53690 HIV/AIDS and Sexual and Reproductive Health Linkages at a glance Why link HIV/AIDS and sexual nancy, childbirth, and breastfeeding. In Sub-Saharan Africa, the majority of new HIV cases are among and reproductive health? women and girls, a major target of SRH services. Despite these overlaps, HIV/AIDS and SRH services The importance of linking HIV/AIDS as a part of have been historically separate and uncoordinated. sexual and reproductive health (SRH) is abundantly The current parallel financing and health service in- clear: the majority of HIV cases--about 85%--are frastructure for HIV/AIDS was developed in response sexually transmitted and both HIV/AIDS and many to the urgent call to address the AIDS crisis and illnesses linked to SRH have the same root causes. the global health community's understanding of the The greater proportion of pediatric HIV infections is disease over two decades ago. spread from mother-to-child in the process of preg- History The international community has evolved consider- Key Definitions ably in its understanding of the disease in the last two decades. In September 1994, the International Terms used in this document are based on defi- Conference on Population and Development (ICPD) nitions developed by WHO, UNAIDS, UNFPA established that the effective prevention and treat- and IPPF in Sexual and Reproductive Health & ment of sexually transmitted diseases, including HIV, HIV/AIDS: A Framework for Priority Linkages, is an integral part of reproductive health services. 2005, and Rapid Numerous meetings have been held since that land- Assessment Tool for SRH and HIV Linkages: A mark conference that have issued important position Generic Guide, 2008: statements that appeal for international action. All confirm the international community's com- Bi-directionality: Refers to linking both mitment to intensify the linkages between SRH with HIV-related policies and programs SRH and HIV/AIDS and recognize the need and HIV with SRH-related policies and pro- to consider the sexual and reproductive grams. health and rights (SRHR), needs, and de- Linkages: Refers to the bi-directional sires of people living with HIV/AIDS (PL- synergies in policy, programs, service and WHA). During the 2008 International AIDS Confer- advocacy between HIV/AIDS and SRH. ence in Mexico City, in the absence of a vaccine, the Integration: Refers to how different kinds case was made to put prevention at the forefront of of HIV and SRH services or operational HIV/AIDS as experts recognized that the pandemic programs can be joined together to ensure cannot be defeated without effective prevention nor and perhaps maximize collective improved can the community meet the UN Millennium De- outcomes. This would include referrals from velopment Goals (MDGs) [4,5,6] of achieving one service to another, for example. It is universal access by 2010. Since no single strategy based on the need to offer comprehensive will be sufficient, a portfolio of all possible biomedi- health services. cal, behavioral, and structural interventions, includ- ing those from the field of SRH, will be needed to Sexual and reproductive health: Re- combat the epidemic in what is being termed "combi- fers to programs and policies related to and nation prevention". including family planning (FP), maternal and newborn health (MNH), STIs, reproductive tract infections (RTIs), promotion of sexual The Benefits of Linking HIV/AIDS and SRH health, prevention and management of gender-based violence, prevention of unsafe Integrated services are now seen as a key strategy abortion and post-abortion care. for overcoming missed opportunities of meeting the needs of overlapping target populations in March 2009 HIV prevention and SRH services. Moreover, there HIV/AIDS & SRH: Key Elements is widespread recognition that strengthening linkages between HIV/AIDS and SRH programs could lead to a SRH Key Linkages HIV/AIDS number of important public · Family Planning · Learn HIV status · Prevention · Maternal & infant care · Promote safer sex · Treatment health, socio-economic, · Management of · Optimize connection · Care and individual benefits, sexually transmitted between HIV/AIDS and · Support such as: infections STI services · Management of · Integrate HIV/AIDS other SRH problems with maternal and improving access to and infant health use of key HIV and SRH services better access of PLWHA Source: WHO/UNAIDS, IPPF/UNFPA (2005) to SRH services tailored to their needs reduction in HIV-related stigma and discrimination; improved coverage of Results: underserved/vulnerable/key populations The majority of studies showed improvements in all outcomes measured. Many reported improved or greater support for "dual protection" (correct