Risky sexual practice, unintended pregnancy, contraceptive utilisation, and its determinants among HIV-infected women in Special Zone of Oromia regional state, Ethiopia

Background: In settings where HIV prevalence is high, management of sexual and reproductive health is critical to reducing HIV transmission and maternal mortality. Integration of family planning with HIV services is appropriate model for HIV therapy, HIV prevention and care with family planning services in a resource limiting area like Ethiopia. The aims of the study were to determine risky sexual practice, unintended pregnancy, contraceptive utilisation, and its determinants among women of reproductive age in Oromia, Ethiopia Methods: A Health facility based cross-sectional study design was conducted with quantitative data collection approach was used to collect data from women living with HIV attending ART clinics in special zone of surrounding Finnne, Oromia Region in ve health centres. Simple random sampling computer-generated sample was used to select 654 respondents. The returned questionnaires were checked for completeness, cleaned manually, coded and entered into EPI INFO 7.1.6 version and exported to SPSSS 23.0 for further analysis. Bivariate and multivariable logistic regressions analysis was used to identify factors association with adjusted odds ratio (AOR) with 95% condence interval (CI) to controlled effects of possible confounders from nal model. Result: After discarded16 spoiled questionnaires, the completed response rate of this study was 97.6% (654/670). There were 654 respondents whose ages ranged between 18 and 49 years. The current family planning utilisation among women of reproductive age living with HIV was 548 (83.8%). The following were identied as determinants of current family planning among HIV-infected women in the area of study: open providers; family planning; of sexual two higher family planning reproductive HIV Oromia This study as had discussed family planning with healthcare providers; knowledgeability on modern family planning; number of sexual partners; unintended last pregnancy; sexual partner HIV status; and discloser status to their families. These ndings are in line with some previous studies’ ndings which identied the determinants of family planning utilisation as obtaining family planning information from health facilities; awareness on MTCT; having a son; partner knowledge of HIV status; use of a contraceptive method prior to diagnosis of HIV; married or cohabiting couples; religion; age; wealth; education and having a child (Nakaie et al 2014:170; Laryeaet al 2014:26; Ngugiet al2014:S80). This study identied factors that increased the likelihood of dual contraceptive use were women who had discussed family planning with healthcare providers; received family planning counselling on the ecacy of each method, side effects and the method mix available; had gotten services from knowledgeable and comfortable ART providers on integrated family planning/HIV services; had an unplanned previous pregnancy; had knowledge of their partner’s HIV status; and discloser status of HIV to their family. These ndings concur with some previous studies’ which revealed determinants of dual contraceptive use as being aware of HIV being comfortable with asking a partner use a healthcare family


Introduction
HIV infection is a pandemic disease. Globally, about 35 million individuals were living with HIV in 2013.
Of these, 24.7 million were in sub-Saharan Africa and 4.8 million in Asia and the Paci c (UNAIDS 2014:131). In 2013, about 16 million individuals living with HIV globally were women aged 15 years and older, and 3.2 million were children under 15 years of age (UNAIDS 2014:120). More than 90% of HIVpositive pregnant women reside in sub-Saharan Africa (Kendall & Danel 2014:48-49). In 2013, 1.5 million HIV-infected women gave birth globally and there were 240 000 new paediatric infections, amounting to one new infection every two minutes (UNAIDS 2014:120-131). HIV is thus the leading cause of death in women of reproductive age globally; it is responsible for one-quarter of deaths during pregnancy and in the postpartum period in sub-Saharan Africa (Kendall & Danel 2014:48-49).
The two top causes of death in women of reproductive age globally are HIV and AIDS (19%) and complications related to childbearing (15%) (WHO, USAID & FHI 2009:43).Sub-Saharan Africa has the highest maternal mortality ratio, reporting levels of 596 deaths per 100,000 live births (Hogan, Foreman, Naghavi, Ahn, Wang, Makela& Murray2010:1609. Further, half of the global maternal deaths occur in the sub-Saharan region. There seems to be a need to suggest strategies that are evidence-based to integrate family planning services with HIV treatment among women who are living with HIV. This may prevent treatable complications among them and their children, which lead to public health concerns in terms of high preventable childbearing complications and morbidity due to HIV/AIDS. The ndings of this study informed the development of strategies to integrate family planning services with HIV services in Oromia Region, Ethiopia, and provided evidence-based input for policymakers and health planners.

