Integration and disintegration in caring for HIV-positive women

In the wake of a new UK Health and Social Care Bill that has disintegrated HIV service provision from sexual and reproductive health (SRH), joined-up thinking around sexual health is more important than ever. A cluster of international papers on HIV in this journal issue makes this crystal clear, by highlighting how HIV affects unplanned pregnancy and how contraceptive choices affect HIV transmission. HIV-positive women not planning a pregnancy badly need effective contraception, yet face potential drug interactions between HIV medication and hormonal contraception, plus, as a South African study highlights, higher risks of HIV transmission with long-acting reversible contraception (LARC). Worse still, they may also face clinicians who do not even discuss contraception with them at all, as an Australian study shows. Some struggle to understand the legal implications of HIV infection, and need better support from clinicians. Meanwhile in resource-poor settings in sub-Saharan Africa where, in contrast to the UK, attempts are currently being made to integrate services, data on contraceptive counselling are often missing.

Together, these papers leave no one working in sexual health with any excuse for complacency or tunnel vision. Showing the dangers of an overly narrow focus on individual HIV or contraception outcomes, however individually important, these articles remind us all to look beyond the boundaries of our own immediate roles and settings, to consider the sexual health of whole individuals. As this journal issue goes to press, World AIDS day celebrates plummeting rates of progression to AIDS and vertical transmission, and rising numbers of non-infectious individuals. HIV is no longer a death sentence. But it remains a serious chronic disease, requiring integrated care, including contraception.

Sandy Goldbeck-Wood

Editor-in-Chief

New vision for SRH launched in the UK

Having launched a new brand and a new vision at its recent annual conference, ‘Current Choices’, the Faculty of Sexual & Reproductive Healthcare’s leaders Chris Wilkinson and Jane Hatfield review progress towards modernisation since the publication of the Faculty’s 2013 vision document. Highlighting key ambitions tailored to the needs of the UK’s four devolved nations, the Faculty reaffirms a commitment to championing women's and men's sexual health at a time when these are under political and budgetary threat. See page 3

Where HIV-positive women are using LARC, extra care is needed to secure HIV prevention

In areas where the incidence of both HIV and unplanned pregnancy are high, decisions to withdraw or continue hormonal contraception must balance pregnancy prevention against HIV prevention. Data suggesting an increased risk of HIV infection in women using hormonal contraception, particularly depot medroxyprogesterone acetate (DMPA), raise a public health dilemma. In this analysis of contraceptive use and pregnancy in women participating in an HIV prevention trial in South Africa, injectable contraception was the most commonly used method (52%) and by far the most efficacious in terms of pregnancy prevention. To help balance the conflict between HIV acquisition and unwanted pregnancy, the authors advocate promoting condom use in women using injectable methods, and argue that the repertoire of available LARC methods must expand. See page 5

HIV doctors often fail to discuss sex and contraception with their female HIV patients

Unintended pregnancy rates are high in women living with HIV, who also face the risk of potential drug interactions with contraceptives, as well as the risk of HIV transmission. Given this, the results of this retrospective study of 128 women living with HIV infection in Australia give cause for concern: discussions about sexual activity were documented for just 54% of women, and contraceptive discussions for less than one-third. To improve SRH care within this at-risk group, the authors suggest that SRH standards need to be included in models of HIV care. This is already the case in the UK, where the British HIV Association's (BHIVA's) document Standards of Care for People Living with HIV advocates annual discussions about sex and contraception for all, but provider backgrounds differ: the Australian HIV care providers were largely infectious diseases physicians. It is possible that UK genitourinary medicine clinicians do better at meeting the SRH needs of their patients, but given the imposed split of HIV and sexual health provision, all those working in UK sexual health face increased challenges to mitigate increased risk to these vulnerable women. See page 12

A low-resource HIV clinic in Malawi integrates reproductive health services into HIV care

The integration and disintegration of contraception and HIV services is contentious in many regions. This includes Malawi, a resource-poor setting, where the Lighthouse Trust operates two public HIV testing, treatment and care clinics caring for over 26 000 people living with HIV. In August 2010, Lighthouse Trust piloted a step-wise integration of SRH services into routine HIV care, aiming to promote contraceptive use, and cervical cancer screening and treatment, finding a 45% increase in contraception uptake, widespread acceptance, and minimal additional resources needed over those needed for provision of HIV care alone. See page 17

Integration of HIV and family planning services in developing countries: better data needed

