As the U.S. Presidential campaign season begins to heat up, a number of advocacy groups are beginning to develop policy platforms for candidates to support and endorse in their campaigns.  The ONE Campaign, which develops these platforms for policymakers around the world on the topics of poverty and HIV/AIDS, is putting together such a document right now.  Regrettably, rumor has it that ONE’s platform will give only passing mention of one of the most effective methods of fighting poverty and hunger, curbing the spread of HIV/AIDS, and reducing child and maternal mortality: family planning and reproductive health care.

A platform that is intended to truly address the solutions to these global development concerns must stress the key intervention that is family planning and reproductive health care – particularly access to contraceptives including condoms, crucial to HIV/AIDS prevention programs. How can we expect to curb the spread of this pandemic without giving people the education, health care and tools they need to protect themselves?  How can parents pull themselves and their children out of poverty if they lack access to contraceptives that enable them to plan the size of their family based on the number of children they desire and their ability to provide for them?  How can we curb maternal and child mortality if young women are unable to delay pregnancy until they are healthy and mature enough to survive childbirth and care for a child?

Recognizing the important links between family planning and many larger development goals, such as poverty reduction, is crucial to making progress.  Bono, co-founder of ONE’s partner organization DATA (Debt. AIDS. Trade. Africa.), recognized this connection when speaking about DATA’s recent report finding shortfalls in the G8 nations’ aid to Africa.  “These statistics are not just numbers on a page, they are people begging for their lives, for two pills a day, a mother begging to immunize her children, a child begging not to become a mother at age 12,” Bono said.  When women and girls are able to prevent unwanted pregnancies and sexually transmitted infections such as HIV/AIDS, they are empowered to get an education and to live a longer, healthier life. 

In light of these truths, why would ONE want to promote a presidential campaign platform on poverty and HIV/AIDS that’s lacking legitimate discussion of the need for family planning and reproductive health care, including access to condoms? We must have heard wrong.

Maternal and infant mortality have declined in Egypt, Indonesia, Bangladesh, Nepal and the Philippines according to a new report released by Save the Children. Much of this good news can be attributed to access to family planning services which give women the ability to space their children at healthy intervals and plan the size of their families. The successes of these five countries show how crucial financial and political commitments to family planning are to curbing child mortality, as well as meeting other development goals.

Egypt’s remarkable 68 percent reduction in child deaths in the last 15 years puts the nation right on track to meet Millennium Development Goal 4 (reducing child mortality by two-thirds by 2015) . After hosting the International Conference on Population and Development in 1994, Egypt committed itself to investing in the health of mothers and children. The country aimed to reduce child mortality, reduce the fertility rate and to improve pregnancy outcomes. Through public health initiatives that provided healthcare for pregnant women and improved access to family planning education and services - including contraceptives - the fertility rate has declined from 4.3 to 3.1 births per woman, contraceptive use has increased to nearly 60 percent and child mortality has declined significantly.

“Voluntary family planning has been estimated to prevent one-fourth of maternal deaths by helping women delay early pregnancy and childbirth, prevent closely spaced births and reduce the risk of HIV transmission,” according to the report. In addition, “[i]nfants spaced more than three years apart are more than three times as likely to survive as infants both less than one-and-a-half years apart.” Considering that each year ten million children under five die - primarily from preventable causes and in poor countries - as well as an additional half a million mothers who die in childbirth or pregnancy, it is clear that family planning must remain on the forefront of any development agenda.

Unfortunately, for over a decade, U.S. support for these life saving programs has steadily declined. The U.S. has cut funding for international family planning by 41% (adjusted for inflation) since 1995, despite family planning’s proven track record of reducing maternal and child mortality. Political and financial support for international family planning must be central to global efforts to save the lives of women and children. The evidence is mounting; now we must act.

As the HIV/AIDS epidemic increasingly affects women, it is more important than ever that HIV/AIDS programs coordinate with and complement family planning and reproductive health programs.  The question is: How can this be done most effectively?

