Family Planning and HIV/AIDS: What are the Concerns?

Concerns related to the general population

The HIV/AIDS pandemic poses problems for family planning services at different levels. Some people fear that ready availability and widespread use of contraception may encourage casual sexual relationships, and perhaps concurrent relationships, which would help the pandemic to spread. At the same time, infertility is a major problem in parts of Africa and fear of infertility may discourage contraceptive use. Worries about the return to fertility after using hormonal methods, and even barrier methods, may be compounded by lack of knowledge and confidence in the ability of condoms to protect against disease.

Studies in sub-Saharan Africa have shown that current use of condoms among women of reproductive age exceeds 1% only in Botswana, Ghana, Malawi, Zambia and Zimbabwe. Men tend to report higher usage (over 1% in Burkina Faso, Cameroon and Senegal, and over 5% in Ghana, Kenya, Malawi and the United Republic of Tanzania). Yet huge numbers of people are at risk of HIV/AIDS in these countries, as elsewhere, and condom use is likely to greatly reduce this risk.

Concerns related to contraceptive users

Contraceptive users may face heightened HIV risk, depending on their choice of contraceptive method. The intrauterine device (IUD), for example, has been associated with increased risk of pelvic inflammatory disease (PID) and may increase the risk of HIV transmission. On the other hand, condoms (and to a lesser extent spermicides and cervical caps) may lower the risk of HIV transmission. Their use may, of course, be more problematic since they require the co-operation or agreement of both partners. In sub-Saharan Africa, trends in fertility regulation have favoured methods that are controlled by women and can be used without the partner's knowledge but that do not protect from STDs. Low status of women and the tolerance of male promiscuity are factors that hinder women from negotiating the use of barrier methods. Ability to exercise choice is further limited by a woman's, and her partner's, knowledge of STD transmission, by her appreciation of the level of risk a partner represents, and by cultural norms regarding discussion of sexual matters and the rights of partners to initiate or refuse sexual activity.

Concerns related to persons with HIV/STDs

Women infected with STDs are often asymptomatic and even those who have symptoms may be unaware of their condition. Studies in Africa indicate that about half of women with a reproductive tract infection may be asymptomatic. Many persons with an STD do not know the links between these infections and infertility. STD sufferers need the information to allow them to choose a method of fertility regulation that will prevent recurrence of infection and safeguard their fertility. If an STD is diagnosed during a family planning consultation, women may need advice and support regarding partner referral. HIV sufferers of both sexes may still wish to have children; they may need counselling about the risk of vertical transmission of HIV. Nursing mothers may need advice on alternatives to breast-feeding.

Concerns related to family planning service providers

Service providers face an ethical dilemma if they advocate contraceptive methods that, while highly effective, put clients at increased risk of HIV. Service providers may be constrained in the advice they can give by the range of methods available, by their own knowledge, by their limited counselling skills and ability to assess a client's risk status, or by respect for a client's privacy and freedom of choice. They may be asked to advise HIV-positive women who want to become pregnant, or to advise the wives of HIV-positive men who want to bear their husbands' children. Staff of family planning programmes may feel their work would be jeopardized if they concerned themselves with the needs of STD sufferers and the sphere of extramarital sexual activity. In addition, health staff who have to perform gynaecological examinations or assist at deliveries may be concerned about their own health and the risk of cross-infection of other patients.

Concerns related to health service managers and policy-makers

Managers and policy-makers are concerned that information and education messages should reinforce each other. This may be difficult where there are stereotyped portrayals of contraceptive users and preconceived associations of method use and sexual lifestyle. For instance, if condoms are promoted for high-risk sexual contacts, this may deter their use in stable partnerships.

Integration of HIV/STD diagnosis and treatment into family planning services may impose a new burden of work on staff.

Integration of HIV/STD diagnosis and treatment into family planning services may impose a new burden of work on staff. Chains ofreferral are needed, decisions must be made about who can prescribe treatments, and consideration must be given to stock adequate amounts of drugs and reagents. Where family planning services are used by only a small fraction of the population, an STD programme operating through these services would reach only the same small fraction. Even in countries with higher rates of contraceptive uptake, STD programme managers may be concerned about reaching groups such as adolescents, migrants or even men who are not being reached by family planning services. Family planning programme managers, on the other hand, may feel they would be swamped by these new demands.

Concerns related to under-served groups

Certain groups who are at risk of unwanted pregnancies and STD infections are poorly served by the programmes designed to provide these services to the general population. It is, for instance, difficult to design sexual health services for adolescents although there is a great need for prevention of unwanted pregnancy and STDs in the 12–19 age group. In many African countries, large numbers of adolescents appear to be sexually active from the age of 14 onwards.