Statement of the problems
There were bene cial synergies in terms of increased 'sexually transmitted infection' (STI) prevention, including syphilis screening and treatment, and early childhood immunisation (Nutman, McKee & Khoshnood 2013:445-460). Another peer-reviewed study illustrated how best to integrate other interventions, such as postpartum contraception or tuberculosis screening and treatment, into services that are already providing some parts of integrated HIV care for pregnant and postpartum women, which is almost non-existent (Tudor-Car, Van-Velthoven, Brusamento, Elmoniry, Car, Majeed & Atun 2011:9).
Dual protection is the prevention of two unplanned and undesirable outcomes-unintended pregnancy and HIV infection-and may be achieved through the use of contraception in long-term, mutual, monogamous relationships. Alternatively, it includes the use of a condom, plus another non-barrier contraceptive method, or the use of a condom alone (including during pregnancy), abstinence, or avoidance of all types of penetrative sex (Orner, De Bruyn, Barbosa, Boonstra, Gatsi-Mallet & Cooper2011:54). One of the most important advantages to 'integrating family planning with HIV services' is the potential contribution of contraception to prevent unintended HIV-positive births, which has been well established through extensive research (Hladik, Stover, Esiru, Harper&Tappero 2009 The sample size was determined through a single population proportion formula by using a case study found in integrated sites in Ethiopia, where 40% of women were family planning users (P) (Scholl & Cothran 2011:9). By considering the design effect of 2, with correction formula since the total population was less than 10 000 (2380) and with a 5% non-response rate considered, the nal sample size was 670 women living with HIV.

Sampling procedure
All hospitals and health centres found in the Special Zone of Oromia Region that provide ART services were identi ed and randomly selected by computer-generated methods to be included in the study. A list of all women living with HIV from each facility, aged between 18 years and 49 years of age, was randomly created. Study sites were prepared and entered into SPSS version 23 by using their pre-ART registration numbers from the health management information system (HMIS) database. A simple random sampling technique by computer-generated samples was utilised at each health centre to select 670 study respondents. The number of study respondents was allocated proportionally for the ve health centres, based on their total number of ART clients.

Data collection
The questionnaire used for data collection was initially prepared in English, and translated to Afan Oromo, and back to English for language experts to con rm its consistency. Finally, the corrected Afan Oromo version was used to collect the data from women living with HIV attending ART clinics. The questions included in the questionnaire were adapted and prepared by reviewing different related literature and variables identi ed to be measured. Training was given for data collectors and supervisors by the primary researcher for two days. Data collectors cross-checked the pre-ART card numbers of women living with HIV who came to the ART clinic with sampled card numbers daily. Five trained data collectors collected data from women of reproductive age. The completed questionnaires were collected and checked daily for consistency and completeness by supervisors and the primary researcher. Data were collected using a pre-tested structured Afan Oromo version of the questionnaire. A pre-test of the questionnaire was done on 5% of the women living with HIV at Ambo health centre, to identify any ambiguity, to con rm consistency in the questionnaire, to determine acceptability, and to make necessary corrections one week before the actual data collection process. The respondents were guided through a questionnaire and chart abstraction conducted at their health facility by trained data collectors.

Data management and analysis
The returned questionnaires were checked for completeness, cleaned manually, coded and entered into EPI INFO 7.1.6 version and then transferred to SPSS version 23 for further analysis. Frequencies, percentages, mean and standard deviation (SD) were used to summarise descriptive statistics of the data and text. Moreover, tables and graphs will be used for data presentation. Bivariate analysis was used primarily to check which variables have an individual association with the dependent variable. Variables which were found to have an association with the dependent variables were then entered into multiple logistic regressions to control the possible effect of confounders. Finally, the variables which have signi cant association were identi ed on the basis of AOR, with a 95% CI and p-value to t into the nal regression model.

Ethical Consideration
The rights of the institution were protected by obtained ethical clearance (Ref.No HSHDC/710/2017) from the Research and Ethics Committee of the Department of Health Studies at the UNISA. Thereafter, a letter of permission to conduct this research was also obtained from the ORHB who requested support for the researcher from each study site to facilitate the data collection process (Ref.No BEFO/HBT64/18/2569).
Written consent was obtained from each study participant, after the nature of the study was fully explained in their local languages as it was attached in the questionnaire. The respondents' right to refuse or withdraw from the study at any stage was respected. Information collected from respondents was kept con dential, and the collected information was stored in a locked space, in a le without the name of the study respondent (anonymously), but codes were assigned for each respondent and have not been disclosed to others except the principal investigators. Scienti c integrity was ensured by avoiding plagiarism, being honest in reporting on the ndings, and accurately citing all consulted sources.

