Overview of the SRH and HIV Linkage Dr. Jean-Baptiste ROUNGOU WHO Regional Office for Africa

Outline Rationale for linking SRH and HIV What has been done so far? What can be done to foster linkages? Challenges Key recommendations

What do we mean by SRH and HIV linkages? This is the fostering of synergies in policy, programmes, service delivery and advocacy between sexual and reproductive health and HIV.  It refers to a broader human rights based approach, of which service integration is a subset.

Rationale for Linking SRH & HIV Majority of HIV infections in sub-Saharan Africa are sexually transmitted, or associated with pregnancy, childbirth & breastfeeding among women Common root causes Poverty Gender inequality Gender-based violence Human rights violations Marginalization of key populations Stigma and discrimination Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, WHO, IPPF, UNAIDS, & UNFPA, 2005 There are clear reasons why it is important to link SRH and HIV (READ SLIDE)

Benefits of Linkages improved access to and uptake of key HIV and SRH services better access of PLHIV to SRH services tailored to their needs reduction in HIV–related stigma and discrimination improved coverage of underserved / vulnerable / key populations greater support for dual protection improved quality of care decreased duplication of efforts and competition for scarce resources better understanding and protection of individuals’ rights mutually reinforcing complementarities in legal and policy frameworks enhanced programme effectiveness and efficiency better utilization of scarce human resources for health Some of these benefits are well established and the current status of the evidence to support these benefits will be introduced later in this presentation. Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009. 5

What has been done so far? Political Commitment (Glion 2004, New York 2004) Framework for priority linkages (2005) Evidence Review (2008) Rapid Assessment Tool for SRH and HIV linkage is available (2008) Indicators to measure linkages have been developed On a number of levels there is a broad consensus on the importance of better linkages between HIV and sexual and reproductive health. These include: - Political commitment: Glion Call to Action on Family Planning and HIV (2005), New York Call to Commitment (2005) and the UNGASS 2006 A priority framework was developed in 2005 highlighting key areas where HIV and SRH can be linked together A systematic evidence review using Cochrane methods was conducted in 2008 and the results of the review are now widely available A rapid assessment tool to support countries to assess the national situation in relation to linkages was developed in 2008 and the roll out at a country level has started

Conceptual Framework This is just a starting point, a sampling of what is possible in a certain context. For example, sometimes STIs are considered HIV services, not SRH services. The categories aren’t rigid. Bi-directionality is key: SRH interventions into HIV service delivery settings, and HIV interventions into SRH service delivery settings. Not just around prevention—treatment too. SRH settings are increasingly delivering treatment services as well. While all of the linkages look like services (integration) there are structural and policies concerns embedded within each one. Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, WHO, IPPF, UNAIDS, & UNFPA, 2005. 7

What can be done? SRH Providers should Provide HIV prevention information and services to all clients; Provide information to prevent unintended pregnancies and HIV/STIs through correct and consistent condom use; Provide nondirective, nonjudgmental and confidential counselling on SRH of people living with HIV; Provide HIV counselling and testing and ART as indicated; Strengthen maternal and child health services Deliver a comprehensive package of PMTCT services Address the SRH needs of key populations and their clients. Not all sites may be able to provide all HIV and SRH services, for example: They may not be able to provide the 4 elements of PMTCT but ideally they should at least facilitate access to all four elements. STIs are not included on this list under the assumption that SRH providers are already addressing these issues, but this may not be true in all settings. Key populations are defined as those populations for whom HIV risk and vulnerability converge. HIV epidemics can be limited by concentrating prevention efforts among key populations. The concept of key populations also recognizes that they can play a key role in responding to HIV. Key populations vary in different places depending on the context and nature of the local epidemic, but in most places, they include men who have sex with men, sex workers and their clients, and people who use or inject drugs. Many women at risk of HIV—as well as those unaware that they are HIV positive—come into contact with the health care system seeking reproductive health services, which presents opportunities for providers to reach them with HIV prevention and treatment services, either directly or by referral. Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008. 8

What can be done? HIV service providers should Address sexual and reproductive health of people living with HIV Prevent, diagnose and treat sexually transmitted infections other than HIV; Refer for prenatal care and high quality obstetrical services; Provide counselling on fertility desires and provide related services and commodities; Better understand and respond to the SRH needs of key populations, including men who have sex with men, people who use drugs, and sex workers and their clients. When integrating SRH services into existing HIV programmes is important not to overburden or compromise the quality of existing services. HIV health providers can ensure the sexual and reproductive health needs of people living with HIV are addressed. A positive HIV diagnosis does not have to mean an end to people’s sexual lives – including their desire whether or not to have children. Access to condoms and other contraceptives, high quality obstetrical care and the full spectrum of prevention of mother-to-child transmission (PMTCT) interventions are essential to both reproductive health and HIV prevention. Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008. 9

Challenges Discrepancies in policies Political commitments for linkages not translated fully into action Lack of joint planning, funding leading to vertical implementation Service providers lack skills to provide integrated services

Key Recommendations: Policy Makers Develop, adopt, adapt and strengthen relevant policies, HIV and SRH strategic plans and coordination mechanisms to foster effective linkages. Advocate for sufficient funding for service delivery, operations research and other activities to further the linkages agenda. Ensure the implementation of a collective approach to SRH and HIV linkages Promulgate and enforce legal frameworks The evidence review made some key recommendations to policy makers (READ SLIDE) Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009. 11

Key Recommendations: Programme Managers Strengthen linked SRH and HIV responses in both directions through: Sustained government and stakeholder commitment Adequate human resources and joint planning Health provider training Client education Improved quality of services Adequate infrastructure Reliable supplies management Programme managers should …. Read slide Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009. 12

Key Recommendations: Researchers Design studies on integrated SRH and HIV services and document best practices. Evaluate key outcomes, such as: Health, Stigma reduction, Cost-effectiveness Trends in access to services Direct research toward areas that are under-studied and innovative service delivery for universal access And researchers: Read slide Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009. 13