is very high and the
    existing family planning infrastructure is strong, there are
    valuable opportunities for integration.  A model is currently being
    tested in Zimbabwe using family planning community based
    distribution (CBD) agents to provide HIV information and referral to
    HIV voluntary counseling and testing.[^7]  

-   *Does the family planning program address the needs of high risk
    populations such as sex workers, transient and mobile populations
    and intravenous drug users (IDUs)?*  In general, these populations
    are not reached by pregnancy prevention programs, yet may have
    family planning needs.  HIV prevention and mitigation activities
    with these populations may offer opportunities for integration with
    family planning.

**Reaching the \"Tipping Point\".** A key concept in behavior change on
a large scale can be referred to as the \"Tipping Point,\"[^8] in which
a diverse array of interventions collectively cause overall social norms
to shift.  Thus it appears that success in HIV prevention in Uganda
resulted from many forces working together which induced a large shift
in behavioral norms.  These included: frequent presidential
pronouncements about HIV prevention, involvement of faith based
organizations (FBOs) and other non-governmental organizations (NGOs),
basic care and support programs for people living with HIV/AIDS,
increased condom use with non-regular sexual partners, delay in age of
first sex, reduction in the number of sexual partners and access to VCT
services.  Any single one of these forces in isolation may not have had
as much of an effect as the multiple reinforcing messages using multiple
channels. Although HIV prevalence has declined significantly in Uganda,
its fertility rate is still among the highest in the world.  Clearly
this could create opportunities to use HIV/AIDS programs to enhance
family planning programs and prevent unwanted pregnancies.  

 

**KEY TECHNICAL APPROACHES CONDUCIVE TO FP/HIV INTEGRATION**

**(not necessarily in order of priority)**

***1.  ABC (ABSTAIN, BE FAITHFUL, USE A CONDOM)***

The three key behavior change messages that are at the core of
successful HIV prevention efforts, \"Abstain, Be Faithful or Use a
Condom\" are also relevant to family planning needs and practices. 
\"Abstinence\" and/or delaying the age of sexual debut can reduce
HIV/STI transmission and help prevent unintended pregnancies among
unmarried people. Declines in HIV prevalence in Uganda can be linked in
part to dramatic increases in the number of 15 - 19 year olds who report
never having had sex; by the 2001 Demographic and Health Survey (DHS),
this included 61% of males and 48% of females.[^9] Moreover, an increase
in contraceptive use coupled with a delay in sexual debut contributes
significantly to smaller, healthier families.  Interventions to delay
sexual debut provide common ground with non-clinical health partners,
such as schools and faith-based organizations.  Postpartum abstinence,
which is widely practiced in Africa, can also have a protective effect
in reducing risk of an additional pregnancy, but may increase the risk
for HIV/STIs if the male partner is not faithful during the postpartum
period.

Being faithful through mutual monogamy or partner reduction is also
important to AIDS prevention.  According to epidemiological data and
modeling, a reduction in the average number of partners, including
\"concurrent\" (which includes visits to commercial sex workers) as well
as "sequential" partners is crucial to contain the spread of any STIs
including HIV.  In Uganda for example, approximately 30% of respondents
in a 1989 Global Programme on AIDS (GPA) survey reported having casual
sex during the previous year; by 1995, this had decreased to about
10%.[^10]^0^ Even for monogamous couples there is need for delaying,
spacing or limiting births especially considering the known health
benefits to women and children. Mutual monogamy coupled with use of a
family planning method can be an effective form of dual protection for
preventing HIV and unintended pregnancy.

Condoms, if used correctly and consistently, are pivotal to prevention
of HIV, some STIs and pregnancy.[^11]^1^ Consistent condom use is
generally greater with non-primary sexual partners as opposed to typical
family planning clients.  In countries with low level or concentrated
HIV/AIDS epidemics, condom promotion in family planning clinics may not
be the most effective HIV prevention approach.  However, particularly in
high-prevalence, generalized epidemics, family planning clinics and
community based FP services may offer important venues for condom
promotion and other HIV prevention activities. 

