1. Integrating Sexual and reproductive health and HIV services SLIDE 1 Integrating Sexual and Reproductive Health and HIV services Thilde Knudsen –Head of Europe Office

2. Integrating Sexual and reproductive health and HIV services SLIDE 2 Children by Choice not by Chance MSI is one of the largest non-governmental organizations providing reproductive health services Our mission is to defend the right of couples and individuals to have: Children by Choice, Not by Chance

3. Integrating Sexual and reproductive health and HIV services SLIDE 3 The MSI Global Partnership scale and impact Prevention of 13000 maternal deaths Over 7 million customers 42 countries +600 centres 8000 staff >1700 franchised clinical providers 12000 clinical outreach locations

4. Integrating Sexual and reproductive health and HIV services SLIDE 4 Integrated Health Services Family Planning Short term methods (dual protection) Long term and permanent FP methods Pre- & post-natal care and deliveries Emergency obstetric care (referral) Safe abortions and post-abortion care HIV/AIDS (and other STIs) Prevention, Diagnosis and treament, counselling, referral, HIV testing, circumcision General Health Care Diagnosis, treatment or prevention of malaria, tuberculosis Treatment of childhood diseases & immunization Partnerships with governments Partnerships with other agencies Vouchrs

5. Integrating Sexual and reproductive health and HIV services SLIDE 5 Service delivery models

6. Integrating Sexual and reproductive health and HIV services SLIDE 6 Why integration is so important mainly affect people of reproductive age share root causes - poverty, gender inequality, harmful cultural norms and social marginalization Both target STI’s with benefits for both pregnancy outcomes and transmission rates In countries with high HIV-prevalence the proportion of maternal mortality attributed to HIV is as high as 67% (Swaziland) (against a sub-Saharan proportion of 10.4%) The great untapped potential –missed opportunities in the 30% of pregnant HIV positive women eligible for HAART and not getting it –and these are the high transmitters The survival of the mother is the survival of the children –regardless of HIV status High unmet need for FP in WLWHA –despite the simplest, cheapest way of combating MTCT

7. Integrating Sexual and reproductive health and HIV services SLIDE 7 A win-win situation Common outcomes such as reduction in maternal, newborn and child mortality, promotion of dual protection, promoting SRH and human rights of all Reach more people, respond holistically to clients sexual and reproductive health needs in one site or by referral Strengthening health systems (a pre-requisite and a secondary effect): – Increased effectiveness and efficiency – Increased access to range of services – Improved health services for women, men and youth – Once implemented more cost efficient

8. Integrating Sexual and reproductive health and HIV services SLIDE 8 Our MoU –a declaration of intent In 2011 MSI and The Alliance agreed on the MOU with the aim to: – Promote and advocate for SRHR and HIV needs and rights for all people – Promote and provide integration HIV and SRHR services incl. FP in policies, programmes, services – Achieve more effective allocation of resources with verifiable results for individuals and communities

9. Integrating Sexual and reproductive health and HIV services SLIDE 9 Self-assessment tool Developed by MSI and the alliance 2011/2012 to indicate the stage, type and quality of integration of HIV prevention and treatment within (MSI’s) SRH programmes 1. To assess: –Integration at Country Support Office, Centre/Franchise, Outreach and community level –The type and coverage of HIV services that are integrated into the range of SRH services offered –The quality of the integrated services from the perspective of clients, providers and observers 2. To understand the current situation using scoring & explanation and plan how to increase coverage & quality of integrated services Piloted in Tanzania and Zambia (2011)

10. Integrating Sexual and reproductive health and HIV services SLIDE 10 Minimum Package of Services MSI ServiceHIV Minimum package Family planning Safe abortion Ante-natal care STI services HIV testing Male circumcision Cervical screening Safer sex counselling Dual protection/Condom promotion & supply HIV testing and counselling STI detection and treatment Addressing gender based violence

11. Integrating Sexual and reproductive health and HIV services SLIDE 11 Key findings Pilot – Governments, MSI staff, local NGOs and clients welcome the focus on integration with great enthusiasm and willingness to engage – Is successful in bringing men and youth to outreach services – HIV interventions exists at various SRH services but lacks consistency and minimum standards – HIV& SRH messages in BCC materials/activities are not integrated – Action to improve condom and VCT supplies needed – Training on integrating FP & VCT is needed. – Uptake of both VTC and LAPM increased as a results of integrated efforts (slide)

12. Integrating Sexual and reproductive health and HIV services SLIDE 12 Results

13. Integrating Sexual and reproductive health and HIV services SLIDE 13 Kenya integration of services Since 2007, MSI’s programme in Kenya partners with the Government and private health providers to deliver high quality and integrated HIV SRH services: – Integrated HIV and SRH services in MSI Kenya’s clinics and through outreach services – HIV and AIDS referral networks (to public and private health facilities) supported by youth peer educators and community health workers – Training public and private providers – Awareness raising activities

14. Integrating Sexual and reproductive health and HIV services SLIDE 14 Outcomes Kenya Access and uptake HIV and SRH services subsequently increased Improved quality of care; Capacity of existing public and private health providers strengthened considerably Services improved for under-served communities eg young people Knowledge, attitudes and practices of clients improved Reduction of stigma and discrimination through increased HIV awareness and normalisation of HIV and SRH services Strengthened support for dual protection Strengthened efforts to tackle common determinants (inequitable access, need for accurate information, women’s empowerment)

15. Integrating Sexual and reproductive health and HIV services SLIDE 15 Cambodia National Assessment In June 2012 MSI and the Alliance led the “National FP-HIV Integration Assessment” in, in close collaboration with the Cambodian Government and PSI (USAID and PEPFAR supported) – To describe current status of and gaps in integration of FP/HIV work in Cambodia in public, private and NGO services – Four levels of enquiry: client, service delivery, health system, policy

16. Integrating Sexual and reproductive health and HIV services SLIDE 16 Key findings Cambodia International support for integration of FP and HIV is strong, but the evidence base for effectiveness and cost- effectiveness is weak In a concentrated epidemic FP/HIV strategies need to be tailored to the country context Most people living with HIV have an unmet need for FP and PLWHA (including sex workers and women who use drugs) need advice on safe pregnancy options

17. Integrating Sexual and reproductive health and HIV services SLIDE 17 Key conclusions Cambodia Referral linkages between the wide range of HIV and maternal health services need to be followed up and documented in patient records, and managed by a client manager The policy environment in Cambodia is extremely supportive of integration. There is political commitment and leadership for linking health services for HIV and family planning.

18. Integrating Sexual and reproductive health and HIV services SLIDE 18 Challenges to realize integration Supply chain: separate request process; stock-outs Quality: improving with training and supervision Increased workload for service providers Manage waiting time for clients Initially increased costs (setting up, training) Motivating donors to support integrated approach

19. Integrating Sexual and reproductive health and HIV services SLIDE 19 Future opportunities – Self-assessment tool shared and used across MSI and HIV/AIDS Alliance programmes – Support MSI programmes’ capacity in HIV prevention, diagnosis, provision or referral for treatment and support services – Provide, in collaboration with HIV/AIDS Alliance, sector wide guidance on HIV-SRHR integration –documenting and sharing best practice – Promote HIV-SRH integration at all levels: individual, community, service delivery, policy level and keeping it a priority for Governments, relevant International donors and large scale initiatives in global health

20. Integrating Sexual and reproductive health and HIV services SLIDE 20 UNFPA maternal mortality trends 2010 World aids day report UNFPA data report 2012 South Africa 59.9%