A family planning intervention to reduce vertical transmission of HIV in Rwanda.

OBJECTIVES: Since contraception is an effective way of preventing the vertical transmission of HIV, we evaluated the impact of a family planning intervention on hormonal contraceptive use and incident pregnancy in a group of HIV-positive and HIV-negative urban Rwandan women. SUBJECTS AND METHODS: In a longitudinal cohort study, 502 women who were not pregnant or infertile and who had been previously HIV tested and counseled viewed an informational video about hormonal contraception followed by a facilitated discussion. They were given access to oral or injectable hormonal contraception and Norplant at the research clinic; those who used these methods were seen every 3 months. RESULTS: Of the 330 HIV-positive and 172 HIV-negative women who underwent the intervention, 120 either became new hormonal method users (n = 40), continued their previous use of a hormonal method (n = 64), or switched to another hormonal method (n = 16) following the intervention. There was a shift to use of longer lasting hormonal methods, and the annualized attrition rate was < 15%, compared to > 50% prior to the intervention. Rates of oral and injectable contraceptive use were similar among HIV-positive and HIV-negative women. Nine per cent of HIV-positive women became pregnant in the year after the intervention compared to 22% in a prior 12 month period when contraceptives were not provided at the study site. The corresponding proportions for HIV-negative women were 20% after the intervention versus 30% before the intervention. CONCLUSIONS: Access to and information about hormonal contraceptives resulted in increased use and reduced attrition among both HIV-positive and HIV-negative women in this study. The reduction in incident pregnancy was greatest among HIV-positive women, suggesting that factors other than access to hormonal contraceptives may have influenced fertility outcomes. Knowledge of HIV serostatus may have an important influence on family planning decisions.

Behavior change strategies for family planning.

The technology of behavior modification is central to most family planning and population control strategies. Positive, differential and negative reinforcement, usually cast in terms of 'incentives' and 'disincentives', have been applied to promoting child spacing and contraceptive use throughout the developing world. A wide variety of options are available to program planners interested in decreased birth rates, increased contraceptive use and/or birth spacing, and general promotion of family planning behavior. Given the tremendous problems with overpopulation and maternal/child health in developing nations today, behavior modification techniques are proposed specifically as the most effective way to motivate behavior change in the area of birth planning. These techniques also provide a useful framework with which to classify current family planning strategies and maximize their overall effectiveness. Given the powerful potential of this technology, understanding relevant ethical considerations and limitations is of paramount importance.