Another behavior associated with increased HIV transmission is drug
use.  The transmission of HIV among injecting drug users is important,
particularly in Eastern Europe and parts of Asia and Latin
America, where IDUs play a significant role in the spread of the
epidemic. There is also evidence that recreational use of other drugs,
including alcohol, reduces inhibitions and makes unsafe sex more
probable.  IDUs, recreational drug users and their partners are also at
risk for unwanted pregnancy.  Program efforts targeted towards
recreational drug users and IDUs, including behavior change messages,
can also provide opportunities to incorporate important pregnancy
prevention information.  USAID is developing guidelines specifically to
address HIV prevention strategies for IDUs.

**PREVENTION IS CENTRAL. * \"***ABC\" behavior change messages should be
a priority area for investment.  Clearly \"A\" and \"C\" can have an
impact on preventing both HIV and unintended pregnancy. The data
increasingly demonstrates that \"B\" contributes to reduction of HIV
prevalence; however the implications for fertility are much more
complex. For example, monogamous couples who use family planning have
dual protection against HIV and unwanted pregnancy.  For family planning
managers, a key message is that successful prevention programs require
activities beyond the clinic setting.  Services provided in family
planning or maternal and child health care (FP/MCH) clinics often only
make a small contribution to the behavior change that is all important
for HIV prevention.  Thus while ensuring that basic HIV prevention
information is provided within clinics, priority should be given to
activities beyond those settings, such as mass and community
communication, social marketing, community-based distribution (CBD),
policy development, activities targeted to youth and specific outreach
to men.  

**SOCIAL MARKETING,** typically used to promote products, can be
expanded to \"sell\" healthy behaviors, such as abstinence/delay of
sexual debut and fidelity, as well as values such as small family size
and gender equity. The concept of marketing healthy lifestyle decisions,
linked to product promotion, has been implemented in several programs. 
In Zambia, the Helping Each Other Act Responsibly Together (HEART)
campaign, developed by youth and for youth, promotes abstinence by
encouraging young people to make healthy lifestyle decisions such as
staying in school, and promotes condoms for adolescents who are sexually
active.[^12]^2^

**DUAL PROTECTION** is not just using a male or female condom to reduce
the risk of both pregnancy and HIV/STIs. It can also include any one of
the following actions:

-   Condom use along with another effective family planning
    method (\"dual use\") 

-   Mutual monogamy with an uninfected partner and use of an effective
    family planning method

-   Abstinence and/or delay of sexual debut

In all family planning and HIV programs, clients need counseling to help
understand their risk of both unintended pregnancy and HIV/STIs in order
to make choices that suit their individual circumstances. Condoms should
be widely available and both men and women should be counseled that
consistent and correct use is needed in order to achieve the benefits of
condoms preventing HIV and pregnancy.  At the same time, it is important
to recognize that, particularly in terms of HIV prevention, condoms are
most frequently used with non-regular partners and that increasing
consistent and correct condom use to very high levels may be an
unrealistic behavior change outcome within the general population. Thus,
promotion of condoms needs to be balanced with both \"A\" and \"B\"
messages as well as access to a variety of effective family planning
methods.  

[ CAVEATS/AREAS FOR FURTHER RESEARCH]{.underline}:

-   It is important to pre-test message content and to include
    evaluation to specifically understand the cultural context in which
    behavior change messages are being developed in order to assure
    their appropriateness and relevance.

-   What are the effects of \"mixing\" messages to include benefits of
    both FP and HIV prevention? Does a mixed approach detract or dilute
    either the promotion of family planning or HIV prevention?  

-   More information is needed to help identify ways to effectively
    translate condom promotion into correct and consistent use,
    including addressing provider bias. 

-   Gender considerations are central to any behavior change strategy
    and must be incorporated into evaluations of these interventions.

