1. Overview of Training Course

Report
Integration of FP into HCT,
PMTCT, and ART Services
Training Package
Powerpoint Content
1. Overview of Training
Course
This Family Planning/HIV Integration course is intended for
trained, practicing HIV providers working in HCT, ART,
and PMTCT services.
It presents key family planning (FP) information for:
• Providing high-quality, efficient FP counseling on all
contraceptive methods and on safer pregnancy into HIV
services
• Initiating clients on condoms, contraceptive pills, and
injectables
• Making FP considerations specific to HIV+ clients
• Recording FP/HIV integration services and referring
clients appropriately
2. Unit 1 Introduction
Unit 1 includes:
• Rationale and benefits of FP/HIV integration
• Importance of dual method use
• Challenges of integration and solutions for successful
implementation
3. Levels of FP/HIV
Integration
• Level 1: Risk assessment for unintended pregnancy;
provision of FP; provision of condoms and pills (including
emergency contraceptive pills).
• Level 2: Includes all elements of the first level and the
provision of injectable contraceptives.
• Level 3: Includes everything in level 2 as well as the
provision of intrauterine contraceptive devices (IUDs) and
implants.
• Level 4: Includes provision of all contraceptive methods
including permanent/surgical methods.
4. Unit 2 Introduction
Unit 2 includes:
• FP decision-making rights of clients
• FP counseling principles and practice
• Importance of informed choice and informed consent
• Special issues for counseling for clients with HIV, men,
and adolescents
5. Basic Rights of FP Clients
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Information
Access
Choice
Safety
Privacy
Confidentiality
Dignity
Comfort
Continuity
Opinion
6. Reasons for Choosing
Contraception
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Desire to delay the birth of a first child
Space the birth of children
Limit number of births/children
PMTCT
Ensure dual method use/dual protection
Protect sexual and reproductive health
Economic reasons
7. FP Counseling
• Explores contraceptive options
• Provides accurate and unbiased information about the
methods
• Clarifies client feelings and values about using
contraception
• Identifies client reproductive goals, and concerns about
safety, effectiveness, and reversibility
• Supports client to come to his or her individual decision
8. Informed Choice
For informed choice, the client needs to know:
• The range of all methods available,
• Characteristics of each method,
• Possible side effects, and
• The risks of not using any method.
9. Informed Consent
• Means a client has been counseled thoroughly regarding all
the components described in the section on informed
choice, and that based on this information, s/he has freely
and voluntarily decided which method s/he wants to use.
10. Screening for FP Need
3 Key Questions:
1. Are you currently pregnant?
2. Do you want to become pregnant in the next year?
3. Are you currently using a contraceptive method?
Conclusions: Unmet FP Need, No FP Need, or Met FP Need
11. Unit 3 Introduction
Unit 3 includes:
• Full information for initiating clients on condoms,
contraceptive pills, and implants
• Key information for counseling and referring clients for
implants, IUD, permanent methods, and natural and
fertility-awareness based methods
• FP considerations specific to HIV+ clients (including
contraindications with ARVs and common OI drugs)
12. Essential Principles of FP
Counseling in HIV Services
• Every HCT, ART, and PMTCT client should be assessed
for FP need.
• HCT, ART, and PMTCT clients have the right to make
their own FP choice, including safer pregnancy for HIV+
women.
• Quality FP counseling and services should reinforce clients’
ability to limit HIV transmission to HIV-negative partners
and to infants, if desired.
13. Key Messages for FP
Counseling in HIV Services
• Generally, HIV-positive clients can use most contraceptive
methods, even on ARVs.
• Dual method use, using condoms to protect against
HIV/STIs and unintended pregnancy, as well as a second
contraceptive method for better protection from unintended
pregnancy, should be included in FP counseling for clients
with HIV.
14. Contraceptive Methods
• Male and female condoms
• Oral contraceptive pills (OCPs), including combined oral
contraceptives (COCs) and progestin-only pills (POPs)
• Injectable contraceptives (DMPA, NET-EN)
• Implants (Jadelle, Implanon)
• Intrauterine contraceptive devices (IUDs)
• Permanent methods (tubal ligation and vasectomy)
• Emergency contraceptive pills (ECPs)
• Natural and fertility-awareness methods
15. Essential Elements of FP
Client Education
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How the method works,
Method effectiveness,
Advantages and disadvantages of the method,
Side effects and complications of the method, and
How to use the method correctly.
