Sexual and reproductive health and HIV linkages
Making the most of it
Von Kevin Osborne
HIV, AIDS, sex and reproduction are intimately connected and linking sexual and reproductive health (SRH) and HIV responses is a fast moving and dynamic field. HIV infection is the predominant sexual health issue facing the world today, especially as it is the leading cause of death in women of reproductive age. (The Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children. 2007)
The global movement to consign HIV infections among children to the annuls of history, prevent HIV infection among women of reproductive age and meet the unmet family planning needs of women living with HIV has the potential to significantly alter the maternal, newborn and child health landscape. (UNAIDS 2011)
It is becoming increasingly evident that a united sexual and reproductive health and HIV response offers one of the most effective routes to reaching the many people vulnerable to HIV infection or to those already living with HIV. It is also clear that the Millennium Development Goals will not be achieved without ensuring access to SRH services and an effective global response to the HIV epidemic. (WHO, UNFPA , UNAIDS and IPPF , 2005)
The ‘why’ and the ‘what’ of linkages has been defined. Yet, despite this rationale being clear, the potential benefits understood (WHO, UNFPA , UNAIDS and IPPF , 2005), and international consensus agreed about the need for linkages (IPPF, UCSF, UNAIDS, UNFPA & WHO, 2008) there is still a misunderstanding about exactly ‘how’ SRH and HIV linkages should best be addressed and scaled up in different kinds of HIV scenarios.
More than the integration of services
Linkages are more than just the integration of SRH and HIV services. Linkages are the bi-directional synergies in policies, programmes, services and advocacy between SRH and HIV. Linkages refer to a broader human rights based approach, of which service integration is a subset. (Rapid Assessment Tool, 2008) Integration refers specifically to how different kinds of sexual and reproductive health (SRH) and HIV services or operational programmes can be joined together to ensure and perhaps maximize collective outcomes. (IAWG on SRH and HIV Linkages, 2011)
It is imperative that any linked responses favourably impact on both SRH and HIV outcomes. However, despite the promise of mutual gains, a linked response has not been the norm; but there are encouraging signs that this is changing.
Policy: Fostering human rights
Policy level linkages between SRH and HIV are needed in order to address the structural determinants of HIV and SRH. (Adapted from UNAIDS, 2011) Otherwise gender inequality, poverty, stigma and discrimination and low levels of education, will continue to impede the gains on the both the SRH and HIV fronts. Linkages support the fundamental principle of national ownership that enables governments, in partnership with civil society, to examine their human rights laws and policies. These include those related to criminalization of HIV exposure and transmission; criminalization of practices and behaviours associated with key populations; access to SRH and HIV services including counselling and testing, rights-based family planning; gender-based violence; marriage, divorce and child custody, including, early and forced marriage; women’s property and inheritance; female genital mutilation; and other punitive laws and policies that affect human rights.
In many countries people from marginalised and/or vulnerable groups are often at an increased risk of HIV infection. Legal systems should provide special protection for key populations ( notably men who have sex with men; sex workers; people who use drugs and the transgender community), people living with HIV, and marginalised groups, as well as access to quality legal services so that human rights violations can be appropriately addressed.
Systems: Strengthening competency, capacity and coordination
Linking SRH and HIV requires that the supportive systems on which health and other services depend are addressed. While there are a number of wider health systems considerations, in the context of SRH and HIV linkages, the following systems should be assessed and strengthened (adapted from UNAIDS, 2011):
Partnerships – for situation analysis, planning, budgeting, resource mobilization, advocacy, implementation, monitoring and evaluation by development partners including civil society
Coordination mechanisms – for SRH and HIV joint planning, management and administration of linked advocacy and policies, and integrated services
Human resources and capacity building – joint SRH and HIV capacity building, including in-service training, of health providers and teachers; increase knowledge, skills and understanding of how to eliminate stigma and discrimination and gender inequality
Logistics and supplies systems – for ensuring SRH and HIV commodities security, preferably combined systems, including but not limited to condoms for dual protection, lubricants, full range of contraceptives, STI drugs, post-exposure prophylaxis kits, delivery kits, ‘dignity’ kits for humanitarian settings, HIV test kits, post-rape kits, antiretroviral drugs, drugs for opportunistic infections, anti-malarials, iron/folate, safe injecting equipment, methadone, etc.