 

***2. INTEGRATED INTERVENTIONS SHOULD BE TARGETED TO YOUTH***

The largest youth generation in history is entering their childbearing
years and about half of all new HIV infections in women occur among
those aged 15-24.  The common ground for preventing HIV and pregnancy in
young people is decreasing their risk of exposure to unprotected sex.
Tools to enhance communication and negotiation skills can lead to
informed and responsible choices among youth. Increasing age at first
sex, reducing the number of sexual partners, improving access to family
planning and condom use have tremendous potential to alter disease
transmission and avoid unintended pregnancy.  It is possible to
influence youth to change sexual behavior in positive ways as evident by
successes achieved with this age group in Uganda and Zambia.  In Uganda,
there has been a decline in HIV prevalence among youth, which in part
can be attributed to an increase in the age of first sex. In addition,
empowerment of young females and women was a key component of the HIV
prevention success in Uganda, which may have improved their ability to
abstain from sex or negotiate condom use.[^13]^3^ Nonetheless, fertility
levels remain very high in Uganda.  In Lusaka, Zambia,
there also appears to have been a decline in HIV prevalence among
youth during the 1990s, mainly due to a significant reduction in the
number of partners, and recent national survey data indicates that
contraceptive prevalence rate (CPR) is rising significantly in Zambia. 

**THE KEY TO SUCCESSFUL BEHAVIOR CHANGE IN YOUTH APPEARS TO BE A
MULTI-PRONGED APPROACH,** recognizing that youth are a diverse group and
that many factors influence young people\'s behaviors.  A variety of
program approaches have had some modest success, or appear promising, in
enhancing young people's knowledge, attitudes, perceptions and skills
relating to HIV and pregnancy prevention.  However, experience suggests
that multiple linked interventions may be the most effective in bringing
about behavior change in youth.   At a minimum, programs need to address
community norms and personal knowledge and skills, as well as increase
access to services.  Ideally, behavior change messages should be
reinforced through multiple channels. Some examples of these programs
include:

-   School and other curriculum-based programs that incorporate best
    practices in education and life skills

-   Certain mass media campaigns targeted to youth where messages are
    reinforced through various communication channels

-   Community level outreach through youth serving organizations and
    youth development organizations, including faith-based organization
    (FBOs).

-   Work place programs[^14]^4^

**\"YOUTH-FRIENDLY\"SERVICES MAY REDUCE BARRIERS TO ACCESS** and
increase quality and use of family planning and HIV services. However,
results have been mixed, reflecting the fact that clinics often fail to
attract unmarried young people for reproductive health information and
services. In some cases, networks of service facilities have been
\"branded\" as youth friendly with some success, which can seen in
Western Europe and to some extent in programs such as Mexfam in Mexico,
Profamilia in Columbia and the private Ghana Midwives Association. 
Non-clinic based and private sector services, including social marketing
of condoms, contraceptives and other behavior change messages, may be
better suited to meeting the needs of many young people.

[CAVEATS/AREAS FOR FURTHER RESEARCH:]{.underline} 

-   Many existing programs tend to reach older youth, in many cases
    after sexual debut.  What are the best approaches for reaching
    younger age groups before they are sexually active?

-   What are effective and affordable approaches to provide FP and
    HIV/STI services to youth?  What elements are essential to
    successful peer education programs?

-   What role do cultural or community norms play in order in supporting
    behavior change, such as delaying of sex and reducing
    cross-generational sex? Are there cultural norms that could support
    the desired behavior change?

***3.  FAMILY PLANNING AND PREVENTION OF MOTHER TO CHILD TRANSMISSION
(PMTCT)***

The World Health Organization (WHO) framework to prevent mother to child
transmission of HIV highlights the centrality of family planning.  The
three pronged framework includes: 1) primary prevention of HIV in young
women, 2) avoidance of unintended pregnancies among HIV-infected women
and 3) provision of ARVs targeted at preventing HIV transmission to
HIV-infected women and their infants, safe delivery, counseling and
support for safer infant-feeding practices. HIV-positive mothers should
have access to quality information and services in order to make their
own decisions regarding future pregnancies and family planning methods.

**WOMEN SHOULD HAVE ACCESS TO PRE-NATAL CARE BASED ON CURRENT WORLD
HEALTH ORGANIZATION EVIDENCE-BASED RECOMMENDATIONS. ** In both
concentrated and generalized epidemics the PMTCT package of services
during prenatal care should also include promoting VCT, counseling for
HIV-positive and negative women about the benefits of family planning
and birth spacing, availability of ARVs for reducing mother to child
transmission, counseling on infant feeding options, and screening and
treatment for syphilis. PMTCT services should help to increase access to
fixed facilities where women can deliver with a skilled provider and
receive the full package of services needed to reduce mother to child
transmission and promote safe birth practices.