16. Safer Pregnancy
Considerations
HIV+ clients desiring a pregnancy need to consider:
• HIV and STI transmission to their partner
• HIV transmission to their baby
• Client health status
17. Safer Pregnancy
Recommendations
HIV+ clients desiring a pregnancy should:
• Ensure both partners have been tested for HIV and have
disclosed their status to each other
• Get appropriate care and treatment
• Avoid sex without a condom except during fertile days of
the woman’s menstrual cycle
• Not take EFV (HIV+ women desiring a pregnancy)
• Reduce the risk of mother-to-child transmission by making
sure: the HIV+ woman’s viral load is not high and her CD4
count is not low, the, the HIV+ pregnant woman attends
regular ANC and PMTCT visits (to get ARV medicine and
infant feeding counseling).
18. Dual Protection and Dual
Method Use
• Dual protection is the use of condoms
to protect against HIV/STIs and
pregnancy. Condoms are very effective
at preventing HIV/STIsand pregnancy
when used correctly and consistently.
• Dual method use means using condoms
to protect against HIV/STIs and
unintended pregnancy and as well as a
second contraceptive method for better
protection from unintended pregnancy.
Dual method use is preferable for
couples who do not desire a pregnancy
because it improves unintended
pregnancy prevention.
19. Condoms
• Effective if they are used correctly every time you have
sexual intercourse
• Provide protection from HIV/STIs, as well as pregnancy
when properly used
• Not as effective for pregnancy prevention as other
contraceptive methods in typical use
• Safe and have virtually no side effects
• Require motivation and partner cooperation to use
consistently and correctly
• Female condoms may require partner cooperation
• PLHIV and their partners, and everyone, young and old,
need to know how to use condoms
20. COCs
• Safe and 98% effective if taken every day; Less
effective if the woman sometimes misses a pill
• Easy to initiate and discontinue; Fertility returns
immediately
• Beneficial non-contraceptive effects: regular/light
menses, protection from ovarian and endometrial
cancer, protection from symptomatic PID and
anemia
• Common side effects: breakthrough bleeding and
spotting, headaches, nausea, breast tenderness,
weight gain (serious complications very rare)
• Not for breastfeeding women
• No protection against STIs, including HIV
21. POPs
• Safe and very effective; Must be taken at approximately the
same time every day
• Do not affect the quantity or quality of breast milk
• Easy to initiate and discontinue; Fertility returns
immediately
• Beneficial non-contraceptive effects: light menses
• Common side effects: nausea, dizziness, headaches, breast
tenderness, irregular menses/spotting (serious
complications very rare)
• Do not have estrogen-related side effects and complications
• Do not protect against STIs, including HIV
22. Injectables
• Highly effective, safe, and easy to use
• Reversible, with some delay in return to fertility
• Have no affect on quality or quantity of breast
milk
• Beneficial non-contraceptive effects: protection
from endometrial cancer, symptomatic PID, sickle
cell crises, and anemia
• Common side effects: irregular bleeding,
prolonged/heavy bleeding, absence of menstrual
bleeding
• Provide no protection from STIs, including HIV
23. Implants
• Highly effective, safe, and easy to use
• Long-term pregnancy protection, but easily
reversible
• Do not interfere with intercourse, private
• Have no affect on quality or quantity of breast
milk
• Beneficial non-contraceptive effects: protection
from symptomatic PID and anemia
• Insertion involves a minor surgical procedure
and some discomfort for a day or two
• Provide no protection from STIs, including HIV
• Provider needed to insert and remove
24. IUDs
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Highly effective, safe, and easy to use
No constant supplies needed
Does not interfere with intercourse
Rapid return to fertility
Provider needed to initiate and discontinue
use
• No protection against STIs, including HIV
• Beneficial non-contraceptive effect: possible
endometrial cancer protection
• Common side effects: mild cramping and
bleeding (serious complications very rare)
25. Voluntary Surgical
Contraception
• Highly effective, safe, and easy to use
• Permanent (male sterilization takes 3 months to
become effective); Chance of regret
• Has no chemical or hormonal side effects
• No protection from STIs, including HIV
• Can be used by women and men of any age or
reproductive parity, who are certain they do not
want/must not have additional children.