Results
The complete response rate of this study was 654/670 (97.6%).
There were 654 respondents whose ages ranged between 18 and 49 years. The mean age of the respondents was 31.86 years with a SD of ± 6.0 years. Most of the respondents in the sample were in the age group 26-35 (n = 374, 57%), and only 96 (14.7%) were in the age group 18-25. Of the 14.7%, 4 (0.6%) were younger than 20 years.
The majority (n = 409, 62.5%) of the respondents had at least attended school from primary level to college/university level, and the least represented were 19(2.9%) who had attained tertiary level education in the form of attending a college or university.
The marital status of respondents is presented in Table 1. With regard to the residential area, the majority of the respondents (n = 518, 79.2%), resided in urban areas, and 136 (20.8%) lived in the rural area. The socioeconomic characteristics of the respondents as summarised in Table 1 are not different from the socioeconomic pro le of Ethiopia. For example, in the general population of the same region, Christian denominations dominate and represent 65% of the population, and the largest ethnic group is Oromo, followed by Amhara which represent 64% of the population (CSA 2016:33). The results are also similar in terms of the proportion of women who are currently married or living together with a partner (65%) in the general population (CSA 2016:34).

Risky sexual practice, condom utilisation, and unintended pregnancy
The ndings on risky sexual practice, condom utilisation, and unintended pregnancy among women of reproductive age living with HIV are presented in Table 2. Have children in the future/fertility desire Yes 324 No 330 Table 2 illustrates that of a total of 654 respondents, almost all of them (n = 641, 98.0%) had a sexual partner. Of these, 33 (5.1%) had two or more sexual partners in the last six months and 174 (26.6%) had changed sexual partners since their HIV diagnosis.
The result also indicated that 608 (94.9%) respondents were sexually active during the last six months; however, only 279 (61.9%) always used a condom; 105 (16.1%) were discordant in HIV serostatus, and 68 (10.4%) did not know their sexual partners' HIV serostatus.
The proportion of condom utilisation in the last six months was reported by 451 (71.6%) respondents, although 106 (23.5%) were inconsistent.
The ndings revealed that the major reasons for not using a condom were that the respondents felt some discomfort or sexual pleasure was reduced; their partner objected to the use of a condom, and some had the desire to conceive a baby; 70 (39.1%), 68 (38%), and 41 (22.9%), respectively.
These results identi ed that 140 (21.4%) respondents' previous pregnancy was unwanted/unplanned, and 324 (49.5%) had fertility desire. Table 2. HIV therapy and disclosure of HIV status The mean years since HIV diagnosis were 5.64 with a ± Std. deviation of 2.777 and all the respondents had started ART, of which 36.9% were greater than or equal to 6 years, with a mean of 4.90 ± Std. deviations of 2.577 in years since they started ART.
According to client cards, study respondents' ART drug adherence level indicated that the majority (n =  Table 3). Family planning and dual contraceptive utilisations Family planning is a programme to regulate the number and spacing of children in a family through the practice of contraception or other forms of birth control (UNAIDS 2015:42). The dual conceptive method is the prevention of two unplanned and undesirable outcomes, namely unintended pregnancy by use of contraception in a long-term mutually monogamous relationship. This includes the use of a condom plus another non-barrier contraceptive method, the use of a condom alone (including during pregnancy), abstinence or avoidance of all types of penetrative sex (Orner et al 2011:54). One of the most important advantages to integrating family planning and HIV services is the potential contribution of contraception to prevent unintended HIV-positive births, which has been well established through extensive research (Hladiket al2009:7691).
Knowledge about modern family planning These measurement variables were related to knowledge about modern family planning methods. Family planning and dual method utilisation of women of reproductive age living with HIV Factors associated with current family planning utilisation Table 5 shows the logistic regression modelling that was undertaken to examine the net effects of a set of explanatory variables over the outcome variables and the odds ratios (OR) were adjusted for all other variables with 95% CIs. In this analysis, the outcome variables, current family planning utilisations, were dichotomised with "1" being utilised and "0" not being utilised. Keynote: ***p < 0.001, **p < 0.01, *p < 0.05 CI = con dence interval, AOR = adjusted Two different models were tted to investigate the factors predicting current family planning utilisation.
