Mitchell and Stephens¹ bring attention to an issue we believe warrants much more emphasis, contraception for HIV infected women. A World Health Organization meeting identified prevention of unintended pregnancies to HIV infected women as a key strategy in preventing mother to child transmission (MTCT).² To date, three different models have shown the potential impact of family planning services on preventing HIV sequelae. Firstly, a simulation model demonstrated that just moderate reductions in unintended pregnancies to HIV infected women would yield equivalent reductions in infant HIV infections as nevirapine for pregnant, HIV infected women.³ Secondly, another model showed adding family planning to MTCT programmes produced major reductions in infant HIV infections and orphans with this strategy.⁴ Finally, a third model found that increasing contraceptive use among non-users of contraception who do not want to get pregnant is at least as cost effective as an equivalent investment in prenatal care programmes that provide and promote nevirapine to HIV infected mothers.⁵

To strengthen the case for contraception, we underscore the contribution family planning programmes are currently making to prevent infant HIV infections. Take sub-Saharan Africa where the HIV epidemic has hit hardest and the impact of contraceptive use in averting HIV positive births is greatest. In 2002, 13% of married African women aged 15–49 used modern methods of family planning: pill 4%, intrauterine device 1%, injection 4%, condom 1%, female sterilisation 2%, and other (for example, implants) 1%.⁶ Taking into account contraceptive failure rates,⁷ pregnancies averted are calculated by subtracting the number of pregnancies occurring among current users of modern contraceptives and the number that would occur if they used no method; for no method use, a conservative initial annual pregnancy rate of 40% was assumed.⁸

Given the 7.8 million births prevented by contraceptive use in sub-Saharan Africa in 2002 and an HIV prevalence of 7.4%,⁹ current contraceptive use in sub-Saharan Africa prevents an estimated 577 200 unplanned births to HIV infected mothers. Assuming a 30% vertical transmission rate in the absence of antiretroviral prophylaxis, we estimate that current contraceptive use prevents over 173 000 unintended HIV infected infants each year in sub-Saharan Africa, or 474 HIV infected infants per day. Current coverage of MTCT programmes would have a minimal effect on this estimated number of infant HIV infections since the weighted coverage of MTCT programmes for Africa is 5%,¹⁰ and less than one sixth of HIV positive women with access to MTCT programmes take antiretrovirals.

Approximately 640 000 children were newly infected with HIV in sub-Saharan Africa during 2003.⁹ Without any contraceptive use, this number would be 813 000 children. Thus, current contraceptive use is already averting approximately 22% HIV positive births annually. However, given the relatively low contraceptive prevalence in sub-Saharan Africa, increasing contraceptive use has great potential for additional impact in averting HIV positive births. The proportion of unintended births is 25% in sub-Saharan Africa¹¹; and assuming that 25% of HIV positive births are also unintended, the potential for contraception to avert even more HIV infections is profound—an addition of over 160 000 HIV positive births averted annually.

As resources are rapidly shifting to focus on providing antiretroviral therapy for HIV infected people, the negative consequences associated with unintended childbearing are likely to worsen for women if funding for contraception does not keep pace with increasing demand.^12,13 Across all developing countries, current family planning spending levels are estimated to prevent 187 million unintended pregnancies.⁸ In turn, more than 100 million induced abortions are prevented annually and 60 million unplanned births are avoided. We already know that contraceptive use has numerous health benefits for women and families; our calculations suggest that contraceptive use to prevent unintended pregnancies can also have a significant effect on reducing infant HIV infections. We urge funders to refocus on family planning, not only to prevent unintended pregnancies but also HIV infections.