What Works for Women and Girls

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2. Programs must adhere to the longstanding international agreement to voluntarism,informed consent, and ensuring the right of individuals and couples to decide freely andresponsibly the number and spacing of their children. [See Chapter 8. Meeting the Sexualand Reproductive Health Needs of Women Living With HIV]3. Providers need training on contraception, including non-directive counseling and reducingstigma and discrimination for HIV-positive women. [See Chapter 8. Meeting the Sexual andReproductive Health Needs of Women Living With HIV]4. Interventions to increase dual protection and dual method use are needed. [See Chapter 8.Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]5. Efforts are needed to capitalize on opportunities to integrate family planning and HIVservices. [See Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women LivingWith HIV]6. Policy guidelines need to specify how family planning should be addressed in HIV prevention,treatment and care. [See Chapter 8. Meeting the Sexual and Reproductive Health Needs ofWomen Living With HIV]7. Women living with HIV need information and access to services for emergency contraception;safe abortion, where legal; and post-abortion care (PAC) services where abortion isillegal. Research is also needed on the safest methods of abortion for HIV-positive women.[See Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]8. Efforts are needed to address barriers to ensure that women living with HIV can accessand use contraceptives without the knowledge of their partner, if desired. [See Chapter 8.Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]9. Potential drug interaction between contraceptive options and treatment for TB and HIVco-infection must be considered. [See Chapter 8. Meeting the Sexual and Reproductive HealthNeeds of Women Living With HIV]10. Additional efforts are needed to reduce the structural barriers, such as gender norms, thatinfluence the behavior or decisions of people living with HIV to engage in unsafe sex. [SeeChapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]11. Providers need additional skills and resources to provide non-judgmental, confidential safersex counseling to people living with HIV. [See Chapter 8. Meeting the Sexual and ReproductiveHealth Needs of Women Living With HIV]214 CHAPTER 9 SAFE MOTHERHOOD AND PREVENTION OF VERTICAL TRANSMISSION
9B. Safe Motherhood and Preventionof Vertical Transmission: Pre-ConceptionAlthough many women don’t learn their HIV status until they become pregnant, for thosewomen who know they are HIV-positive prior to choosing to become pregnant, pre-conceptionassessments may inform both her and her partner of the safest way to become pregnantwithout HIV transmission to the infant or HIV transmission between serodiscordant couples.Therefore, throughout their reproductive years, women living with HIV need ongoing comprehensivepre-conception care that is incorporated into primary care services so they can makeinformed choices about pregnancy prior to conception.While maternal health services traditionally do not“It is also important to know yourstatus even before you becomepregnant so that you can at leastknow the ways of not letting thebaby get infected.”—Kenyan woman (Centerfor Reproductive Rights andFederation of Women Lawyers—Kenya, 2007)provide pre-conception care but rather start once a womanis pregnant with antenatal care, women with HIV canbenefit from pre-conception care. As PMTCT programs arescaled up, including pre-conception care as part of maternalhealth services should be considered.Pre-conception care should include counseling onbarrier methods of family planning to decrease transmissionof HIV and prevent secondary infection, skills tonegotiate condom use, assessment of a woman’s nutritionalstatus, education and counseling on perinatal HIVtransmission and pregnancy risks, and support and counselingfor partner disclosure on HIV status before pregnancy.Specific recommendations include for health care providers to “ask about pregnancyintentions to every woman, every visit,” and to discuss “the risks and effects of pregnancyon…[preexisting] medical condition[s], and the effects of the medical condition on pregnancyoutcomes…so that the patient can make an informed decision about becoming pregnant…Education and counseling for HIV-infected women about perinatal HIV transmission risks,strategies to reduce those risks, the potential effects of HIV or its treatment on pregnancy, andthe risk of transmission during breastfeeding, allows patients to be fully aware of the issuesconcerning HIV infection and pregnancy before conception” (Aaron and Criniti, 2007).“Because it is important for HIV-positive women receiving HAART to time their pregnanciesat a point when their CD4 cell count is high and their viral load is low, women should becounseled to use contraceptives until laboratory testing can determine that these levels areoptimal for becoming pregnant” (Sable et al., 2008). [See also Chapter 7C. Treatment: ReducingTransmission] Women should also know that studies conflict regarding an increased risk ofHIV acquisition during pregnancy (Morrison et al., 2007 and Gray et al., 2005), but that pregnancydoes not increase the risk of early death (Allen et al., 2007a). “For those with access tofertility centers, longitudinal data show that conception can occur with a very low risk of HIVtransmission… While the experience with assisted reproductive health technologies is encour-WHAT WORKS FOR WOMEN AND GIRLS215
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WHAT WORKSFOR WOMEN AND GIRLSEviden
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Authors:Jill Gay, MAKaren Hardee, P
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Jose Esparza, MD, Ph.D.Senior Advis
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Shyam Kottilil, MD, Ph.D.Staff Clin
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Larry Slutsker, MD, MPHChief, Malar
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Table of ContentsList of Abbreviati
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List of Abbreviations3TCACTAHIANCAP
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PEPPHAPHRPIDPLHAPMTCTPPEPPTPRPTPRBP
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MethodologyMeasuring “what works
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2. Hormonal contraception is safe f
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outcomes has been more difficult to
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2. Promoting contraceptives and fam
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International Political Commitments
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established national action plans o
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Organization of the DocumentThis do
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Table 1.1Countries included in What
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understanding the epidemic in any g
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girls in school, for example. The c
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Within each intervention, studies a
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Chapter 3.Prevention for WomenA. Ma
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Special Risks for WomenStill, despi
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AIDS cases reported from 1982 to 20