• Beneficial non-contraceptive effect of female
sterilization: protective from ovarian cancer and
symptomatic PID
• Does not interfere with intercourse
• Surgical procedure (with some discomfort)
26. Emergency
Contraceptive Pills
• Prevent or delay the release of eggs
from the ovaries
• Do not work if taken accidentally
when woman is already pregnant
• Prevent fertilization
• Prevent transport of the sperm and
egg
• Effective when taken within the first
5 days after unprotected intercourse;
the sooner the better
27. Natural Methods
• Includes: Abstinence, Coitus Interruptus,
Fertility-Awareness Based Methods/Periodic
Abstinence (such as Standard Days Method)
– Require partner cooperation, no sideeffects, difficult to practice, no STI/HIV
protection
– Can be combined with condom use
during fertile period for better
effectiveness
• Lactational Amenorrhea Method (LAM) –
highly effective when conditions met (no
menses, first 6 months, feeding 8-10 times
day/night), temporary, no STI/HIV
protection
28. FP Considerations for HIVPositive Clients (1)
• FP/HIV Integration Provider Reference Tool: Family
Planning Considerations Specific to HIV-Positive Clients is
a useful tool to show key messages for FP/HIV integration
counseling and to identify the interactions between
contraceptives and safer pregnancy, and ARVs and
common OI treatment.
• It shows that most FP choices are appropriate for HIV+
clients with no reservations.
29. FP Considerations for HIVPositive Clients (2)
It also shows that it is generally possible for:
• Clients on NNRTIs to use COCs, POPs, NET-EN
injectables, or implants, but these clients should be advised
to practice dual method use by adding condoms and
practicing perfect use of the method (taking pills at the same
time every day, returning for injection on time).
• Clients on Ritonavir/Ritonavir-boosted Protease Inhibitors
to use NET-EN injectables or implants, but these clients
should be advised to practice dual method use and practice
perfect use of the method.
• Clients with clinical AIDS (not doing well on ARVs) to
undergo VSC unless the risk of infection outweighs the
client’s desire for the procedure.
30. FP Considerations for HIVPositive Clients (3)
Finally, it shows that it is NOT recommended for:
• HIV+ clients desiring a safer pregnancy to use EFV,
Certain Anti-Convulsants, or Systemic Anti-Fungals. Also,
clients desiring a safer pregnancy should not have
untreated Chlamydia and/or gonorrhea, or have clinical
AIDS (not doing well on ARVs).
• Clients on Ritonavir/Ritonavir-boosted Protease Inhibitors
to use COCs or POPs.
• Clients on Rifampicin and/or Certain Anticonvulsants to
use COCs or POPs.
• Clients with untreated Chlamydia and/or gonorrhea, or
clinical AIDS (not doing well on ARVs) to initiate IUD use.
31. Unit 4 Introduction
Unit 4 includes:
• Reporting on FP counseling and services
• Referring HIV clients for FP services
• Putting FP/HIV integration into practice through planning
32. FP/HIV Integration
Recordkeeping
Three columns are useful to collect FP counseling and service
information:
• 1. FP Need – “Met”, “Unmet”, or “No need’
• 2. Method Provided – method name, also indicate new or
continuing user
• 3. Referral – method name and facility location
• Providers trained in FP/HIV integration should negotiate
adaptations to register forms with local health
management.
33. Referrals
• Co-located services (same physical location) may not
require any referral.
• Intra-facility referral integrated services are offered through
different services within the same facility.
• Inter-facility referral is when the client will have to see
another provider in another facility to get their method of
choice.
• All HIV service sites should have FP referral directories
that list which services are available—these should include
intra- and inter-facility services, and should also indicate
costs, distances, and contact persons, if possible.
Thank You
June 2010
Alden Nouga MPH, Pathfinder International
Alemayehu Ayalew MD, Pathfinder International/Ethiopia

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