Preventing Unintended Pregnancies

An analysis that modeled the potential benefits of adding family planning to national strategies to achieve universal access to PMTCT found that focusing on unintended pregnancies as well as preventing vertical transmission is highly cost-effective. Modeling was based on 14 countries which contain four-fifths of all HIV-positive pregnant women living in 139 countries: South Africa, Nigeria, Mozambique, Democratic Republic of Congo, Uganda, United Republic of Tanzania, Kenya, Zambia, Ethiopia, Malawi, Zimbabwe, India, Cameroon, and Côte D’Ivoire. The average level of unmet need for contraception is 23% in these 14 countries and 17% globally. Even if all women in need accessed the most efficacious antiretroviral regimen available, this would prevent 240,000 infant HIV infections in the 14 countries with the highest HIV prevalence (300,000 globally) at a cost of US$131 million (US$208 globally). However, almost 72,000 infant infections would still occur in the 14 countries (over 90,000 globally). Preventing unintended pregnancies costs only US$26 million in the 14 countries (over US$33 million globally). Costs of treatment were based on 28 weeks of ARVs, including AZT, 3TC, and sdNVP.

*Although this evidence is based on modeling, it is based on the well-established correlation between contraceptive use and fertility rates using a linear regression of the contraceptive prevalence rate (CPR) on the total fertility rate (TFR) (Ross and Frankenberg, 1993). Included in the total fertility rate is unintended pregnancy, including among women who are HIV-positive and may or may not know their status. Therefore expanding access to contraception among all women will result in a reduction in unintended pregnancy, including among women who are HIV-positive and do not know their status when they get pregnant. The analysis by Reynolds et al., 2008 also assessed the cost per HIV-positive birth averted by family planning and PMTCT services. However because the analysis compared the cost of family planning with the cost of nevirapine, which is no longer recommended for us in PMTCT programs, that part of the analysis is not included here.

In the fifteen PEPFAR countries, Botswana, Mozambique,  Namibia, South Africa, Zambia, Ethiopia, Kenya, Rwanda, Tanzania, Uganda, Côte d’Ivoire, Nigeria, Guyana, Haiti and Vietnam, the annual number of unintended HIV-positive births currently averted by contraception use is over 220,000. Unintended births are composed of both those that were unwanted (i.e. wanted no more children) and those that are mistimed (i.e. pregnancies that were wanted later). This analysis used estimates of (1) contraceptive and HIV prevalence; (2) the number of women of reproductive age; (3) the number of annual births to HIV-infected women; (4) the rates of pregnancy and vertical HIV transmission; and (5) the proportions of unintended and unwanted births. The product of these estimates is the number of HIV-positive births currently averted by contraceptive use and the number of unwanted and unintended HIV-positive births.

A study by the US CDC in Uganda found that unwanted pregnancies may account for almost a quarter of all HIV-positive infants in Uganda. Satisfying family planning needs should be seen as an additional key PMTCT strategy. Estimation of the contribution of unmet family planning needs was done through Spectrum, a UNAIDS/WHO demographics software by entering the official national adult HIV prevalence; ARV uptake for PMTCT; total fertility rate and the wanted total fertility rate (the total fertility rate after removing unwanted fertility). In 2006, the authors estimated 100,900 women with HIV were pregnant with 19,200 vertical transmissions, 44,900 children needing ART and 16,700 pediatric AIDS deaths. PMTCT averted an estimated 1,200 vertical infections, 700 children needing ART and 2,000 AIDS deaths. The projected scale up from 2006 to 2015 of PMTCT based on single dose nevirapine may avert 23,100 deaths, whereas unmet family planning needs may account for a projected 33,800 infections; 4,700 children needing ART in 2015 alone; and 20,500 deaths. Between 2008 and 2012, family planning will reduced the need for pediatric ART by 13.1%. Every day, family planning averts approximately 20 vertical infections and 9 pediatric deaths. In addition, improved access to family planning would reduce the high maternal mortality and abortion rates, which are illegal and “are often carried out informally with greater risk for the mother" (Hladik et al., 2009: 6).

A demographic model using data from 25 low- and middle-income countries—where 91% of HIV-positive pregnant women live—found that if in addition to providing 90% of HIV-positive pregnant women with ART or more effective ARVs as recommended by WHO, new HIV infections among reproductive age women were reduced by 50% and unmet need for family planning for HIV-positive women was eliminated, these interventions would avert approximately 1,174,000 of 2.1 million new child HIV infections between 2010 and 2015, resulting in a 73% overall reduction in new child infections between 2009 and 2015. If no ARV prophylaxis were provided to prevent vertical transmission, an estimated 454,000 infants would acquire HIV; with the same 2009 levels of ARV prophylaxis, 367,000 infants would acquire HIV, and if 90% of women were reached with services matching 2010 WHO guidelines, primary new infections among women was reduced by 50% and the unmet need for family planning was eliminated, only 95,000 infants would acquire HIV by 2015. Approximately 36 million unintended births between 2010 and 2015 would be avoided and 1,209,000 fewer HIV-positive pregnant women would required ARVs.