Introduction
Family planning and HIV services have multiple overlapping objectives, which may not be fully achieved through separate, vertical programs. Linking these services makes intuitive sense, as the same behaviors that result in pregnancy also put people at risk for HIV. With HIV a growing problem among women of childbearing age, linked services allow women utilizing family planning services to also access HIV services [1]. Avoiding unintended pregnancies among HIV-positive women is the second component of a three-fold strategy to prevent mother-to-child transmission of HIV [2]. Family planning services offer a critical platform for providing HIV services because women and couples living with HIV may access family planning services both to prevent unintended pregnancies and to plan for healthy pregnancies when desired [3,4].
The potential benefits due to linking family planning and HIV services have begun to receive increased international attention and are key to successful achievement of the United Nations Millennium Development Goals [5]. Anticipated benefits include increased uptake of health services; increased ability of women and their partners, including people living with HIV (PLHIV), to plan pregnancies and allow for birth spacing; prevention of sexually transmitted infection (STI); and prevention of mother-to-child transmission (PMTCT) of HIV [6–10]. Although many international agencies have called for stronger linkages [7,11–14], the evidence for such linkages has not been rigorously assessed.
Family planning is one component of sexual and reproductive health; other components include maternal and child health (MCH), gender-based violence prevention and management, STI prevention and management, and management of other sexual and reproductive health (SRH) issues, such as gynecologic cancers, obstetric fistula, and menopause. We conducted a broad review of the linkages between SRH and HIV services [10]. In this article, we present results from the review specifically focusing on family planning and HIV-linked services. The objectives of this review were to understand the effectiveness; optimal circumstances; and best practices for strengthening family planning and HIV linkages by conducting a systematic review of the literature. To our knowledge, this is the first systematic review of linkages between family planning and HIV interventions.
Methods
A systematic review of interventions linking SRH and HIV services was conducted following standard methods for systematic reviews [15]. Full results from the larger systematic review are reported elsewhere [10]. A brief description of the methods as they relate to this subset of studies linking family planning and HIV services is reported below.
Definitions
For this systematic review, family planning interventions were defined as contraceptive service/commodity provision, counseling, and education. Although not a method of family planning, studies on abortion were also included. HIV interventions were defined as HIV counseling and testing, element 3 of PMTCT (defined as any intervention intended to prevent HIV transmission from an infected mother to her child, according to the third element of the WHO PMTCT strategy) [16], clinical care for PLHIV, and psychosocial and other support services for PLHIV. Linkages were defined as policy, programmatic, service and advocacy bi-directional synergies between family planning and HIV services [8]. To be included in this review, a study had to report on a family planning–HIV linkage service provision intervention that met the above definitions.
Inclusion criteria
The present review included both peer-reviewed studies and unpublished (‘gray’) literature, referred to hereafter as ‘promising practices.’ No restrictions on language of publication were imposed.
Inclusion criteria for the peer-reviewed studies component of the review were as follows:
- Published in a peer-reviewed journal between 1 January 1990 and 31 December 2007.
- Presented post-intervention evaluation data of a family planning–HIV linkage intervention.
- Utilized a pre/post or multi-arm comparison of individuals who received the intervention versus those who did not to assess quantitative outcomes of interest (biological, behavioral, or process outcomes).
Inclusion criteria for the promising practices component of the review were as follows:
- Published or presented in some form (peer-reviewed or otherwise) between 1 January 1990 and 31 December 2007.
- Presented evaluation data (either qualitative or quantitative assessment of process or outcome measures) or lessons learned from a family planning–HIV linkage program.
- Implemented the intervention in a low-income or middle-income country as categorized by the World Bank [17].
Exclusion criteria
Studies in which HIV services only included prevention, education, and/or condom provision linked with family planning were excluded from the final analysis as these linkages have been previously reviewed elsewhere [18–20].
