Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 1 - 2 EDITORIAL South African action plans on HIV and Contraception The South African National department of Health has been pro-ac- tively monitoring evidence, re-evaluating policy and recommend- ing program changes since 2013 to reproductive health for all women and specifically women at high risk of HIV. Interventions include a revised contraceptive policy, development of a coun- selling tool, training, media communications and the establish- ment of a task team including government, academia, researchers, non-governmental organisations and civil society. Some of the key action plans put forward by the representatives of the task team during the many planning meetings aimed to improve quality of service and are mentioned below: • DMPA should not be withdrawn from the available meth- od mix. Not every South African woman is at high risk of HIV. Many women are already living with HIV. Fur- thermore, there are women with health conditions that limit contraceptive options. Others prefer a particular method because it offers non contraceptive benefits and improves existing conditions. For these reasons, all meth- ods of contraception currently available will continue to be available. A withdrawal of any method violates policy and reproductive rights. Such action hazards an increase in the unmet need for contraception and spiraling abor- tion, maternal morbidity and mortality. • Counseling and evidence based verbal and written infor- mation on all methods should be provided and individual risk assessments performed by health care providers after which women should be empowered to choose the saf- est and best method for them. Clear messages about any risks associated with particular methods must be relat- ed to clients. Counseling tools, risk assessment tools and take home information should be widely available. • Skills up-scaling must be prioritized so that service pro- viders can efficiently provide all methods of contracep- tion. • Clear messaging about HIV prevention including pre-ex- posure prophylaxis (PrEP) and barrier contraception should be promoted. • Review and research must continue and local research should be encouraged including improvement in data quality and monitoring of the countries information sys- tem. • Expanded method mix, new contraceptive technologies and antiretroviral therapies that have less interaction with contraception should be considered and procure- ment plans should proactively ensure stock outs are min- imized. • Sexual reproductive health and rights policy should ex- pand beyond just contraception and promote integration of services as a facility standard of care. It must address programmatic gaps, strengthen reproductive health ser- vices including termination of pregnancy, safe concep- tion, breast and cervical screening, HIV and STI preven- tion. On the 19 th June 2019, a week after the release of the ECHO results, a high level meeting was convened with the task team and invited delegates from the pharmaceutical industry, implementing partners, HIV experts, youth groups, ECHO team members and communication experts. The commission deliberated over the re- sults and reiterated and reaffirmed that the pre-ECHO plans are still applicable. Many valuable recommendations arose especially from the young advocates. A finalized action plan will be published by national government shortly, emphasizing the following notable ideas: • Effective communication and dissemination of the re- sults to all service providers and the general public using appropriate language and info graphics on media plat- forms and published statements. Advocacy groups and peer educators should play a role in this regard. Informed choice and improving access to all available contracep- tive methods will allow women to truly have a choice. Expanding the contraception method mix to include the lower dose subcutaneous injectable DMPA (DMPA-SC), other combined hormonal contraceptives (vaginal ring, patch and newer oral contraceptives) and hormonal in- trauterine systems among others must go hand in hand with ensuring competent provision of these new methods hence translating policy to practice. • Scaling up of HIV and STI prevention strategies and in- tegration into family planning and other services. The importance of dual contraception must be emphasized especially in the background of high levels of new HIV infections and STI prevalence shown by the ECHO study. • Educational programs, including targeting health care providers from undergraduate level with a need to focus on provision of a high quality, women centered, integrat- ed reproductive health service. Public and school educa- tion should also be addressed. • Engagement with male partners and male wellness pro- grams should be initiated. In conclusion, eradicating HIV and providing safe, effective contraception are key priorities of the National Department of Health in SA. For this reason, these issues will always be closely intertwined, whether or not HC and HIV share a cause and ef- fect relationship. The National Contraceptive Policy highlights the rights based approach to reproductive health ensuring that all cou- ples make an informed choice from a wide method mix. 7 Grounded in this foundation, SA can achieve success with these public health goals. The commitment and investment from National leadership is clear and palpable however there is much expectation placed on ground level service providers to step up and translate policy to practice. Among other things, ECHO has re-established the safety and efficacy of DMPA, IUDs and implants, and also proven that South African women find a wide range of methods acceptable by their readiness to be randomized. References 1. Sedgh G, Singh S, Hussain R. Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends. Stud Fam Plann 2014; 45(3): 301–314. doi:10.1111/j.1728-4465.2014.00393.x. 2. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. South Africa Demographic and Health Survey 2016. Pretoria, South Africa, and Rockville, Maryland, USA: NDoH, Stats SA, SAMRC, and ICF 2017. 3. Polis CB, Curtis KM, Hannaford PC, Phillips SJ, Chipato T, Kiarie JN, Westreich DJ, Steyn PS. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30(17): 2665–2683. 4. Hapgood JP, Kaushic C, Hel Z. Hormonal contraception and HIV-1 Acquisition: Biological mechanisms. Endocr Rev 2018; 39(1): 36–78. 5. ECHO study update. 2019. http://echo-consortium.com/wp-content/ uploads/2019/05/ECHO-update_-final_22MAY2019.pdf (Accessed 6 June 2019). 6. ECHO trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. The Lancet 2019; in press. doi:10.1016/ S0140-6736(19)31288-7 7. Department of Health, Republic of South Africa. National contraceptive and fertility planning policy and service delivery guidelines and National contraceptive clinical guidelines. 2012. OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 2