In testing the tness of the logistic model, if the HL goodness-of-t test statistic is greater than 0.05, the model is considered as a well-tting model, implying that the estimates of the model t the data at an acceptable level. Accordingly, the HL test for the following two models showed chi-square p-values > 0.05, which proved the goodness-of-t of the applied models for this study at p = 0.84 for the current family planning utilisations model. Table 5 provides evidence based on the stated criteria that the factors that were identi ed through binary logistic regression were age, marital status, family monthly income, residence, discussion on dual method use with healthcare provider and with partner, knowledge family planning methods, number of sexual partners, previous pregnancy, future fertility desire, and partner's HIV status, respectively. These identi ed variables were entered into multiple logistic regression analyses. Table 5 depicts that the respondents who had discussed family planning with healthcare providers during follow up were 2.9 times more likely to utilise family planning services as compared to those who had not. Women who had one or a single partner were at 2.7 times higher odds of family planning utilisation as compared to those who had two or more sexual partners. Moreover, women living with HIV whose last pregnancy was not intended were 2.6 times more likely to utilise family planning as compared to those who had intended their pregnancy.
The results further show that women who had a sexual partner with the same serostatus (concordant and discordant) were 4.8 times and 4.4 times more likely to utilise family planning services as compared to unknown serostatus partners. Those women of reproductive age who had disclosed their HIV result to their family were at 1.7 times higher odds of family planning utilisation as compared to those women who did not disclose their serostatus. Factors associated with dual contraceptive utilisation Table 6 presents potential factors associated with dual contraceptive utilisation from both binary and multiple logistic regressions. Logistic regression modelling was undertaken to examine the net effects of a set of explanatory variables over the outcome variables, and the ORs were adjusted for all other variables with 95% CIs. In this analysis, the outcome variables, dual contraceptive utilisations were dichotomised with "1" being utilising and "0" being not utilising dual contraceptive methods. Two different models were tted to investigate the factors predicting dual contraceptive utilisation.
Accordingly, the HL test for the following two models showed chi-square p-values > 0.05, which proved the goodness-of-t of the applied models for this study at p = 0.74 for dual contraceptive methods use. Keynote: ***p < 0.001, **p < 0.01, *p < 0.05 CI = con dence interval, AOR = adjusted odds ratio As presented in Table 6, women who had attended family planning counselling during follow up were 2.18 times more likely to utilise dual contraceptive methods as compared to those who had not attended family planning counselling.
The reproductive-aged women who had discussions about family planning with their healthcare providers during follow up were also 3.6 times more likely to utilise dual method services.
Women who had received family planning counselling on the e cacy of each method, side effects and the mixed methods available to them were 3.8 times more likely to have higher odds of dual method utilisation as compared to women who had not received family planning counselling during follow-up.
Women of reproductive age who had a history of their last pregnancy being unwanted/unplanned were 3.36 times more likely to use dual methods as compared to a wanted/planned pregnancy.
Women who had received services from knowledgeable and comfortable ART providers of integrated family planning/HIV services had 2.9 times higher odds of dual method utilisation as compared to those who were seen by unknowledgeable and uncomfortable ART providers.
Those women of reproductive age who had disclosed their HIV status to their family had 3.57 times higher odds of dual method utilisation as compared to those who had not disclosed their HIV status.
This study identi ed factors that increased the likelihood of dual contraception among reproductive-aged women living with HIV in Oromia Region, Ethiopia. These were found to be women who had discussed family planning with their healthcare provider and received family planning counselling about the e cacy of each method, the side effects and the mixed method available; women who received services from knowledgeable and comfortable ART providers for providing integrated family planning/HIV services; women who had experienced a previous unplanned pregnancy; a partner's HIV status and discloser of their HIV status to their family resulted in higher odds of dual contraception utilisation.

Discussion
With regard to the residential area, the majority of the respondents (n = 518, 79.2%), resided in urban areas, and 136 (20.8%) lived in the rural area. The socioeconomic characteristics of the respondents were not different from the socioeconomic pro le of Ethiopia. For example, in the general population of the same region, Christian denominations dominate and represent 65% of the population, and the largest ethnic group is Oromo, followed by Amhara which represent 64% of the population (CSA 2016:33). The results are also similar in terms of the proportion of women who are currently married or living together with a partner (65%) in the general population (CSA 2016:34).