In the United States, both the President’s Emergency Plan for AIDS Relief (PEPFAR) and international family planning funds are subject to severe and hampering restrictions further limiting the flexibility of these funds to address women in need.  The Global Gag Rule denies foreign organizations receiving U.S. family planning assistance the right to use their own non-U.S. funds to provide legal abortion, counsel or refer for abortion, or lobby for the legalization of abortion in their country.  The Prostitution Pledge requires all groups receiving PEPFAR funds sign a pledge opposing prostitution.  The abstinence-until-marriage earmark in PEPFAR requires one third of all prevention funding to go toward abstinence-until-marriage programs.  The myriad of rules and regulations on both PEPFAR and family planning funding hurt the very people that these programs are supposed to be helping.

Until these harmful restrictions are repealed, it is important to understand and work within the existing policy framework in order to provide the most efficient and effective reproductive health services possible.  Since in the US policies follow the provision of services, PAI urges that  programs funded by the US  formally coordinate their services so that woman benefit while we work to remove the harmful restrictions that hamper these programs. In addition, we urge country governments and other funding sources to continue to work to make prevention programs as strong as possible.  It is crucial that these programs do not adopt the restrictions that hamper U.S. funding.

Coordination of PEPFAR and family planning requires funding for both.  However, as we discussed here last week, despite international family planning’s successful track record, there has been a 41% drop in assistance since 1995 (adjusted for inflation).  In fact, the U.S. no longer funds any family planning at all in five PEPFAR focus countries: Botswana, Cote D’Ivoire, Guyana, Namibia, and Vietnam.  This devastating oversight prevents women around the world from accessing high quality, U.S.-supported reproductive health programs and services, hindering PEPFAR’s fight against the spread of HIV.

As Ambassador Mark Dybul, U.S. Global AIDS Coordinator, stated to the House Committee on Foreign Affairs last month, “HIV/AIDS does not exist in a vacuum. It is inextricably tied to other threats to public health, and it has ramifications for a wide range of development-related issues.”  By working together, international family planning and PEPFAR can improve the lives of women and families around the world.  But, without U.S. resources for family planning, PEPFAR is losing the fight against the spread of HIV—and women are the ones who pay the ultimate price.

Experts, activists and government officials agree on one thing: Meeting the needs of women is paramount to reducing worldwide HIV infections. Unfortunately, the U.S. response to achieving this goal has been at cross purposes. Rather than playing a starring role in reducing HIV infection in women and children, family planning programs are suffering from diminishing or a total lack of U.S. funding in almost all of the President’s Emergency Plan for AIDS Relief’s (PEPFAR) fifteen “focus countries.” In effect, while the U.S. response to HIV/AIDS grows, its support for the very health programs where women have sought care for over four decades has lost considerable ground.

Despite the outstanding success of international family planning programs and their cost- and life-saving benefits in reducing HIV infections, U.S. funding has suffered a 41% decrease in assistance since 1995 (adjusted for inflation). Family planning, including contraceptives, reduces unintended pregnancies in HIV-positive women – preventing additional HIV-positive births. Research has shown that increasing contraceptive use among non-users who do not want to get pregnant averts almost 30% more HIV-positive births than HIV counseling, testing and nevirapine treatment alone.

In fact, the President’s FY 2008 budget requests a decrease in family planning assistance in over half of the PEPFAR focus countries (Haiti, Ethiopia, Kenya, Mozambique, Nigeria, South Africa, Tanzania and Zambia). Five focus countries – Botswana, Cote d’Ivoire, Namibia, Vietnam and Guyana – are slated to receive no family planning at all. This alarming trend hampers PEPFAR’s potential for success, effectively withholding one of the most effective tools that exists against the HIV/AIDS pandemic.

PEPFAR’s purpose is to address the global HIV/AIDS epidemic and it should remain so. But when PEPFAR aims to tackle the unique vulnerabilities of women to HIV infection and the family planning needs of HIV positive women, it must do so in concert with existing, successful, and trusted family planning programs.

