Integration of services for young women would decrease both HIV incidence and unwanted pregnancies amongst young women.

By Ruth Akulu

Today is HIV Vaccine Awareness Day, an important day to acknowledge. After all, an HIV vaccine would be the most efficient, inexpensive way to control and possibly eradicate this stubborn, decades-old virus.

While research to develop a vaccine is vitally important, albeit years away from coming to market, there are several new, and existing ways to prevent HIV now.

But, ask any young woman in Uganda what she fears most—pregnancy or HIV?  Many say they fear pregnancy. Yet HIV is potentially life-threatening when not treated while pregnancy is one of life’s most affectionately anticipated milestones for the majority of girls.

“I would rather get HIV than be seen pregnant and be chased out of home and drop out of school,” said a 20-year-old woman at Makerere University Business School in Kampala. Also, during a poll on Twitter on what is most commonly accessed by young women, 85% voted for family planning as the most commonly accessed product compared to PrEP.

In Uganda, like many neighbouring countries, high rates of adolescent girls and young women receiving family planning (FP) services show up at the clinic presenting with HIV. According to recent UNAIDS data, approximately 570 young women aged 15 to 24 acquire HIV every week in Uganda.

To reduce new HIV infections, there is a need to integrate HIV prevention, such as PrEP and HIV screening, into FP facilities. Currently, such services only exist in a limited number and cater mostly to HIV treatment rather than prevention.

The World Health Organization defines Family Planning as “the ability of individuals or couples to anticipate and attain their desired number of children and the spacing and timing of their births.” This is achieved through the use of contraceptive methods. FP is critical in preventing unintended pregnancies and reducing the spread of sexually transmitted diseases.

PrEP (pre-exposure prophylaxis) is the use of antiretroviral medication to prevent people from acquiring HIV. It is safe and highly effective and comes in the form of a daily oral tablet, a monthly vaginal ring or a bimonthly injectable. Oral PrEP and the Dapivirine vaginal ring and were approved by the Uganda National Drug Authority (NDA) in 2017 and 2021 respectively while the bimonthly injectable (cabotegravir for PrEP) is currently under NDA review.

Unfortunately, oral PrEP uptake has been slow in Uganda. Integrating this highly effective intervention into FP services would be an efficient way of reaching young women, the population most at risk for HIV. Similarly, new PrEP products, such as the ring and the injectable would reach more at-risk women if rolled out at the FP clinics where they frequent. Over 25 percent of adolescent girls and young women in our region currently access contraceptives requiring FP clinic visits for pills or injections. These clinic visits could potentially align with visits for PrEP refills or injections.

Studies have shown when PrEP and FP are co-delivered, as opposed to separate, siloed services, the use of both PrEP and contraception increases. One South African study showed that synchronized provision increased contraceptive use from 12 to 75 percent.

However, to date, access to both FP and PrEP services have revealed common challenges among young women including lack of information, restrictive age of consent laws, and poor attitudes from moralizing health workers. Addressing these challenges of PrEP-FP integration now will facilitate the introduction of existing PrEP and pave the way for future combination PrEP-contraception products, also referred to as multi-prevention technologies (MPT).

For example, the forthcoming Dual Prevention Pill (DPP) protects women from both pregnancy and HIV in one tablet. The DPP is a 28-day pill regimen containing the same active pharmaceutical ingredients in oral PrEP and oral contraceptive pills (OCPs). This MPT is expected, possibly, as early as the end of 2024.

On the policy end, the Ministry of Health has made great strides to develop and launch the National Strategy for Integration Services 2022-2025. The strategy lays a firm foundation for PrEP and FP integration. What’s needed now is to operationalize the strategy, to fund and program preventive health services for young women under one roof. This way, we’ll never have to fear either unwanted pregnancy or HIV.

Ruth Akulu is an HIV prevention advocate at the International Community of Women Living with HIV Eastern Africa and an AVAC Fellow.