Laboratories – for the combined needs of SRH and HIV including haemoglobin concentration, blood grouping and typing, STI diagnosis, HIV diagnosis (including rapid tests), CD4 count, HIV viral load, liver function tests, urinalysis, random blood sugar, pregnancy testing, diagnosis of cervical and other cancers etc.
Services: Beyond the ‘low hanging fruit’
For many the integration of SRH and HIV services appears to be the most easily understood
component of the linkages agenda. Yet, at the services level SRH and HIV have only tended to be partially integrated within a few ‘easy to link’ services such as integrating family planning services with HIV prevention education and condom distribution. (IPPF, UCSF, UNAIDS, UNFPA & WHO, 2008) A 2008 systematic review by the Cochrane Collaboration HIV Review Group assessed the current evidence base for linkages. Of the 227 studies included in the review, only 58 looked at the integration of HIV services beyond HIV prevention, education and condom distribution. The matrix below clearly identifies the potential integration that can take place and the lack of research in certain integration fields.
Enablers and disablers: Walking the talk
Implementing the linkages agenda requires a paradigm shift in the way in which all relevant stakeholders - including the donor community - work in unison. All too often the SRH and HIV fields have often been forced into territorialism and an unhealthy competition for scarce resources rather than actively encouraged to act on any of the natural synergies. Fully realizing the anticipated benefits inherent in linking the HIV and SRH responses requires a change in the stereotypical ‘business as usual’ approach.
A Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages (2009) is highlighting the strengths and gaps in current national responses SRH and HIV linkages. The Tool, which has been implemented in 19 countries to date also enables countries to gain a ‘snap shot’ of the current situation regarding SRH and HIV linkages, identify gaps and develop action plans.
The factors that promote linkages between SRH and HIV include: positive attitudes and good practices among providers and staff; an institutional commitment to ongoing capacity building; the active involvement of the community and government during planning and implementation; the addition of simple and easily applied services which add very limited costs to existing services; the development of a ‘stigma-free’ environment in which services are provided; the involvement of male partners and the engagement of key populations.
Factors that impede or inhibit linkages include: a lack of commitment from stakeholders; non-sustainable funding to support increased work on linkages; clinics that are understaffed or which have a low morale and high staff turnover; lack of capacity development for staff and providers; inadequate infrastructure, equipment, and commodities; women who not sufficiently empowered to make SRH decisions; cultural and literacy issues; adverse social events including domestic violence incidence; poor programme management and supervision and stigmatizing attitudes that prevent a wide range of potential clients from utilizing services.
Determining the ‘optimal model’ for integrating services depends on a variety of factors. To date, successful methods of service integration have captured the ground realities faced by a variety of service providers. From delivering all SRH and HIV services by one provider to providing selected high quality health and other services through innovative partnerships, the success of many integrated SRH and HIV services rests on the quality and effectiveness of referrals. (Chabikuli NO et al, 200) Facilitated referrals need to be strengthened to ensure that many of the opportunistic illnesses related to HIV are addressed, including tuberculosis, malaria and hepatitis; and SRH concerns such as infertility and cervical cancer are made priorities in HIV services.
Enhancing the efficiency of both SRH and HIV services is often highlighted by both policy-makers and programme specialists as one of the key anticipated benefits of integration. While care must be taken to not overload staff and other scarce resources; there are different areas of possible ‘value for money’ gains that strengthened linkages could facilitate:
At the governance level (such as co-ordination of strategic and operation planning, and performance level) efficiency may be improved by sharing scarce resources, such as skilled planners and managers. Joint or co-ordinated planning and management may also improve allocative efficiency, as (or if) planners allocate their scarce resources across interventions taking into account the relative cost-effectiveness of services.
