Rwanda is the most densely populated country in Africa, and Total Fertility Rates (TFR) range from 4.7 in urban to 5.7 in rural areas. Use of modern contraception has increased from 10% in 2005 to 27% in 2008, including 15% injectable and 6% oral hormonal methods. Less than 2% of women have access to long-acting reversible contraceptives (LARC) - specifically the contraceptive implant and the intra-uterine device (IUD) - and few couples know about these methods. To safeguard economic development and lower TFR to 3, increased access to LARC is essential. Following our training in two large clinics in Kigali, the capital of Rwanda, the proportion of family planning (FP) clients choosing IUD or implant has risen from 2% to 65%, confirming receptivity among providers and clients and feasibility of adding LARC to the method mix. Our previous NIH funded work in Rwanda has led to the adoption of Couples Voluntary HIV Counseling and Testing (CVCT) as national policy in antenatal clinics, where >85% of husbands are now tested and >10,000 discordant couples are identified and counseled each year. In a research setting offering the full range of contraceptive options, 81% of fertile discordant couples wish to cease childbearing and >40% choose LARC. Self-report and biological markers confirm that LARC users maintain consistent condom use. Prevention of unplanned pregnancy is the lowest cost perinatal HIV prevention strategy, and contraceptive use is associated with longer survival in HIV+ women. Couples'family planning counseling results in high uptake of LARC, and combining this with CVCT can mutually leverage heterosexual and perinatal HIV prevention. Unfortunately, in government clinics CVCT is currently limited to pregnant couples, FP services are attended by women without their partners and do not offer HIV testing, and no safer-conception services are in place for discordant couples that wish to conceive. Integration of HIV prevention and fertility management will require investigation and intervention at several levels. Following formative research with policymakers, funding agencies, HIV and family planning service providers, and clients;1200 fertile couples - 300 each HIV M+F+, M+F-, M-F+, and M-F- - recruited from infant vaccination clinics will be offered CVCT+FP/LARC/safer conception counseling and services tailored to their fertility desires, and followed for three years with quantitative and qualitative assessments. We will include urban and rural, Catholic and non-Catholic clinics with a focus on: 1) Preventing unplanned pregnancy, perinatal HIV, and HIV-related maternal mortality through provision of LARC to couples;2) Optimizing condom use in discordant couples who do not want to conceive through dual method use, and 3) Preventing sexual transmission in discordant couples attempting to conceive. Leveraging our dual role as a 25-year old research project and a Center of Excellence for CVCT and LARC training, we will secure commitment from, and provide ongoing feedback to, policymakers and funders to ensure that research results are implemented nationwide in Rwanda and shared with other countries in Africa.
Three quarters of African adults are in cohabiting unions, where most new HIV infections occur and where demand for family planning is greatest. The proposed research project aims to optimize the integration of family planning services to prevent unplanned pregnancy and perinatal HIV, with couples'voluntary counseling and testing (CVCT), the only behavioral intervention proven to reduce HIV infection in couples. The government of Rwanda's support for access to the full range of contraceptives to reduce total fertility rate and thus protect economic development, and the ongoing nationwide dissemination of CVCT services make Rwanda an ideal setting for this research project.