It may seem obvious that women living with HIV should be able to benefit from effective interventions to prevent unplanned pregnancy, but in developing countries this is often difficult to achieve. Adamchak et al., on behalf of the development organisation FHI 360, looked at 39 centres providing HIV care in four sub-Saharan African countries to assess recording of provision of family planning services. The authors found that data capture was very variable and as a result they propose methods by which better data could be recorded, with the aim of achieving a clearer understanding of client loads in order to allocate resources more efficiently and effectively. See page 24

People living with HIV need help in understanding the law as it relates to HIV

The non-intentional transmission of HIV following consensual sex remains a contentious issue with legal implications. The BHIVA care guidelines exhort clinicians to address the legal implications of HIV transmission in a sensitive, non-judgmental fashion in order to support individuals living with HIV and avoid ‘reckless transmission’. This questionnaire-based investigation of how well people living with HIV understand the law relating to HIV reveals considerable vulnerability, and suggests ongoing support and education from health care professionals is essential. See page 30

Evidence grows that LNG-IUS is a first-line option for nulliparous women

It is now 10 years since the National Institute for Health and Care Excellence (NICE) issued its guidance encouraging increased access to LARC. LARC methods are more cost-effective than the combined oral contraceptive pill and will reduce the number of unintended pregnancies. In this prospective survey of 109 nulliparous women at a student health clinic in the USA the majority had the levonorgestrel-releasing intrauterine system LNG-IUS fitted. This 18-month follow-up survey found very high satisfaction and continuation rates. This adds to a growing literature supporting the use of intrauterine devices in young, nulliparous women. The overriding message is that the LNG-IUS is an appropriate first-line contraceptive in this group. See page 36

Cervical screening creates a psychosocial burden that needs to be addressed

All screening carries the potential for harm, including overtreatment and the creation of worry where it did not previously exist. In the TOMBOLA trial, which compared proactive with more conservative approaches to low-grade cervical cytology abnormalities, women completed psychosocial questionnaires at the time of colposcopy, and again at follow-up. Looking at certain context-specific worries – about cervical cancer, sex, future fertility and general health – the authors found a prevalence of such worries was high, with general health worries highest. The risk did not differ according to the mode of management and appeared to persist long term. While this study cannot tell us about unscreened women, it does highlight a psychosocial burden that may be screening-related, and that needs to be addressed. See page 43

Creating a whole-institution approach to in-service SRH training in Uganda

Uganda has one of the world's highest fertility rates with women having nearly six children each. Sadly the maternal mortality rate is also stubbornly high and there is a high unmet need for family planning. This project, at Bwindi Community Hospital, identified barriers to contraceptive use including misconceptions about the side effects of contraceptives and inadequate training of health care workers. A whole-institution approach to the problem was taken by providing in-service training for all health workers and specialist training for clinical staff. Training was well received and gave staff the confidence and skills to discuss sexual health and contraception with patients. The initiative stimulated service change by empowering health workers to extend both the reach and quality of family planning services. See page 52

Contraception counselling at abortion fails to change future outcomes

Counselling of various kinds – relating to both the decision and future contraception – is provided in most centres offering abortion, but evidence for its efficacy is mixed. This systematic review of six randomised trials looking at contraceptive counselling provided to women before or after abortion aimed to address the question “How effective is such counselling in preventing further unplanned pregnancies, influencing uptake of LARC, or continuation of chosen contraceptive method?”. Counselling did not appear to influence the outcomes, although contraceptive knowledge among counselled women did improve. The authors conclude that research in this area would benefit from larger multicentre trials with longer follow-up and that there should be further research into interventions that encourage continuation of effective methods of contraception. See page 59

Telephone consultation and manual aspiration can improve abortion provision in remote settings

The provision of abortion care in remote areas has its own particular challenges due to the large distances involved and the smaller densities of population in rural communities. This article evaluates four new service initiatives to improve access and minimise delays in the abortion service in the Scottish Highlands. Telephone consultations and manual vacuum aspiration were successful and need further evaluation, whereas early medical abortion has logistic difficulties that are insurmountable due to legal constraints. See page 68

After almost fifty informative and entertaining articles, our Consumer Correspondent tiptoes away

In this, her final Consumer Correspondent article for the Journal, Susan Quilliam looks back over the fifty or so articles that she has written over the last 12 years, and highlights those that she feels have been particularly successful in achieving her original brief, namely “bridging the gap between patient and [SRH] professional”. Susan also mentions a few of the more memorable articles, including one in particular that ended up attracting rather more media attention than she expected or wanted. See page 78