The average rigor score was 3.4 out of 9, with a range of 1–5. The most commonly noted methodological strengths were reporting of preintervention and postintervention data and following a cohort prospectively; all but two studies controlled for potential confounders [34,37]. By contrast, no study randomly selected participants for outcome measurement. Two studies randomly assigned participants to the intervention group, and these were the only studies to have at baseline intervention and control groups that were equivalent in terms of the outcome [29,39]. Only one study documented equivalent groups at baseline assessed in terms of sociodemographic characteristics , and four documented follow-up rates greater than 75% [30,35,37,38]. The studies varied widely in terms of the duration of time postintervention that contraceptive outcomes were measured, ranging from the same day the intervention was delivered to 18 months later.
Contraceptive uptake was the most common family planning-related outcome reported. All but one of the 12 studies reported method-specific contraceptive use, allowing assessment of the effect of the intervention on use of methods other than condoms. Only three studies measured pregnancy incidence as an outcome [31,32,39]. With the exception of one study that measured family planning use 3 months following VCT , none examined contraceptive continuation.
Eight studies documented significant increases in contraceptive use by HIV service clients. In three of the studies, these increases were driven primarily by an increase in self-reported condom use [30,31,33]; another saw an increase in dual method use . Three studies, two of which were implemented by the same research group, demonstrated a substantial increase in uptake of long-acting contraceptive methods among HIV-positive and serodiscordant couples [29,37,38]. Follow-up data from one of these studies also reported a decline in pregnancy incidence . Another study reported successfully increasing dual method use among serodiscordant couples as well as reducing pregnancy incidence . An evaluation of a large-scale family planning/HIV integration program using retrospective service data found family planning clinic attendance increased and contraceptive distribution rose following integration . A study following a cohort of ART clients in Zambia reported that 62% of the women desiring a contraceptive method following the reproductive health counseling intervention successfully accessed family planning services within 90 days . Two of the studies evaluating the integration of family planning services into VCT reported lower contraceptive method provision and uptake than expected; however, they both also noted that the client population had lower than expected unmet need for family planning [33,35].
Four of the studies were designed to allow for comparisons between groups exposed to the family planning/HIV integration intervention and control groups [29,31,32,39]. One of these, a randomized controlled trial conducted in Zambia with four study arms, found significant increases in contraceptive uptake across the four arms, all of which received couples contraceptive counseling and provision of a wide range of methods on-site and free of charge . Participants exposed to an additional video-based component of the intervention focused on the intrauterine device and implants were more likely to choose a longer acting method. Over time, participants who were contraceptive users at baseline but switched to a longer acting method after viewing the video had lower pregnancy incidence . The study in Thika, Kenya, which similarly offered couples contraceptive counseling and free, on-site provision of a range of methods to the intervention group, also reported substantial increases in noncondom contraceptive uptake and declines in pregnancy incidence . Minimal change was observed in the comparison sites. The fourth study, which was a retrospective analysis of clinical data from Kenya, reported greater incidence of family planning use per 100 person years among the intervention group compared with the control group (58 vs. 45); the difference was primarily due to condom use . New use of methods other than condoms was lower in the integration arm, and no difference in pregnancy incidence between the two groups was observed.
In addition to the four studies with a clear comparison group, a fifth study compared a ‘basic’ integration intervention to one that was ‘enhanced’ with training for family planning service providers, facility level support, and community mobilization . Contraceptive use, primarily condoms, increased in both groups, but the enhanced intervention did not produce significant differential increases in contraceptive use. A sixth study compared a referral-based model of family planning integration with a model offering on-site provision of contraception in the HIV service setting . Uptake of long-acting reversible contraception (implants) was significantly higher at the site offering on-site method provision (32% compared with 6% at the referral site).
Six of the 12 studies included process evaluation data for assessing the extent to which the intervention was implemented as intended. In four of those studies, the process measure used was reports of the provision of contraceptive counseling by HIV service providers or counselors after the family planning integration intervention [30,33,35,36]. A fifth study used service ratios as a process measure . The most extensive process evaluation data came from the ‘facilitated referrals’ study in Tanzania, which documented through client reports the extent to which all seven service delivery steps in the facilitated referrals model were implemented . All of the studies measuring provision of contraceptive counseling reported increases in counseling after the intervention, though in some cases it was still lower than expected. For example, in the VCT intervention clinics in Ethiopia, nearly 60% of women and 70% of men did not receive contraceptive counseling after integration . Similarly, only 17% of providers at the youth VCT clinics in Kenya reported always screening a female client for risk of unintended pregnancy . That study also reported that only 33% of the providers interviewed had been trained in family planning/HIV integration, providing further evidence of low fidelity to the intervention.