Unintended pregnancy, family planning and dual contraceptive utilisation
This study identi ed that 21.4% of last pregnancies were unintended, which is consistent with the ndings of a study conducted by Heffronet al (2010:261-267). The latter revealed that 21.2% of women were found to be pregnant during follow up; the pregnancy incidence rates were 16.3 (95% CI 14.9-17.7) per 100 person-years. A study done in Mumbai, India, found that 16.6% of women had unintended pregnancies (Joshiet al2015:168). In contrast, a DHS conducted in 21 low-and middle-income countries revealed that the unmet need for family planning, a pregnancy risk, family planning methods, and use of postpartum family planning remain high at 61%, while pregnancy risks can peak at 6 to 11 months after childbirth. The same study claims that women often rely on short-term methods only (51-96%) (Mooreet al2015:31). Another study conducted on HIV-infected clients in Lusaka found that 49% reported that the pregnancy was unplanned (Hancock et al 2016:392). There are thus still gaps in the provision of care and continued limited availability of long-acting contraception for those who need it. This observation could be explained by the fact that, as this study shows, strengthening counselling on dual contraceptive method use for effective protection are crucial among these populations. Moreover, the issue of unintended pregnancies would be particularly important in terms of its contribution to new paediatric HIV infections. It is thus vital that there be reconsideration on dual method use for effective protection of unintended pregnancies among this population.
The current study indicated that 94.9% of women living with HIV were sexually active and 71.6% had used condoms, of which 61.9% always used condoms and 23.5% used condoms inconsistently. These ndings were supported by a study conducted in Thailand which revealed that 82.3% of women were sexually active and 69.8% had used condoms (Munsakulet al 2016:8). This observation could be explained by the fact that, as this study shows, some sexually active reproductive-aged groups still ignore the modes of HIV infection.
The proportion of current family planning utilisation was 83.8% at 95%CI which ranged from 81.2 to 86.8% among women living with HIV. These ndings were lower than what was reported in the previous study done in Thailand, which mentions that 96.3% of respondents had used a contraceptive method (Munsakulet al2016:8). Also, a study in Cambodia re ected that 68.5% of respondents used contraceptive methods (Nakaieet al2014:170), and South Ethiopia revealed that 77.4% used at least one form of family planning method (Feyssaet al 2015:3). These indicate the need for family planning among women living with HIV in family planning/HIV service settings. There is a need for increased comprehensive care in order to meet the women living with HIV's diverse need for integrated family planning/HIV services under one roof.
The prevalence of dual contraceptive utilisation was 73.8% with 95%CI of 70 to 77.3%, of which 80.7% were consistent, and 72% were sustained users of the dual method in Oromia Region, Ethiopia. This prevalence was high compared to previous studies conducted among respondents with similar characteristics. For instance, in Mumbai, India, it was reported that 69% of respondents wished to use dual contraceptive methods for effective protection (Joshi et al 2015:168). In Thailand, 29.6% used dual contraceptive methods (Munsakulet al 2016:8). Different countries had the following prevalence: in Cambodia, 17.5% employed a dual contraceptive method (Nakaieet al2014:170); South-East Nigeria reported that 27.2% had practised dual method use, of which 26.8% used consistently in the preconception period but the majority (73.2%) sometimes used in an inconsistent way (Lawaniet al2014:39); and a prospective study by Heffron et al (2010:621-628) revealed23.5% dual contraceptive prevalence and consistent use. This discrepancy may be due to the fact that 83.0% of recent study respondents had discussed dual method utilisation with healthcare providers, and 65.3% with their sexual partner. Another possible contribution for this difference may due to service provision systems as evidenced from service providers and focal persons reporting that all health facilities offered sexual reproductive health services within HIV services with the same provider and offered on the same day, which accounts for 100% of respondents.