**FAMILY PLANNING COUNSELING AND SERVICES DURING THE POST-PARTUM
PERIOD** are critical for both HIV-positive and negative women.  In some
countries there is an increased risk for HIV exposure after childbirth
due to practices of postpartum abstinence concurrent with partner
infidelity. While condoms are central to prevent HIV transmission and
unintended pregnancy, especially among sero-discordant couples,
longer-term methods still play a vitally important role for women
regardless of their HIV status. All contraceptive methods can be
appropriate for HIV positive women (including the IUD, based on
FHI-supported research) and should be provided based on the women's
choice.

**BREASTFEEDING.** The benefits of exclusive breastfeeding to child
health and its contribution to child spacing are well documented. 
However, the risks associated with breastfeeding and HIV transmission
from mother to infant are also well understood. Due to the sensitivity
around this issue, the range (or lack of) infant feeding options in
different settings and the changing evidence, program managers should
refer to USAID's Breastfeeding Promotion Policy (ADS chapter
212).[^15]^5^ All HIV-infected mothers should receive infant feeding
counseling, including general information about the risks and benefits
of various infant feeding options, and specific guidance in selecting
the option most likely to be suitable for their situation.

[CAVEATS/AREAS FOR FURTHER RESEARCH**: **]{.underline}** **

-   A considerable number of HIV-positive pregnant women who receive
    pregnancy related services and/or VCT may never receive appropriate
    counseling or may be lost to follow-up.  Evidence from selected
    Elizabeth Glaser Pediatric AIDS Foundation MTCT Call to Action sites
    indicates that almost 50% of pregnant HIV positive women and their
    newborns who should have received both Nevirapine and other services
    including family planning were lost to follow-up.[^16]^6^   Further
    research is needed to reduce these losses. Community-based
    approaches may be promising.

-   Further research is needed on the safety and efficacy of exclusive
    breastfeeding and program models for alternatives if required.

***4.  VOLUNTARY COUNSELING AND TESTING AND FAMILY PLANNING*:**

Unprotected sex may lead to unintended pregnancies, sexually transmitted
infections and HIV infection. During HIV VCT, the counselor explores the
client\'s personal risk behaviors and then engages the client in a
discussion about realistic and reasonable approaches to reducing HIV
risk. In addition, the counselor refers the client to care and support
options, guided by the client\'s serostatus and related needs. Family
planning is a critical component of the continuum of care and support
for VCT clients, regardless of their serostatus. The client-provider
interaction during a VCT session can provide an opportunity to
incorporate family planning messages and contraceptive counseling guided
by the needs and readiness of the client. During VCT, the importance of
pregnancy prevention and its role in the prevention of MTCT as well as
the benefits of birth spacing can be discussed with both HIV positive
and HIV negative clients. When family planning counseling is provided
during VCT, counselors need to address a range of options in accordance
with Tiarht[^17].

**IF FAMILY PLANNING SERVICES ARE NOT AVAILABLE IN VCT SETTINGS, FAMILY
PLANNING SERVICE OR REFERRALS SHOULD BE AVAILABLE**.  Family planning
sites, particularity in generalized epidemics, should provide HIV
prevention counseling and referral for VCT.  Evidence for effective
contraceptive counseling in VCT and VCT provision in family planning
settings remains limited and further research is needed.

**COUPLE AND PREMARITAL VCT MAY BE AN IDEAL OPPORTUNITY** to assist both
concordant and discordant couples to develop personalized plans
regarding family planning and HIV prevention. A key lesson learned from
family planning programs includes the need to engage men in reproductive
decision-making.  Assessing the need for family planning should be an
integral part of the counseling process for all couples. While
counseling couples during pre-test VCT may provide an ideal opportunity
to discuss family planning, as with any HIV counseling, there are
challenges and risks associated with counseling couples, such as coping
with a new HIV diagnosis, potential for domestic violence and/or
exclusion from family, especially for HIV-positive women in
sero-discordant couples.[^18]^7^

 

[CAVEATS/AREAS FOR FURTHER RESEARCH:]{.underline}   

-   There is considerable concern about over-burdening already stretched
    VCT centers and FP clinics with additional services.  Studies are
    underway to examine the most efficient and effective approaches to
    such integration and linkages.