In the study in Nigeria comparing basic and enhanced integration interventions, client reports of family planning counseling by ART providers increased in both groups postintervention; however, clients reporting receiving referrals to family planning services for noncondom methods remained low at follow-up: 26% of women in the basic group and 33% in the enhanced group . The other referral-based intervention study in Nigeria reported service ratios relating completed referrals at family planning clinics to service utilization at the referring HIV clinics as a process measure . Overall, service ratios were low, but increased after integration by four, 34, and 42 per 1000 clients from VCT, ART, and PMTCT clinics, respectively. The process evaluation data from the facilitated referrals study in Tanzania were more promising, with marked increases observed for several of the service delivery components of the integration intervention . For example, client reports of a care and treatment provider discussing contraceptive methods with them increased from 56% preintervention to 75% postintervention, and reports of receiving a referral from the care and treatment provider increased from 7 to 47%. As was found in the earlier review, none of the 12 studies reported cost or cost–effectiveness data associated with the family planning/HIV integration intervention.
Efforts to meet the family planning needs of people living with HIV have long been hampered by a lack of evidence-based service delivery strategies . However, a body of evidence is emerging to help shape future integration priorities. Nearly all the studies included in our review produced encouraging results and important lessons to guide future research and programmatic efforts focused on reducing unintended pregnancies among women and couples living with HIV. Although overall study rigor was low, the studies showed that family planning/HIV service integration is effective in increasing contraceptive uptake among clients with HIV who do not wish to become pregnant. These findings largely reinforce the conclusions presented in the 2009 systematic review of studies examining integrated family planning/HIV services.
Most studies included in our review represent small-scale pilot investigations. With the exception of the Nigerian evaluation using data from 71 public health facilities, none evaluated a family planning/HIV integration program being implemented at scale. However, seven of the 12 studies were conducted in public sector clinics delivering HIV services in the context of common health system constraints, thus increasing understanding of the feasibility and effectiveness of the integrated services in ‘real world’ settings. Theoretically, service delivery interventions successfully implemented in such settings hold greater promise for being taken to scale than interventions tested under highly controlled conditions. That said, the impact of the family planning integration interventions in the public sector-based studies was lower than expected, particularly with respect to noncondom contraceptive uptake.
In contrast, the four studies with the most dramatic increases in noncondom contraceptive uptake were implemented in the context of clinical trials and are less generalizable to typical health system circumstances. Women who chose to participate in the study in Thika, Kenya were part of known serodiscordant couples and may not have been representative of the general population . In addition, they initially agreed and were regularly counseled to avoid pregnancy so as not to affect their study participation. Outside a clinical trial setting, HIV programs with fewer resources would likely have less frequent contact with clients for follow-up care and may not be able to offer contraceptives free of charge. Nevertheless, the Thika study offers promising results related to increasing dual method use among HIV-positive women; furthermore, this is one of the few family planning/HIV integration studies to measure pregnancy incidence as an outcome.
The three studies that showed increases in uptake of long-acting reversible contraception are similarly unique in that the data are from women or couples who chose to enroll in research projects focused on HIV prevention [29,37,38]. Moreover, the randomized controlled trial in Zambia and the longitudinal cohort study in Rwanda and Zambia were conducted with a highly selected group of couples who opted for joint HIV testing [29,38]. Nevertheless, these studies suggest that on-site provision of long-acting methods is effective at increasing uptake among HIV-positive clients. Further, the studies generate evidence of effective program strategies to increase the use of longer acting and more effective contraceptive methods by HIV-positive and serodiscordant couples and postpartum PMTCT clients. Given the high reliance on condoms for pregnancy prevention by HIV-positive women, these studies make important contributions regarding ways to increase contraceptive method mix among HIV-positive clients. However, the feasibility of offering these methods free of charge in public sector facilities and outside the context of a clinical trial remains unexamined.
Six of the studies highlight potential for engaging men through family planning/HIV integration. The four studies targeting the intervention to couples were successful in increasing noncondom contraceptive uptake or decreasing pregnancy incidence [29,32,38,39]. In Nigeria, the proportion of men attending family planning clinics was significantly higher among clients referred from HIV clinics compared with nonreferred family planning clients . In Ethiopia, increases in provision of contraceptive counseling and methods to men were similar to those reported for women . These findings suggest that HIV services may be a promising platform for reaching men with family planning information and services. Given the influence male partners often have over decisions related to childbearing and contraceptive use, these opportunities warrant further investigation. Indeed, for women with HIV, disclosing their HIV status to their male partners and talking with them about the number of children they want has been associated with greater contraceptive use [13,42]. Moreover, the broader reproductive health literature has long endorsed constructive male engagement as central to effective family planning programming . However, male engagement efforts should be undertaken with the intention of not only promoting acceptance and uptake of family planning, but also fostering greater gender equality and transformation of harmful gender norms that limit women's ability to achieve their reproductive intentions . More research is needed to understand how men's attendance at HIV services can be leveraged to achieve better reproductive health and gender-related outcomes.