Search strategy
Search terms were generated and electronic databases, including PubMed, CINAHL, and EMBASE were used to search the peer-reviewed literature. In addition, we handsearched the tables of contents of 14 peer-reviewed journals, examined reference lists of included articles and other key documents, searched relevant websites for promising practices, and contacted experts to identify additional citations. Citations were downloaded into bibliographic management software (EndNote V.10) and screened using a three-step process to determine the list of included articles.
Data extraction
Data were extracted from included articles by two members of the study team (for peer-reviewed articles) or by a single member with review and confirmation by a second member (for promising practices). Differences in data extraction or interpretation were resolved by discussion and consensus. The following information was extracted from each article: type of linkage, location, setting, target group, years of program and evaluation, intervention description, study design, unit of analysis, sample size, age and sex of participants, length of follow-up, reported numerical outcomes and results, text summary of outcomes, integration direction (i.e. family planning adding HIV services, HIV services adding family planning services, or simultaneous linkage), study objective, format of integration (on-site, referral, etc.), factors which authors reported either promoted or inhibited intervention success, and author recommendations.
Study rigor
Study rigor was assessed using a 9-point scale based on study design and quality measures with a range of 1 (low rigor) to 9 (high rigor). This scale was adapted from previous reviews of HIV behavioral interventions [21,22]. Studies received one point for meeting each of the following criteria: study design includes pre/postintervention data; study design includes control or comparison group; study design includes cohort; comparison groups equivalent at baseline on sociodemographic characteristics; comparison groups equivalent at baseline on outcome measures; random assignment (group or individual) to the intervention; participants randomly selected for assessment; control for potential confounders; and follow-up rate greater than or equal to 75%.
Key outcomes analysis
Nine key outcomes were selected and analyzed across all studies. Eight of these outcomes (HIV incidence, STI incidence, condom use, contraceptive use, uptake of HIV testing, quality of services, stigma, and cost) were chosen a priori due to their relevance to the field of SRH and HIV linkages, and one outcome (unintended pregnancy) was added following feedback on preliminary results.
If reported, each outcome was assessed to determine whether that outcome was related to the intervention (i.e. whether the intervention was designed to affect that outcome). Outcomes determined to be related to the intervention were then categorized as having a positive effect, negative effect, no change, or mixed effects; mixed effects indicated the outcome showed both negative and positive effects, either across different measures of the same outcome or across measurements of the same outcome at different follow-up time periods.
Results
A total of 16 studies met the criteria for inclusion in the analysis [23–38], 10 peer-reviewed studies and six promising practices (Table 1). In terms of direction of integration, half of the studies involved existing family planning services adding HIV services (eight studies), with seven studies involving existing HIV services adding family planning services; simultaneous implementation was only reported in one study.
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Table 1: Descriptions of programs included in the review.
Location
Of the 16 studies included in the analysis, all but two were conducted in low-income countries. The majority of studies were conducted in Africa (11 studies), whereas a few were conducted in the Caribbean (two studies), Europe (two studies), or Asia (one study). None of the included studies were conducted in North or South America.
Study design and rigor
Study design varied greatly. The most common study design was serial cross-sectional (six studies), with the next most common designs being randomized control trials (three studies) and cross-sectional studies (three studies). The least common designs were pre/post studies (with only one follow-up assessment period; two studies) and time-series studies (with multiple follow-up assessment periods; two studies).
The average rigor score for these 16 studies was 3.25, with a range of 1–8. The majority of studies scored below 3.0 (11 studies). The majority of studies included a control or comparison group (11 studies), but only five studies randomly selected or assigned participants to the intervention.
Categories of interventions
Although all studies provided some form of linkage between family planning and HIV services, the particular intervention components can be categorized into six types (Table 2).
Table 2: Categories of interventions.
