Hiding in Plain Sight: The Role of Contraception in Preventing HIV

Published in the Guttmacher Policy Review (Winter 2008, Volume 11, Number 1), this article calls for renewed attention to the role of contraceptive services in fighting AIDS. Author Susan Cohen articulates the need for progress on prevention, a demand which is in keeping with the shift that the President's Emergency Plan for AIDS Relief (PEPFAR) has made away from treatment.

Cohen cites several studies to illustrate the motivation behind her focus on contraception, including:

• According to a 2007 Guttmacher Institute study cited here, one in four married women in Sub-Saharan Africa is sexually active and does not want to have a child or another child in the next two years, but is not using any method of contraception.
• According to a study published in JAMA in 2006, 84% of the pregnancies among women in three prevention of mother-to-child transmission (PMTCT) programmes in South Africa were unintended.
• The Centers for Disease Control and Prevention (CDC) reported in 2008 that 93% of the pregnancies among pregnant women receiving antiretroviral therapy in Uganda were unintended.
• Family Health International (FHI) research from 2006 of women in HIV counselling and testing clinics (where most women are HIV-negative but are at high risk for HIV), substantial majorities in Kenya (59%), Tanzania (66%), Zimbabwe (77%), and Haiti (92%) said they did not want another child in the next two years.
• FHI researchers estimate that if the HIV-positive women in Sub-Saharan Africa who are currently using modern contraceptive methods to prevent unintended pregnancy were not able to do so, the number of HIV-positive births in the region would be 31% higher than it is now. This would translate to 153,000 more HIV-infected unplanned births each year.
• Researchers at the Johns Hopkins University Bloomberg School of Public Health and the World Health Organization (WHO) published an analysis in AIDS in 2004 demonstrating that even a modest decline in the number of unintended pregnancies among HIV-positive women in Botswana, Cote d'Ivoire, Kenya, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe could lead to the prevention of the same number of births of HIV-positive infants.
• United States Agency for International Development (USAID) figures (2006) show that adding family planning to PMTCT programs could almost double the number of child infections averted and nearly quadruple the number of child deaths prevented compared to PMTCT programmes without family planning.

"Yet, despite the ever-rising demand for contraceptive services and the fact that a woman's ability to control her own fertility is integrally linked to almost all other aspects of health and development, U.S. funding for family planning has been lagging." Citing figures to support this claim, Cohen lays out her vision of what it would mean to legitimise contraceptive services as a core HIV prevention intervention: ensuring that HIV treatment programmes also provide contraceptive services directly or by referral, making family planning services more widely available through PMTCT programmes, and (in high-prevalence countries) promoting greater integration of HIV counselling and testing services into family planning programmes.