Stay tuned for more in-depth analysis next week on why, in addition to robust funding for HIV/AIDS programs, family planning and maternal and child health programs must be strengthened – not left to wither on the vine.

Each year, over 600,000 children around the world are infected with HIV through mother-to-child-transmission (MTCT), totaling 2.3 million children living with HIV or AIDS today.¹ The majority of these infections is occurring in sub-Saharan Africa and are acquired from mothers during pregnancy, labor, delivery or breastfeeding.  While programs to prevent the transmission of HIV from mother-to-child (PMTCT) are invaluable, they are currently reaching only an estimated five percent of the HIV-positive population.² Instead of working in isolation, these programs should tap into the already existing network of family planning services and programs, achieving wider coverage and reaching more women, couples and infants. Preventing HIV infection among women of childbearing age and helping HIV-positive mothers avoid unintended pregnancies should be the primary emphasis of strategies to reduce MTCT.

Family Planning Prevents Primary HIV Infection In Women

Preventing primary infection in women is the first step toward preventing infections in infants. Yet, in 2006, 17.7 million women were living with HIV globally, and the proportion of women affected by the epidemic continues to increase.³ In sub-Saharan Africa, half of those living with HIV or AIDS are women, and the majority of all new HIV infections are occurring among women of childbearing age.

Women, especially young women, are at additional biological and social risk of HIV infection. Recent evidence shows that pregnant women may be at a higher risk of HIV infection than lactating women or non-pregnant, non-breastfeeding women.⁴

Male and female condoms are the only technology available for protection from sexual transmission of HIV and are thus critically important to curbing the spread of the epidemic. Family planning programs have been providing critical information, counseling and services to prevent and treat sexually transmitted infections (STIs) and promote consistent and correct condom use among women and men for over four decades. 

Family Planning Prevents Unintended Pregnancy Among Women With HIV Infection

In sub-Saharan Africa, the risk of MTCT is exacerbated by a high level of unintended pregnancy – a major cause of which is limited access to family planning services, including stock-outs of contraceptive supplies. In addition, HIV-positive women on highly active anti-retroviral therapy (HAART) may be more vulnerable to unintended pregnancy, because while HIV might suppress fertility, HAART reduces viral loads and is likely to increase fertility.⁵   In developing countries, maternal mortality is nearly double in HIV positive women than in those who are not infected.⁶

More than 200 million women in developing countries say they would prefer to avoid pregnancy but are not using any form of modern contraception. Unmet need for family planning is highest in sub-Saharan Africa (as high as 36 percent in some countries), where the HIV/AIDS epidemic is most prevalent.⁷

Recent research shows that lowering HIV infection rates among sexually active adults by 1 to 5 percent can in fact achieve the same reduction in infant HIV infections as nevirapine interventions (an antiretroviral drug).10 Not only does contraceptive use avert more HIV-positive unintended pregnancies, but it does so at a lower cost than the use of the nevirapine alone. Adding family planning services to PMTCT programs can achieve the same effect as increasing drug coverage. For the same cost, family planning services can avert nearly 30 percent more HIV-positive births than antiretroviral drugs.11

Helping HIV-positive women and couples avoid unintended pregnancies could prevent many child infections and deaths. Current levels of contraceptive use in sub-Saharan Africa, as low as they are, are already preventing an estimated 22 percent of HIV-positive births.⁸ A 2003 study found that adding family planning to PMTCT services in 14 high-prevalence countries prevented more than 150,000 unintended pregnancies. Averted child infections and deaths nearly doubled and quadrupled, respectively.⁹

A Closer Look: A Town In Eastern Uganda

In the rural town of Tororo, Uganda, a country where women have an average of more than seven children, over 90 percent of HIV-positive women who are pregnant did not wish to have more children, according to a recent study by the Centers for Disease control. Yet less than a fifth of married women who do not wish to become pregnant use contraceptives. Tragically, the HIV/AIDS rates are still rising, with 4.3 million new infections in 2006, according to the U.N. agency on AIDS (UNAIDS).