In recent weeks, global health policymakers, implementers, advocates and others have been celebrating the 10th anniversary of the President’s Emergency Plan for AIDS Relief (PEPFAR). At the heart of these celebrations has been attention to the incredible gains that have been made in preventing mother-to-child transmission of HIV (PMTCT). Secretary of State John Kerry marked the anniversary by noting, “Thanks to the support of PEPFAR, we have saved the one millionth baby from becoming infected with HIV.”
One million HIV-free babies. What a remarkable achievement, and one that symbolizes how far we have come in advancing HIV prevention science and practice over the past decade. The development of Anti-Retroviral (ARV)-based interventions to interrupt transmission from a pregnant woman with HIV to her baby — and PEPFAR’s success in expanding access to perinatal ARVs — has prevented new infections, saved lives, and given hope to women and men affected by HIV who wish to become parents. Indeed, this progress has generated worldwide momentum and political commitment for achieving an AIDS-free generation and led to the development of a Blueprint for getting there.
But this isn’t the full story. As we applaud the milestones associated with greater access to ARV prophylaxis for PMTCT, we should also take stock of how meeting the contraceptive needs of women living with HIV also contributes to fewer infections among children and better outcomes for mothers. In a previous publication, we estimated that current levels of contraceptive use by women and couples in the 15 PEPFAR focus countries prevented over 730,000 unintended pregnancies to women living with HIV and averted over 220,000 new infant infections annually. That’s on top of the roughly 230,000 infections averted annually through ARV prophylaxis to HIV-positive pregnant women in PEPFAR-supported programs at that time. Thanks to continued access to voluntary contraception for many women, we can safely assume that the number of infant infections averted over the past decade exceeds one million.
As exciting as these numbers are, however, one aspect has been overlooked. Closer examination of data from several studies suggests that many of the women who have benefited from ARV prophylaxis during and immediately after pregnancy did not want to become pregnant in the first place. Although the numbers vary across studies, about two-thirds of HIV-positive women report that their most recent pregnancies were unintended. Even though prevention of unintended pregnancies among women with HIV has long been deemed an essential pillar of a comprehensive approach to PMTCT, many women are still not effectively supported to achieve their desires to space or limit pregnancies.
Stronger efforts to prevent unintended pregnancies among women with HIV – through both renewed commitments to increase access to contraception globally and better integration of family planning services into HIV platforms – will not only accelerate progress toward eliminating HIV transmission to infants, but also minimize the risks that unintended pregnancy poses to HIV-positive women. In addition, it will enable them to reap the powerful social and economic benefits that come with being able to control their fertility.
Looking forward, PEPFAR is more committed than ever to achieving the goal of an AIDS-free generation. In its Blueprint, PEPFAR acknowledges that it must “support women living with HIV to make informed decisions about their future reproductive life, with special attention to preventing unintended pregnancies.” In addition, we must help those women with HIV wishing to conceive to achieve their desired family size goals as well. Detailed guidance from PEPFAR exists to support its implementing partners in translating this policy imperative into practice. As family planning interventions become a more routine component of HIV programs, hopefully future PMTCT milestones reported by PEPFAR will highlight not only the number of infants born free of HIV, but also the number of women living with HIV whose need for family planning has been met.