-   Information is needed to determine whether integrating these
    services increases the adoption of family planning or the uptake of
    VCT.  Efficacy and cost effectiveness studies are needed.

-   Questions remain regarding the best time to provide contraceptive
    counseling during VCT, how integrated vs. stand alone VCT sites
    differ in terms of FP provision and how family planning clinics can
    best refer or provide VCT. 

-   Research on the most effective approach for counseling couples is
    needed.

-   Risk for HIV infection is not spread evenly across populations.
    Therefore when choosing to introduce VCT into family planning
    settings, it is important to assess the HIV risk of the specific
    population of those clinics.

 

***5.  STIs ARE IMPORTANT BUT\...\...***

STIs are an important co-factor in the transmission of HIV and can also
influence fertility.  The introduction of STI screening into family
planning settings, often using a syndromic approach, has been a major
area of program intervention. For a number of reasons, however, the
results have been unimpressive and sometimes even deleterious.  STI
diagnosis and treatment are often introduced without data on prevalence
and types of STIs, resulting in the introduction of services in
populations with low incidence and prevalence.  In addition, syndromic
management of vaginal discharge is not technically sound for the
diagnosis of cervical STIs - gonorrhea (GC) and chlamydia (CT).
Unfortunately, there are currently no viable diagnostics for detecting
these STIs among women in most developing countries. Syndromic
management can be a very useful approach to detect genital ulcers and
urethral discharge in men. All counseling and services related to STIs
should also include information about HIV and unintended pregnancy and
clients should have access to condoms.

**INFORMATION ABOUT STI PREVALENCE IS A CRITICAL INVESTMENT** for both
HIV and family planning program managers and an essential step before
considering major program interventions.  Required information includes
knowledge of the types of STIs, their prevalence in various populations
and information on drug availability and anti-microbial resistance. 

**IN CONTRAST TO SYNDROMIC MANAGEMENT OF VAGINAL DISCHARGE (SMVD), OTHER
FORMS OF SYNDROMIC MANAGEMENT APPEAR EFFECTIVE. ** This is particularly
true for genital ulcers and urethral infections in men. Some countries
have adopted approaches to address this issue through private sector
pharmacies. Where appropriate, family planning providers should include
syndromic management of genital ulcers and services for men and assure
access to condoms for clients and their partners.  In addition, HIV
outreach services and VCT sites should also make referrals for STI
treatment if genital ulcers or urethral discharge is identified.

**SYNDROMIC MANAGEMENT OF VAGINAL DISCHARGE IS NOT EFFECTIVE FOR
GONORRHEA OR CHLAMYDIA (GC/CT)** in women in general service delivery
settings.  Vaginal discharge is indicative of vaginitis and is generally
responsive to treatment.  In particular, Metronidazole may provide
relief to women with uncomfortable discharge.  This medication is
generally cheap, widely available and can be used against both bacterial
vaginosis (BV) and trichomoniasis.  Despite the disadvantage that there
may be little lasting effect, especially if all male partners are not
treated, this treatment should provide relief of symptoms and, as such,
be perceived as a quality service.

**THE LOGISTICS AND COSTS OF DRUGS ARE A BARRIER TO EFFECTIVE STI
DIAGNOSIS AND TREATMENT PROGRAMS** and must be considered up front by
program managers.  Although USAID funds can be used to procure STI drugs
and reagents, these investments should be considered in light of other
funding priorities. Prior to launching an STI initiative, information
about prevalence and patterns of drug resistance are critical and
mandatory planning components.

[CAVEATS/AREAS FOR FURTHER RESEARCH]{.underline}: 

-   Better and less expensive diagnostic tests are needed to diagnose
    cervical infections and vaginal discharges in women.