Family planning services provided to voluntary counseling and testing clients
One of the most common intervention linkages was the provision of family planning services to clients attending voluntary counseling and testing (VCT) centers (four studies). The average rigor score for studies in this category was 3.25, the same as the average rigor score for all studies. All four interventions involved providing a variety of SRH services, including family planning, to clients receiving VCT [26,28,29,38].
Family planning and voluntary counseling and testing services provided to maternal and child health clients
Also common were interventions linking MCH care, including both antenatal care (ANC) and postnatal care settings, to family planning and VCT services (four studies). The rigor score for this category (3.25) was the same as the overall average. One study from South Africa provided family planning, STI screening, and VCT referral to women attending MCH clinics [34], whereas another in China provided women in postpartum care with VCT, partner VCT, and condom use counseling [32]. The final two interventions provided family planning and VCT to women attending MCH clinics [23,35].
Family planning services provided to people living with HIV
The next most common type of intervention linkage was providing family planning services to PLHIV (three studies). The average rigor of studies in this category was 5.00, higher than the overall average. One study from the UK evaluated a hospital-based intervention expanding existing SRH services, including family planning provision, tailored to the needs of PLHIV [24]. The other two interventions were randomized trials testing provision of different types of family planning methods to HIV-positive women [27,31].
Family planning and HIV services provided by community health workers
Two interventions provided family planning and HIV services through community health workers. The average rigor of these studies was 3.00, slightly below the overall average. Both interventions involved community health workers expanding their existing family planning services to include VCT referrals and supportive care for PLHIV [25,33].
Voluntary counseling and testing provided to family planning clinic clients
Two interventions provided VCT to clients of family planning clinics, and the average rigor score of these studies (1.50) was well below the overall average. One study from the Dominican Republic added VCT and HIV treatment to existing family planning services provided at a clinic [36], whereas another study from South Africa compared on-site provision of VCT to family planning clinic clients with off-site VCT referral [37].
Voluntary counseling and testing and family planning provided to women receiving postabortion care
One study from Tanzania provided VCT and family planning in a hospital setting to women presenting for postabortion care [30]. This study had a rigor score of 2.00.
Key outcomes
Of the 16 studies, 11 reported at least one key outcome, whereas five studies did not report any key outcomes [25,26,31,33,34]. Of the nine key outcomes, only five were reported in any of the studies (condom use, contraceptive use, uptake of HIV testing, quality of services, and cost). No studies reported on the remaining four outcomes (HIV incidence, STI incidence, unintended pregnancy, or stigma). Of the 11 studies that reported key outcomes, five studies reported only positive effects, three studies reported only mixed effects, and three studies reported a combination of positive and mixed effects. No studies reported negative effects.
Only one study from South Africa provided full integration (on-site VCT) and partial integration (referral to off-site VCT) and compared these with standard practice. This study reported positive effects with regard to uptake of HIV testing for both types of integration compared to the control condition, and mixed results regarding the impact of both types of integration on condom use, quality of services, and cost. The authors concluded that full integration may be more efficient if staff time and resources are available, but that partial integration can also be successful given resource limitations or underutilized VCT centers nearby [37].
Uptake of HIV testing
Three studies reported uptake of HIV testing (average rigor = 1.75) as an outcome. All studies found positive effects [29,32,37]. In Haiti, a 62-fold increase in uptake of HIV testing occurred over 15 years due to the integration [29], whereas in China, partner testing for women attending postpartum clinics increased from 19 (12-month pre-intervention) to 24% (12-month post-intervention) [32]. The final study in South Africa found HIV testing increased pre/post-intervention both for fully integrated services (25–30%) and for partially integrated services (28–39%) compared with a decrease in the control group (32–27%) [37].
Condom use
Four studies reported condom use as an outcome (average rigor = 3.75). One study found positive effects of the intervention on condom use [32]; the other three studies showed mixed effects [24,27,37].
The study with positive effects in China showed that ‘sometimes condom use’ increased from 6 (pre-intervention) to 41% (6-month post-intervention) [32].