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experience observed in clinical tri
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Female Condoms Are the Only Female-
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condom if it gives them more pleasu
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Correct use of the female condom ha
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A two month prospective study from
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A study of trends from Demographic
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8. Peer education for women can inc
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3B. Prevention for Women: Partner R
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matic focus on partner reduction, y
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of HIV acquisition, but were either
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four visits, each participant was i
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What Works—Prevention for Women:
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vention immediately following the b
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Chapter 4.Prevention for Key Affect
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2010). Transgender men and women al
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confidentiality—violate human rig
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there were major socio-demographic
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and post-intervention were used to
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tent condom use and 1.5 times more
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to their peers, distribute condoms
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Gaps in Programming—Female Sex Wo
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of a sexual relationship with a pri
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than were naltrexone or placebo. HI
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attributed to …swift introduction
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Promising Strategies:5. Sex-segrega
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9. Programming to prevent initiatio
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D’Ivoire, Cuba, Estonia, Indonesi
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Gaps in Programming—Women Prisone
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EVIDENCEPromising Strategies:1. Vol
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In fact, as of September 2008, 66 o
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Transgender women and men are often
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2009). “The invisibility and marg
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especially young women, have their
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negotiation skills and other critic
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to be reached with sex and HIV educ
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What Works—Prevention for Young P
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44% and 100% of participants (Kirby
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tudes, self-efficacy, intentions, a
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as young people in this area had li
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ical validity of the findings that
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study reported having received info
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nancy. Almost 87% of men and 89% of
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last sex, having ever used a condom
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Gap noted, for example, in South Af
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Disaggregated Data Is NeededEffecti
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were also effective in increasing u
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Chapter 6.HIV Testing and Counselin
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Equitable Access to Testing and Cou
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they would come for HIV testing, re
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their jobs (Human Rights Watch, 200
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What Works—HIV Testing and Counse
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women. Of all married HIV-positive
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A study in Ethiopia found that inco
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At a provincial hospital in Mombasa
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Between June and December 2007, mob
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Promising Strategies:6. Encouraging
Page 165 and 166: 10. Counseling may reduce risk beha
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Page 169 and 170: Chapter 7.TreatmentA. Provision and
Page 171 and 172: Treatment Has Been Successfully Adm
Page 173 and 174: HIV Prevention Is Needed as well as
Page 175 and 176: Gaps in Programming—Provision and
Page 177 and 178: These practices and tools are usefu
Page 179 and 180: Non-judgmental, non-stigmatizing in
Page 181 and 182: percent among ART-experienced patie
Page 183: (Donnell et al., 2010). (Abstract)
Page 186 and 187: The sexual health of women is an im
Page 188 and 189: [ for women living with HIV]: impro
Page 190 and 191: Available GuidelinesA number of sex
Page 192 and 193: advantages of dual method use, alon
Page 194 and 195: contraception: 57% used hormonal co
Page 196 and 197: different; and progression to WHO c
Page 198 and 199: HIV-related behavioral or biologic
Page 200 and 201: use was positively associated with
Page 202 and 203: Gaps in Programming—Meeting the S
Page 204 and 205: Interactions between ARVs and oral
Page 207 and 208: Chapter 9.Safe Motherhood and Preve
Page 209 and 210: Pillar 1: Preventing Primary HIV In
Page 211 and 212: mission of HIV. HIV testing and cou
Page 213 and 214: EVIDENCE1. Preventing unintended pr
Page 215: Gaps in Programming—Reducing Unin
Page 219 and 220: EVIDENCEPromising Strategies:1. Dis
Page 221 and 222: Gaps in Programming—Pre-Conceptio
Page 223 and 224: 9C-1. Safe Motherhood and Preventio
Page 225 and 226: tion (Kershaw et al., 2006). “…
Page 227 and 228: outine tests. Fifty percent of the
Page 229 and 230: An evaluation of UNICEF-funded PMTC
Page 231 and 232: and syphilis (by rapid plasma regai
Page 233 and 234: 2. Additional efforts are needed to
Page 235 and 236: for their own disease” (ITPC, 200
Page 237 and 238: own health needs has never been eva
Page 239 and 240: dine and lamivudine during pregnanc
Page 241 and 242: chose elective cesarean section to
Page 243 and 244: their current pregnancy or a past p
Page 245 and 246: Promising Strategies:5. Integrating
Page 247 and 248: Gaps in Programming—Treatment1. I
Page 249 and 250: cesarean, and 221 were non-elective
Page 251 and 252: 3. Efforts are needed to ensure tha
Page 253 and 254: “There is no doubt that there are
Page 255 and 256: formula feeding increases the risk
Page 257 and 258: of age. For breastfed infants, the
Page 259 and 260: weeks of gestation and continued un
Page 261 and 262: A study in Côte d’Ivoire with 54
Page 263 and 264: during breastfeeding compared with
Page 265 and 266: 3 times higher for infants who were
