Behind the COVID-19 headlines of 2020, the HIV pandemic continued to claim hundreds of thousands of lives and newly infected over 1.5 million people. For those in the HIV movement, 2020 also marked the endpoint of several global targets for preventing HIV, including the UNAIDS goal of reducing new infant infections to fewer than 20,000 per year. Unfortunately, we missed that goal – and we missed by a lot. The global health community must now redesign its HIV programs to meet this target, and new modeling suggests that expanding women’s access to contraception might be the key.
In 2019 there were an estimated 150,000 new HIV diagnoses among children under the age of nine, the vast majority of which resulted from mother-to-child transmission (MTCT). HIV can be passed to infants during pregnancy, delivery, or breastfeeding. Fortunately, the risk of MTCT decreases substantially from 15-45 percent to less than 5 percent if women are on treatment for HIV. Consequently, expanding women’s access to uninterrupted HIV treatment (currently ~85 percent of women living with HIV are on treatment) continues to be the major way to prevent new infant HIV infections. However, even full treatment access will not eliminate MTCT as long as women’s contraceptive needs remain unmet. Recent modeling shows that over 40,000 new infant HIV infections could be averted annually across 70 countries if unintended births to women living with HIV could be prevented. Of those new infections preventable by meeting women’s contraception needs, 18,000 would be among children born to women already on HIV treatment.
Contraception is well known for its health and social benefits for women desiring to prevent, delay, or space childbirths. It is widely recognized that contraception reduces the risk of maternal and infant mortality, and contributes to better health outcomes for women and their families. Yet, the role of contraception for HIV prevention is less widely discussed. Despite the fact that contraception is considered a central pillar of preventing MTCT by every major international HIV funder, global funding continues to be outpaced by the global need for contraceptive commodities. Contraceptive stock-outs are common, and in some high-burden HIV areas, like South Africa, they are the most common stockout reported in U.S.-funded HIV clinics. International HIV donors and national governments that are serious about ending MTCT need to prioritize fixing contraceptive stock-outs and meeting women’s contraceptive needs.
Scale-up of global investments to improve contraception access must be based on the key principles of voluntarism and choice of method. Voluntarism in family planning services refers to the ability of clients to make a free and informed choice about reproduction and reproductive health services without coercion or undue incentivization. Voluntarism is vital in all health services, but the need to safeguard voluntarism for women living with HIV is particularly important given persistent reports of forced or coercive experiences with family planning programs.
In addition, global investments in contraception should focus not only on expanding contraceptive access overall, but on expanding women’s choice of contraceptive options. Research has shown that diversifying women’s available options encourages overall use in addition to upholding women’s reproductive rights and agency. Donor investments in single contraceptive methods can inadvertently skew country contraceptive method mix. Donor and national government coordination will be required to ensure that adequate contraceptive options are available at the clinic level. Investing in quality family planning programs, based in these key principles, will pay dividends towards improving women’s health and preventing HIV.
In the post-2020 world, the global health and HIV community must work to both scale-up HIV treatment and meet women’s contraceptive needs if we are to reach our HIV prevention goals. The science is clear. HIV and family planning services work best when clients can access them in the same location. Success will depend on our ability to bring HIV and contraceptive services together to those who need them. Donors and governments cannot continue to view HIV prevention services and contraceptive commodities as siloed issues — women certainly don’t.
Jennifer Sherwood is amfAR Policy Manager and Elise Lankiewicz is amfAR project coordinator.