Of the three studies reporting mixed effects, two studies were classified as such because their interventions were designed to increase rates of contraceptive use, so although condom use declined following the interventions, the authors interpreted this positively because other contraceptive use increased [24,27]. The third study showed different results for different measures of condom use; ‘condom use at last intercourse’ increased for both full and partial integration interventions compared with the control, whereas ‘always using condoms’ increased for partial integration and the control group but decreased for full integration [37]. For studies with mixed results, authors concluded that condom use decisions were likely associated with uptake of other family planning methods.
Contraceptive use
Four studies reported contraceptive use as an outcome (average rigor = 4.25); two studies found positive effects [28,30] and two found mixed effects [23,27].
Of the two studies reporting positive effects, one study in Rwanda found hormonal contraceptive use among women receiving VCT and family planning counseling increased from 16 (pre-intervention) to 24% (5-month post-intervention) [28], whereas another in Tanzania found hormonal contraceptive use increased among women in post-abortion care receiving VCT and family planning counseling and provision from 26.7 before to 52.5% after the intervention (significance not reported) [30].
Of the two studies with mixed results, one study from the UK provided VCT and family planning provision to women attending ANC and found contraceptive use decreased among HIV-positive women from 23 to 16%, but increased among HIV-negative women from 17 to 18% (significance not reported) [23]. The other study from Zambia provided contraceptives and family planning information to HIV-positive women and found that though vaginal chemical barrier use increased following the intervention in the entire study population, there was no difference between the intervention and control groups at follow-up [27].
Quality of services
Four studies reported on quality of services (average rigor = 2.25); three found positive effects [24,35,38] and one found mixed effects [37].
Among the three studies reporting positive effects, one study from the UK found that documenting of SRH service provision to HIV-positive women (an indicator of intervention implementation) increased following the intervention [24]. Another study from the Ukraine found that the quality of interpersonal communication and counseling skills among staff providing family planning to HIV-positive women increased following the intervention [35]. The third study from Kenya found that integration training improved providers' knowledge and attitudes toward family planning, and trained providers were more likely to engage in family planning discussions than nontrained providers [38].
The one study with mixed effects from South Africa found that full integration of family planning/HIV services did not change the quality of services, whereas partial integration increased the discussion of all types of contraception between the provider and client, except the discussion of family planning injectables [37].
Cost
Three studies, all promising practices, reported cost data related to the study intervention (average rigor = 1.67) [36–38]. One study from South Africa compared full integration to partial integration of services and found that staff training for integration required an up-front investment in training of US$5000–7000 per clinic and supplies costs of approximately US$1600 per clinic year; however, no structured incremental unit cost comparison between the two interventions or with standard services was provided [37]. Another study from the Dominican Republic found that adding antiretroviral treatment at two clinics incurred an annual cost of US$2157 per person-year, but this cost was not compared with other delivery models [36]. The final study from Kenya found that integrated services incurred an annual cost of US$351 per staff person trained, but the study authors did not provide cost data for all components involved in integrated service delivery [38].
Discussion
To our knowledge, this is the first paper to present a systematic review of interventions linking family planning and HIV services. A total of 16 studies met the inclusion criteria and were included in the review. Concerning effectiveness, the majority of studies reported positive or mixed intervention effects on five reported key outcomes; no studies reported negative effects. Overall, authors reported that linking family planning and HIV interventions was feasible and effective.
However, studies varied widely in terms of research questions, target groups, and settings. In addition, the rigor of evaluations from these studies was generally low, with an average rigor score of 3.25 out of 9. Although the majority of studies did include a control or comparison group, very few studies randomly selected or assigned participants to the intervention.