-   Partner treatment is essential to prevent immediate reinfection.

-   Promising research is currently underway to identify microbicides
    that may be effective alone or in combination with female barrier
    methods in preventing transmission of HIV/STIs and pregnancy.

-   More data are needed on the clinical and public health impact of
    social marketing antibiotics for treating genital ulcers and
    urethral discharge in men through STI kits before such marketing is
    expanded.

 

***6.  POLICIES BUILT ON CULTURAL VALUES CONTRIBUTE TO CHANGING SOCIAL
NORMS AND PROMOTING HEALTH BEHAVIORS***

Experience has demonstrated the powerful contribution of policy changes
in reaching the \"tipping point\" and achieving success in both HIV and
family planning programs.  In Uganda, President Museveni promoted the
concept of \"z*ero grazing\"* referring to monogamous relationships. 
The contribution of his open discussion and support is

widely recognized.  Despite Uganda\'s success in HIV reduction, women on
average have seven pregnancies during their reproductive years, with
significant negative consequences to themselves and their infants.
Recently contraceptive prevalence is starting to show increases, and it
is hoped that the remarkable policy level success Uganda experienced in
HIV prevention will be translated into this arena as well.[^19]^8^

**ESPECIALLY FOR YOUTH, A SUPPORTIVE POLICY ENVIRONMENT IS NEEDED** to
assure access to quality and appropriate information, support and
services for HIV and pregnancy prevention.

**FUNDING AND PRIORITY SHIFTS CAN AFFECT FAMILY PLANNING PROGRAMS** as
limited host country health resources, particularly in high prevalence
countries, are fully engaged in combating the epidemic.  The analysis of
family planning trends in Africa provides solid evidence of the
diminished priority assigned to family planning and pregnancy
prevention.^19^ In addition, in places where mortality from HIV or other
causes is particularly high, a pronatalist stance may also result. It is
important to consider the promotion of birth spacing as a means to
saving many lives. This is particularly critical in the context of AIDS
in order to ensure that every child be born as healthy as possible.

**BIRTH SPACING IS IMPORTANT IN REDUCING MATERNAL AND CHILD MORTALITY
EVEN IN HIGH AIDS PREVALENCE SETTINGS**. For countries with high
fertility and HIV/AIDS prevalence above 1% in general populations, the
overall well being of families can be promoted through HIV and pregnancy
prevention. In these environments, information concerning the positive
effects of increasing birth intervals on maternal, infant and child
mortality can be an important tool for policy dialogue. Evidence shows
that even in countries with high HIV prevalence, there is still a
significant unmet need for family planning.[^20]^0^

[CAVEATS/AREAS FOR FURTHER RESEARCH:]{.underline}   

-   What are the cultural values to promote changed social norms or
    health behaviors that reinforce both the prevention of HIV and
    family planning?

-   What role do community leaders play in reinforcing behavior change
    approaches that support both the prevention of HIV and prevention of
    unintended pregnancy?

-   How do integrated policies (for both FP and HIV) effect program
    implementation?

***7.  COMMUNITY-BASED APPROACHES ARE CENTRAL TO SUCCESS***

Working with community organizations, including faith-based
organizations (FBOs), is important to reinforce behaviors to prevent
both unintended pregnancies and HIV/STIs, and to facilitate access to
services.  Community-based programs provide a key opportunity to change
social norms relating to issues such as stigma, ideal family size and
the empowerment of women and youth.  In addition many community and
faith-based organizations are important service providers.

**COMMUNITY BASED DISTRIBUITION (CBD) PROGRAMS CAN SOMETIMES EFFECTIVELY
INTEGRATE HIV PREVENTION INFORMATION*.***  In higher HIV prevalence
communities they can also provide referrals and links to VCT services
through their community outreach efforts.  The Zimbabwe national family
planning CBD program, which has a long history of being an effective
program, is currently working to scale up this type of integrated
approach, nationwide. 