Determinants of contraceptive utilisation among HIVinfected women
This study identi ed factors that increased the likelihood of the use of modern contraceptives as women who had discussed family planning with healthcare providers; knowledgeability on modern family planning; number of sexual partners; unintended last pregnancy; sexual partner HIV status; and discloser status to their families. These ndings are in line with some previous studies' ndings which identi ed the determinants of family planning utilisation as obtaining family planning information from health facilities; awareness on MTCT; having a son; partner knowledge of HIV status; use of a contraceptive method prior to diagnosis of HIV; married or cohabiting couples; religion; age; wealth; education and having a child (Nakaie et al 2014:170;Laryeaet al 2014:26;Ngugiet al2014:S80).
This study identi ed factors that increased the likelihood of dual contraceptive use were women who had discussed family planning with healthcare providers; received family planning counselling on the e cacy of each method, side effects and the method mix available; had gotten services from knowledgeable and comfortable ART providers on integrated family planning/HIV services; had an unplanned previous pregnancy; had knowledge of their partner's HIV status; and discloser status of HIV to their family. These ndings concur with some previous studies' which revealed determinants of dual contraceptive use as being female; receiving care; being aware of HIV status; being comfortable with asking a partner to use a condom; communication with a healthcare provider about family planning; household wealth; and HIVpositive women. These women were signi cantly more likely to use dual contraceptive methods (Munsakul et al 2016:4-5;Antelman et al 2015, Kimaniet al 2015. These ndings demonstrate the importance of integrating reproductive health services into routine HIV care. In contrast, another study identi ed factors associated with decreased odds of dual method use as being of older age; being separated or/divorced; having fewer living children; and reporting that their partner wants a child (Munsakul et al 2016:4-5).

Conclusion
Modern family planning utilisation among women of reproductive age living with HIV was relatively high at 83.3% in the study area. The identi ed determinants of modern family planning utilisation were a discussion with healthcare providers in terms of family planning; knowledge about modern family planning; number of sexual partners; previous unplanned pregnancy; partner's HIV status; and disclosure status of HIV to their family. These determinants signi ed higher odds of family planning utilisation among women of reproductive age living with HIV in Oromia Region, Ethiopia.
The prevalence of dual contraceptive utilisation was 73.8%, of which 80.7% were consistent and 72% were sustained users of the dual method in Oromia Region, Ethiopia. The identi ed factors associated with dual contraception method utilisations were discussion with healthcare providers regarding family planning; unplanned previous pregnancy; partner's HIV status; discloser status of HIV to their family; family planning counselling e cacy, and services from trained ART providers, respectively.
The current family planning utilisation among women of reproductive age living with HIV was 548 (83.8%). The following were identi ed as determinants of current family planning among HIV-infected women in the area of study: open discussion on modern family planning utilisation with healthcare providers; being knowledgeable about modern family planning; number of sexual partners; previous unplanned pregnancy; partner's HIV status; and disclosure status of HIV to their family. The last two factors led to higher odds of family planning utilisation among women of reproductive age living with HIV in Oromia Region.
The study further established that contraception utilisation was in uenced by the fact that 608 (94.9%) respondents were sexually active during the last six months. Disclosure of HIV status added to the list whereby 589 (91.4%) respondents had disclosed their HIV serostatus to a regular sexual partner and 499 (76.3%) had disclosed to family.

Recommendation
Integrated family planning/HIV services contribute to the national family planning programmes to provide full access to a variety of contraceptive methods so that couples and individuals can obtain the method that best suits their needs. The main contribution of the study to the level of health policy is as follows: Increases consistent and sustainable dual contraceptive users among women of reproductive age living with HIV in Oromia Region, Ethiopia.
Provide quality counselling to improve the knowledge of reproductive-aged and empowered women by service providers on the integrated family planning/HIV services.
Healthcare providers should be trained, equipped, and encouraged to take ownership of the implementation of the reproductive-aged women-centred integrated family planning /HIV strategic plan.
Strengthening implementation of integration of family planning and HIV services should lead to an increase in the utilisation of family planning, dual contraceptive methods, need for family planning being met, prevent repeated unwanted pregnancy, and offer HIV services. This will ultimately improve the quality of life of reproductive-aged women, the community, and families at large.
Facilitate capacity building training for health professionals, health managers, women living with HIV and peer educators, including mother-to-mother support groups, so that all key actors are equipped with the necessary skills in sexual reproductive health services, family planning, and HIV.
Innovate and scale-up best practices for the integration of maternal health service utilisation with HIV programme interventions.
Establish a policy framework for institutional implementation, monitoring and sectorial coordination aimed at promoting and integrating sexual reproductive health services, family planning, and HIV focused on reproductive-aged people living with HIV. The framework can be tailor-made across sectors with the set goals of improving treatment outcomes and quality of life for people living with HIV, especial women of reproductive age living with HIV.