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The 2019 results of the ECHO (Evidence for Contraceptive Options in HIV Outcomes) trial, which evaluated differences in risk of acquiring HIV among women using three different forms of contraception, revealed astoundingly high rates of HIV incidence in women across the study. Though none of the methods themselves comparatively increased one’s risk of HIV, the high incidence alone elevated a long-standing call for the integration of HIV prevention and sexual & reproductive health (SRH) services. The recent early stop of the HVTN 702 vaccine trial in South Africa showed similar rates of new infections among women—as with ECHO, over 4 percent incidence rates, well above the WHO definition of “substantial risk” at 3 percent in their oral PrEP recommendation.
Taken together, these results underscore the need to bring integration to service delivery, programs and products, including the need for new multipurpose prevention options as a public health imperative.
Integrating HIV and SRH has been successfully put into practice for family planning in HIV care and treatment clinics and prevention of mother-to-child transmission (PMTCT) services in maternal and child health clinics. But integrating HIV prevention—most recently the addition of oral PrEP—and SRH services has been slow.
Effective integration of HIV/SRH requires multilayered prevention, an issue highlighted in AVAC Report 2019: Now What?. Multilayered prevention can—and should—encompass both SRH and HIV services and products, including multipurpose prevention technologies (MPTs), such as condoms or the dual prevention pill (see below); and embed these services and products in “multisectoral strategies”, such as policy reform, community norms-changing and economic empowerment.
More MPTs must be developed and ultimately brought to market. Imagine a single pill that combines both oral PrEP and oral contraception, or, eventually, combining both strategies in a vaginal ring, injectable or implant. For young women who are inconvenienced by going to one clinic for PrEP and another for family planning, likely traveling far and waiting in long lines for both, a dual prevention pill could lessen the burden and provide the same protection against HIV and unintended pregnancy. In a multilayered context, that dual prevention pill would be available at whatever clinic they prefer to use, and once there they are connected to other services that speak to their most pressing needs.
AVAC, as part of its HIV Prevention Market Manager (PMM) project, worked with partners to understand what it will take to integrate HIV prevention and SRH services, and has developed a number of new resources:
- HIV & SRH Integration: Key Learnings from Research and Projects
- Literature review: Exploring Integration of Family Planning and HIV Services
- Applying Lessons from Family Planning to HIV Prevention Product Introduction
It’s time to act on tried and tested approaches as well as spur new efforts to deliver comprehensive services that address the comprehensive health needs of girls and women.
In addition, to learn further from integration efforts to date, AVAC began rapid assessments of HIV/SRH integration in Kenya and Zimbabwe in late 2019, in collaboration with both countries’ Ministries of Health.
In early 2020, AVAC co-convened a meeting with Kenya’s National AIDS and STIs Control Programme (NASCOP) and the Department of Family Health to build on the findings and develop tangible ways to integrate HIV prevention and SRH. A multisectoral group of national and county-level Ministry of Health officials, implementing partners, researchers, frontline providers, civil society and youth lent their diverse perspectives and agreed on several next steps. Among them, a technical working group (TWG) on integration and policy guidance will be formed, and select health facilities will pilot integrated services to better understand what approaches work and can be replicated.
Stronger integrated services can help improve existing delivery, particularly where reaching adolescent girls and young women has been a challenge, and help pave the way for a smooth introduction of MPTs. Initiative and innovation are needed in both services and products. AVAC is leveraging its strong partnerships to push for integration in both:
- A dual prevention pill that combines oral PrEP with an oral contraception is in development now. Because both products in separate formulations are currently safe, effective and available, the combined product may have an accelerated path to market. Currently, the drugs are being tested for compatibility in a combined form. This will be followed by a smaller study to determine that the drugs are just as safe and effective when combined in one pill as when taken separately. AVAC, CHAI, Mann Global Health and the Population Council, with funding from the Children’s Investment Fund Foundation (CIFF) are collaborating to plan for its market introduction. Population Council (with funding from CIFF) and Mylan (with funding from CIFF and the Bill and Melinda Gates Foundation) are concurrently developing the product.
- The USAID-funded Coalition to Accelerate and Support Prevention Research (CASPR) is building a cadre of advocates who understand the overall women’s HIV prevention research agenda as well as the MPT pipeline and are prepared to engage with policymakers, product developers and communities around the introduction of new options. In the near-term, a positive regulatory opinion on the dapivirine vaginal ring could lay the foundation for a future multipurpose vaginal ring.
- Following the ECHO results, the Civil Society Advocacy Working Group on HC-HIV led by and for women in Africa is working to develop funded country plans for integrated services that center women and affirm the right to full information and informed choice.
- A North-South collaboration of civil society organizations, known as COMPASS, is advocating for ambitious targets—in PEPFAR, Global Fund and locally-funded programs—to be set around integration of services in national and regional programs.
A health system that is responsive to the lives of girls and women will recognize that pregnancy, HIV, and STI prevention options should be readily available, accessible, and layered with behavioral and structural interventions. Integration of HIV prevention and SRH is a critical step toward providing this holistic, person-centered care.
Check out AVAC’s new webpage focused on HIV/SRH integration, where these and future resources will be housed to help inform evidence-based approaches to integration.