**FAITH BASED ORGANIZATIONS (FBOs) CAN AND DO PLAY A CRITICAL ROLE IN
MANY COUNTRIES** and have a tremendous influence over the lives and
decisions of community members.  In many instances FBOs deliver health
services, including family planning.  While, some FBOs may not promote
condoms or other forms of contraception, they can nonetheless play an
important role in encouraging different aspects of behavior change, such
as delay of sexual debut, partner reduction and use of natural family
planning such as lactational amenorrhea method (LAM) or the standard
days method (SDM).  In these cases, programs should ensure that clients
have access to information about all forms of prevention, including
condoms and other contraceptive methods through alternative channels. 
The effects of positive engagement by FBOs can be seen in countries such
as Uganda, Indonesia and Senegal.

**FAMILY PLANNING INFORMATION CAN BE INTEGRATED INTO COMMUNITY SERVICES
RELATED TO HOME-BASED CARE.  ** Home-based care agents in Kenya have
received FP/RH training and are able to provide these services within
the home to both HIV-infected persons and other household members. While
the need for family planning may be slight when individuals are sick, if
they begin to feel better after receiving care services they may become
sexually active. Caregivers, who are frequently adolescent females, may
also benefit from information concerning family planning. Information
about family planning may also be welcome among those individuals
concerned about orphans or engaged in orphan care.

[CAVEATS/AREAS FOR FURTHER RESEARCH:]{.underline}   

-   What are the costs and potential sustainability of FP and HIV
    programs implemented through CBOs and FBOs?

-   What is the capacity of CBD agents to effectively integrate HIV
    services into their existing programs?  What is the appropriate
    level of skills training needed to enhance their work in both HIV
    and unintended pregnancy prevention?

-   What is the best strategy to engage FBOs in family planning and HIV
    programs?

***8.  COMMODITIES AND LOGISTICS SYSTEMS***

Strengthening logistics systems is important to assure the success of
any program for requiring a product.  In the past, USAID has primarily
supported vertical logistics systems for family planning commodities. 
There are drawbacks to using parallel logistic systems, such as a
country\'s capacity to handle procurement of drugs and reagents. In some
cases, this has presented constraints for condom procurement and
distribution systems, as managers work to make the product available for
both family planning and HIV programs.  In addition, because of the long
history of USAID population assistance, the strongest logistics managers
in national health systems are often associated with the family planning
programs.  This can also present an opportunity as strong logistics
systems can be built upon to improve access for newer HIV commodities,
particularly if the program is functioning in or moving towards a truly
integrated system.  Where systems are weak, commodity needs of both
programs should be a priority.  A major effort needs to be made to
prevent commodity stock-outs and consider the effects of health care
reform and attempts to integrate vertical systems.  Given these
complexities, the pros and cons of dual commodity systems should be
analyzed prior to fully integrating systems.

**WITHOUT A PRODUCT YOU MAY NOT HAVE A PROGRAM**. Managers need to
consider both programs when undertaking projections for procurement and
distribution of condoms and other family planning methods**. ** In
addition there are burgeoning needs related to commodities and drugs for
HIV programs, for example for VCT.  In some environments, existing FP
commodity procurement and distribution infrastructure may be effectively
used for these products.    

***9.  PROMISING AREAS FOR THE FUTURE***

***Services offering male circumcision:***  The evidence is increasingly
compelling that male circumcision may reduce the risk for men of
acquiring HIV by 60% or more.[^21]^1^ As a consequence, it
is reported that uncircumcised men are beginning to seek out this
reproductive health service. Circumcision services could offer a
promising opportunity for programs to increase male involvement and
integrate broader messages about positive reproductive health behavior,
including those related to family planning and gender equity. Pilot
programs are needed to test this hypothesis and to continue to study
other issues related to circumcision, such as safety, behavioral
\"disinhibition\" and cultural issues regarding the introduction of
services into a community that traditionally does not circumcise.

***Family planning counseling and links to services can be included in
HIV hotline interventions.*** Motivation to call an HIV hotline is often
due to perceived risk exposure, which can also result in an unintended
pregnancy.  Thus counseling and referral to family planning services may
be appropriate. HIV hotlines continue to expand globally, and present an
important opportunity to use this communication vehicle to transmit
correct information about family planning. 