At the financing level, technical efficiency may improve by merging the costs of separate financing systems. Co-ordinated financing systems may also reduce perverse incentives that may be created by competing programmes, and thus impact efficiency.
At the health management systems level, improvements in technical efficiency through reductions in management systems costs may occur. This can include joint procurement, sharing of middle managers, joint training and supervision, sharing of information, education and communication materials, and joint management information systems.
At the facility level, reductions in facility costs resulting from joint utilization of fixed factors of production could be facilitated.
At for patients, integration can lead to reductions in patient/community level costs resulting from fewer visits to facilities, greater proximity of services; stigma reduction and reduced delays.
Conclusion: Looking ahead
Linking SRH and HIV recognizes the vital role that sexuality plays in people’s lives, and the importance of empowering people to make informed choices about their sexual and reproductive health. There is clear momentum behind efforts to mainstream HIV into sexual and reproductive health and rights responses, and there is a strong recognition that this programmatic integration is necessary both to achieve SRH goals and to meaningfully respond to the HIV epidemic. World leaders adopted a new Political Declaration on HIV/AIDS “Intensifying our Efforts to Eliminate HIV/AIDS” at the recent UN High Level Meeting. The Declaration sets out the direction and commitments for the global response to HIV for the period up to 2015 and it clearly recognises the linkages between HIV and sexual and reproductive health in numerous key places. Despite a number of programmatic and policy challenges, progress on advancing the linkages agenda has significantly increased. Political will for linkages is increasing with national strategies to support SRH and HIV linkages being developed and funding available through some key funding mechanisms such as the Global Fund for AIDS, Tuberculosis and Malaria and PEPFAR.
The ongoing SRH and HIV linkages agenda must be supported by:
1. encouraging, promoting and supporting the integration of SRH and HIV services through sustainable financing, harmonized policies and good practice;
2. promoting and fostering collaborative action research to address some of the key research gaps - especially those relating to costs and benefits of integrated services;
3. strengthening ties between key maternal and newborn health initiatives and relevant aspects of the HIV response notably around the elimination of new HIV infections among children by 2015 and keeping their mothers alive;
4. maximizing the understanding and promotion of linkages in concentrated HIV epidemics to better address the SRH needs of key populations;
5. fostering and safeguarding a culture of human rights on which the success of linked HIV and SRH responses is built.
*Kevin Osborne is the Senior HIV advisor at the International Planned Parenthood Federation (IPPF), London, United Kingdom. As a native South African with extensive and varied experience in the HIV field, the current focus of his technical skill and expertise is in integrating HIV more fully into the sexual and reproductive health agenda. Contact: firstname.lastname@example.org, www-ippf.org
- The Inter-Agency Task Team On Prevention of HIV Infection in Pregnant Women, Mothers and their Children (2007) Guidance for Global Scale Up of Prevention of Mother-to-Child Transmission of HIV: Towards universal access for women, infants and young children and eliminating HIV and AIDS among children
- UNAIDS (2011) Countdown to zero: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive
- WHO, UNFPA , UNAIDS and IPPF (2005). Sexual and Reproductive Health & HIV: A Framework for Priority Linkages
- IPPF, UCSF, UNAIDS, UNFPA & WHO (2008) Linkages: Evidence Review and Recommendations
Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages: A Generic Guide. IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2008
- IAWG on SRH and HIV Linkages (2011) Top Ten: Frequently Asked Questions. www.srhhivlinkages.org
- IPPF, UCSF, UNAIDS, UNFPA & WHO (2008) Linkages: Evidence Review and Recommendations
- IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW & Young Positives (2009) Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages: A Generic Guide
- Chabikuli NO, Awi DD, Chukwujekwu O, Abubakar Z, Gwarzo U, Ibrahim M, Merrigan M & Hamelmann C (2009) The use of routine monitoring and evaluation systems to assess a referral model of family planning and HIV service integration in Nigeria. AIDS. 23(Suppl 1), pp. S97-S103