None of the included studies reported HIV incidence, STI incidence, stigma, or unintended pregnancy as outcomes, most likely because these outcomes are difficult and expensive to measure. Limited cost data were presented, despite the fact that the cost-effectiveness and efficiency gained by linking family planning and HIV interventions are among the main arguments for linked services and remain critical unanswered research questions. Although in theory integrating services should be cost-effective and more efficient, this has yet to be demonstrated based on our results. In addition, distal outcomes such as HIV and STI incidence are important ultimate goals of linkages and should be measured and reported when feasible.
Based on our review, the two most common intervention types were family planning services provided to VCT clients and family planning and VCT services provided to MCH clients. Across the different categories of interventions, there were no clear patterns in terms of efficacy. Although the addition of family planning services to already existing services for PLHIV may increase staff time with clients, no studies reported negative outcomes as a result of integrating services. The limited number of studies makes it difficult to determine the optimal setting for integration of services and identify best practices, and more documentation of existing programs is needed.
Unfortunately, none of the included studies were specifically designed to test the benefit of providing linked services compared with unlinked services, which would have allowed us to directly compare intervention effectiveness. Only one study compared fully linked services to partially linked services; both led to increases in HIV testing and quality of services compared with standard practice [37].
A key limitation to this systematic review is that the majority of included studies were not designed to specifically meet our objectives. We purposefully employed broad inclusion criteria to capture all studies evaluating any type of family planning–HIV linkage intervention. However, this meant that although studies may have met the inclusion criteria, they did not necessarily address our objective to determine the effectiveness of linkages or to report on our predefined key outcomes. This limited our ability to determine the effectiveness, optimal circumstances, and best practices for strengthening family planning and HIV linkages.
Reporting bias in the form of publication bias must be acknowledged, as studies reporting negative effects are less likely to be published. This bias may be more or less of a concern with unpublished program reports. Although program reports are often required by funding agencies regardless of the success or failure of the intervention, they have not received the scientific scrutiny of peer review. As we did not conduct a meta-analysis, we did not quantitatively assess publication bias.
Overall, linking family planning and HIV services was found to be effective and did not result in negative effects of our nine key outcomes. To determine optimal circumstances and best practices for integration, more rigorously designed studies are needed to specifically test whether linked family planning and HIV services improve outcomes compared with vertical programs. This would include direct comparison of linked to unlinked services, inclusion of a control group, random selection or allocation of participants, and more detailed data collection and reporting processes. Research should evaluate key outcomes, including HIV incidence, STI incidence, unintended pregnancies, stigma reduction, and cost-effectiveness. Although these are challenging outcomes to measure and may require larger studies with longer follow-up periods, they are crucial to effectively documenting the impact of linked programs. Finally, programs should assess and report factors contributing to success or failure of interventions so that future programs can learn from these experiences.
Acknowledgements
The present research was supported by the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the International Planned Parenthood Federation (IPPF), and the Joint United Nations Program on HIV/AIDS (UNAIDS). Financial support was provided by WHO and UNFPA.
All authors assisted with analysis and interpretation of the data, reviewed the manuscript for important intellectual content, and provided final approval of the version submitted for publication. Additional contributions of individual authors are listed below.
Alicen Spaulding served as lead study coordinator for the substudy of family planning and HIV linkages, critically reviewed study protocol, screened and extracted data from peer-reviewed articles, and drafted manuscript.
Deborah Bain Brickley assisted with substudy of family planning and HIV linkages, and screened and extracted data from promising practices.
Caitlin Kennedy served as lead study coordinator and coordinator for peer-reviewed studies, co-led design of study protocol, conducted online database searches, and screened and extracted data from peer-reviewed articles.
Lucy Almers served as coordinator for promising practices and screened and extracted data from promising practices.
Laura Packel co-led design of study protocol and screened promising practices.
Joy Mirjahangir screened and extracted data from promising practices.
Gail Kennedy served as overall project coordinator, assisted with design of study protocol, screened and extracted data from promising practices.
Lynn Collins, Kevin Osborne, and Michael Mbizvo conceptualized study and critically reviewed study protocol.
Conflicts of interest: None.
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