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counseling tools are needed. Studie
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Chapter 10.Preventing, Detecting an
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latent infection. Some immunocompro
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concurrent active TB and HIV infect
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mortality of HIV-positive people re
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in a 65% decline in mortality and t
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1. Efforts are needed to reduce TB-
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al., 2004 cited in Slutsker and Mar
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stillbirths by 33%. Three cluster-r
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Gaps in Programming—Malaria1. Fur
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dose global coverage was just 27% i
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Chapter 11.Strengthening the Enabli
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combining microfinance and training
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pants meeting once per week for thr
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the men believed that they should n
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in the intervention village were si
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positive impacts. The quasi-experim
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Samoa, Serbia and Montenegro, Thail
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factor associated with sexual assau
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What Works—Strengthening the Enab
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worked with women’s groups, radio
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of school in addressing gender-base
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11C. Strengthening the Enabling Env
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also widely used worldwide and part
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ecognize women’s property rights
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Promising Strategies:2. Community o
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11D. Strengthening the Enabling Env
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more likely to report having used a
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likely than illiterate women to kno
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of the women surveyed were HIV-posi
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countries extending the fee aboliti
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families and separated from their c
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used the resource “Understanding
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6. Support groups for people living
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11G. Strengthening the Enabling Env
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EVIDENCEPromising Strategies:1. Inv
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Chapter 12.Care and SupportA. Women
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ical care provided by family member
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dealing with their sorrow, grief, a
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What Works—Care and Support: Wome
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2. Peer support groups can be highl
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discriminated unjustly against them
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6. Home-based antiretroviral therap
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12B. Care and Support: Orphans and
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(Thurman et al., 2007). As of 2008,
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care and services were provided, wh
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for treatment can be safely monitor
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A study done in Kenya (year not giv
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ather than a narrowly defined HIV/A
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7. Further interventions to provide
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ning providers, antenatal care and
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What Works—Structuring Health Ser
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counts available at primary health
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Pregnant women reported feeling out
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Before implementation of the PMTCT
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accessing PMTCT. An evaluation of 3
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A mathematical model based on TB tr
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1. Improved integration is needed b
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15. Additional efforts are needed t
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Community-based Care is holistic ca
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Microfinance is often defined as fi
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Sexuality is a central aspect of be
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References 1Aaron, E. and S. Crinit
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Akabaysh, H. and G. Psacharopoulos.
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Andia, I., A. Kaida, M. Maier, D. G
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Auvert, B., D. Taljaard, E. Lagarde
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Barker, P., C. McCanno, N. Mehta, C
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Berer, M. 2008b. “Male Circumcisi
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Bong, C-N., S. Chen, Y-J. Jong, T-S
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Brou, H., G. Djohan, R. Becquet, G.
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Campbell, L. and M. Lambey. 2002.
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Chama, C., W. Gashau and S. Oguche.
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Chimwaza, A., J. Chimango, C. Kapon
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Cluver L. and F. Gardner. 2007. “
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Coovadia, H. 2004. “Antiretrovira
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De Bruyn, M. 2006a. There’s Nothi
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Dharmadhikari, A., J Gupta, M. Deck
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Druce, N. and A. Nolan. 2007. “Se
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Epstein H. 2009. “Universal volun
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Farrell, B. and N. Rajani. 2007.
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Ford, N., D. Wilsono, P. Cawthorne,
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Galvez-Buccollini, J., S. DeLea, P.
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Gogna, M., M. Pechny, I. Ibarlucia,
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Grimes, D., J. Benson, S. Singh, M.
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“What Works compiles a wealth of
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