Despite prevention of unintended pregnancies among women with HIV being a core PMTCT program strategy, only two of the family planning interventions included in this review were introduced and evaluated in PMTCT clinics. This may be due, in part, to the challenges associated with delivering family planning interventions to traditional PMTCT clients. For example, PMTCT services typically begin in antenatal care (ANC) – after women are already pregnant . As evidenced by reports of high rates of unintended pregnancies among PMTCT clients, many of these women need to be reached before they become pregnant. In addition, the postpartum impact of contraceptive counseling delivered in the antenatal period has been questioned . After ANC, loss to follow-up occurs at each subsequent step in the PMTCT service cascade. In 2009, only 26% of pregnant women in 22 countries most affected by HIV/AIDS received HIV testing; among those pregnant women living with HIV, an estimated 53% received antiretroviral prophylaxis . With only a small fraction of PMTCT clients returning to facilities for postnatal care, the impact of a family planning integration intervention in this setting has been limited. However, the expansion of Option B+ PMTCT services, whereby women identified during pregnancy as HIV-positive initiate lifelong ART, may create greater opportunity for the provision of postpartum services, including family planning. The two studies with PMTCT clients we reviewed suggest that targeting family planning interventions to these women – most of whom are in sexual unions, are of proven fertility, and are likely to be highly motivated to space or avoid future pregnancies – still warrants attention [34,37].
The findings from our analysis reveal an expanding evidence base for integrated family planning/HIV service delivery innovations. However, given the low rigor scores for most studies, the quality of evidence is relatively weak. While one future direction of effort could be investing in research designs that produce more precise findings about the effectiveness of integrated services, we believe the greatest opportunity for achieving public health impact lies in identifying solutions to practical service delivery challenges. Our results underscore the need to understand and resolve the health system obstacles to delivering integrated services and achieving better outcomes under typical service delivery conditions .
Systems factors at policy, infrastructure, and service delivery levels – such as lack of policy guidance on integrated care, staff turnover and shortages, poor oversight, ambiguous service delivery guidelines, and inadequate monitoring systems – have been identified as challenges to delivering integrated services [49,50]. The interventions included in our review consisted of complex, multipronged service delivery enhancements, many of which would be difficult to implement in the absence of a solid health system foundation. Indeed, the process evaluation data reported in several studies suggest that weak fidelity to the intervention may explain the lower than expected impact observed. As family planning/HIV integration is scaled up, increased attention must be focused on examining and strengthening fundamental health system components to allow service delivery interventions to be implemented with high fidelity and to achieve maximum impact .
Advances in understanding and resolving challenges rooted in health system constraints can be made through investments in implementation research, the discipline that applies multidisciplinary methods to arrive at solutions for increasing access to, use of, and public health impact of evidence-based interventions . Specifically, as integrated services are scaled up, studies are needed to assess the process, cost, and outcomes of those services, and to identify the factors facilitating and impeding success in different contexts . Implementation research studies would produce needed evidence regarding how to deliver high-quality, effective, and sustainable integrated services at scale under routine health service circumstances . Such studies could also produce data on the costs of integration and the cost savings achieved through systematic service linkages.
Integrating family planning and HIV services holds promise as an effective strategy for increasing access to contraception among women with HIV who do not wish to become pregnant. Although our review suggests that many scientific and programmatic gaps related to family planning/HIV integration persist, we document that both the quantity and quality of the evidence base is evolving. Moreover, two notable, well designed integration trials funded by the Bill & Melinda Gates Foundation – the FACES trial in Kenya and the Integra Initiative in Kenya, Swaziland, and Malawi – recently ended. New findings from those studies are presented in this Supplement [55–57]. Efforts to translate the growing body of evidence supporting family planning/HIV integration into widespread practice, coupled with implementation research and broader health system reinforcements, have the potential to produce win-win gains on both reproductive health and HIV-related outcomes.
All authors contributed to conceptualizing the paper and reviewing and interpreting relevant studies. R.W. screened and identified articles to include from the peer-reviewed literature. T.H. and S.A. independently reviewed the studies and assigned rigor scores. R.W. and T.H. wrote the drafts of the paper, and S.A. and W.C. contributed to critical revisions. The authors would like to thank Tricia Petruney for her assistance in screening articles from the literature search for inclusion in our review.
Conflicts of interest
Support for this study was provided by FHI 360 with funds from the United States Agency for International Development (USAID), Cooperative Agreement Number GHO-A-00–09-00016-00, although the views expressed in this publication do not necessarily reflect those of FHI 360 or USAID.
The authors declare they have no conflicts of interest.
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Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
contraception; family planning; HIV; integration; prevention of mother-to-child transmission