[^1]: ^1^ International Family Planning Perspectives: Issues Integrating
    HIV/STI and Family Planning, June 2002

[^2]: ^2^ The Manager, Volume VII, Number 3, Fall 1998.

[^3]: ^3^ Primary HIV Prevention and the \"ABC\" Approach, USAID
    information sheet, 2002
    [ ]{.underline}<http://www.usaid.gov/pop_health/aids/News/abcfactsheet.html>

    For additonal information: USAID ABC Meeting Report:
    [www.usaid.gov/pop_health/aids/TechAreas/prevention/abc.pdf](http://www.usaid.gov/pop_health/aids/TechAreas/prevention/abc.pdf)

[^4]: ^4^ USAID Handbook of Indicators for HIV/AIDS/STI Programs, March
    2000.

[^5]: ^5^ WHO, The Condom Situation: Assessment in 11 Asian and Western
    Pacific Countries, June 2001.

[^6]: ^6^ La Cellule de Planification et de Statistique (CPS/MS) Mali
    and ORC Macro. Preliminary Report 2001. Calverton, Maryland, USA.

[^7]: ^7^ Advance Africa is currently integrating HIV prevention
    information into the Zimbabwe Family Planning Association (ZNFPC)
    CBD program. For more information visit
    [www.advanceafrica.org](../www.advanceafrica.org).

[^8]: ^8^ Gladwell, Malcolm, \"The Tipping Point: How Little Things Can
    Make a Big Difference.\"

[^9]: ^9^ Uganda Bureau of Statistics (UBOS) and ORC Macro. 2001. Uganda
    Demographic and Health Survey 200-2001. Calverton, Maryland, USA:
    UBOS and ORC Macro.

[^10]: ^10^ What happened in Uganda?: Declining HIV prevalence, behavior
    change, and the national response. USAID (2002) Hogle, J. et al. 

[^11]: ^11^ Contraceptive Technology Update, March 2000, Volume 21,
    Number 3.

[^12]: ^12^ Johns Hopkins Center for Communication Programs: Key Youth
    Programs, Zambia HEART Campaign,
    [www.jhuccp.org/resources/youth](../www.jhuccp.org/resources/youth).

[^13]: ^13^ What happened in Uganda?: Declining HIV prevalence, behavior
    change, and the national response. USAID (2002), Hogle, JA et al. 

    <http://www.synergyaids.com/Documents/WhatHappenedUganda.pdf>

[^14]: ^14^ Advancing Youth Adult Reproductive Health:  Actions for the
    next decade - end of program report, FOCUS on Young Adults, 2001.

[^15]: ^15^ Background Paper, ADS Chapter 212 : Breastfeeding Promotion
    Policy and ADS Chapter 212 : Cross-Sectoral Implementation Guidance

[^16]: ^16^ Dr.Dirk Buyse, Elizabeth Glaser Pediatric AIDS Foundation
    Call to Action, Global Health Council Meeting 2002.

[^17]: USAID requires "that individuals served by USAID-assisted family
    planning programs receive information or referral to sources of
    information about a broad range of methods and services in the
    country, and prohibit the use of targets for number of births,
    "acceptors" of family planning or specific family planning methods
    and incentives for the achievement of such targets, the denial of
    rights or benefits based on the acceptance of family planning or a
    specific method of family planning; require the provision of
    comprehensible information to "acceptors" about health benefits and
    risks, inadvisabilities and adverse side effects of the family
    planning method chosen."

[^18]: ^17^ Grinstead, et al, AIDS 2001, 15:1045-1052

[^19]: ^18^ Uganda Bureau of Statistics (UBOS) and ORC Macro. 2001.
    Uganda Demographic and Health Survey 200-2001. Calverton, Maryland,
    USA: UBOS and ORC Macro.

[^20]: ^20^ Ibid.

[^21]: ^21^ Weiss H.A., Quigley M.A., Hayes R. Male circumcision and
    risk of HIV infection in sub-Saharan Africa: a systematic review and
    meta-analysis. AIDS 2000;14:2361-2370.

    For more information about male circumcision:
    [www.rho.org/html/menrh_mc_mtg.html](http://www.rho.org/html/menrh_mc_mtg.html)