and increased access to and uptake of services, includ- consistent condom use to prevent HIV and unin- ing HIV testing; health and behavioral outcomes; tended pregnancy) condom use; HIV and sexually transmitted infection improved quality of care (STI) knowledge; and overall quality of service. Link- decreased duplication of efforts and competition ing SRH and HIV was considered beneficial and for resources feasible, especially in FP clinics, HIV counseling and better understanding and protection of individuals' testing centers, and HIV clinics. Results from the few rights cost-effectiveness studies suggested net savings from HIV/STI prevention integrated into maternal and child mutually reinforcing complementarities in legal health services. (See additional results in Table 1.) and policy frameworks enhanced program effectiveness and efficiency ii. A review focused on HIV/AIDS and FP integration better utilization of scarce human resources for literature was carried out by numerous experts of health. an Interagency Working Group on HIV/AIDS-FP integration (2008) that focused on three models of integration: FP/HIV counseling and testing, FP/ Current Evidence on HIV/AIDS PMTCT, and FP/HIV care and treatment. and SRH Linkages Results: There have been three major recent efforts to exam- The result of this process was the development of a ine the evidence and determine promising ways of tool for adaptation and use by partners--Strategic linking HIV/AIDS and SRH: Considerations for Strengthening the Linkages between Family Planning and HIV/AIDS Policies, i. A systematic review of HIV/AIDS and SRH linkages Programs, and Services: A Tool for Planning and literature was conducted by WHO, UNFPA, IPPF, Implementation, 2009. UNAIDS, and UCSF (2008) following Cochrane Collaboration methodology, that included peer- HIV service clients have substantial unmet need reviewed as well as `grey' (non-peer-reviewed) for contraception in both concentrated and gen- literature (1990­2007). Overall, 58 studies and eralized epidemics. One of the most important program reports were included in the review; 36 factors to consider is the scale of the epidemic on were in Africa, 11 were in the UK or the USA, and how HIV should be integrated into FP programs, 11 were in Asia, Eastern Europe, Latin America particularly when resources are limited; targeted and the Caribbean. HIV programming would have more impact in a concentrated epidemic. Though most of the evi- and treatment had unmet need for contracep- dence is from studies in Sub-Saharan Africa with tive services, yet few were being systematically generalized HIV epidemics, many of the recom- screened for that need. Estimating unmet need mendations that have emerged from the experts for HIV counseling and testing services among will be applicable to other regions and countries. women using FP services is more ambiguous Once the tools for practically linking HIV/AIDS as most women report being monogamously and SRH, i.e., integrated IEC/BCC, and monitor- married, and few report using condoms. With- ing and evaluation tools, are made available, it out knowing about partner behavior and the will be imperative for these efforts to be evaluated potential risk of exposure to HIV, it is difficult and documented for furthering the evidence-base. to ascertain their risk of HIV acquisition, and There will also need to be adequate consideration the need for CT services. Many providers in the of health systems requirements for effectively link- integrated services had not been trained in the ing HIV/AIDS and SRH, such as, human resources, newly added cross-service despite there being information systems, leadership and governance, a specific integration strategy, and job aids and commodities/supply chain, and financing. supportive supervision were lacking. Many of the clinics visited had had some stock-outs of HIV iii. A five-country study of HIV/AIDS and FP integra- test kits or contraceptive supplies (condoms & tion in Africa--Ethiopia, Kenya, Rwanda, South injectables) and the clinics often lacked IEC ma- Africa, and Uganda--examined three models terials that would generate demand for the new with high potential for public health impact: FP in service. Generally providers were more likely to HIV counseling and testing, FP in HIV care and report having provided integrated services than treatment, and HIV services in FP. The programs clients were likely to report having received such included in the study had a specific integration services. strategy, had been functional for a minimum of three months, and operated at a minimum of three Overall results of these three efforts suggest gener- sites. The study included client characteristics and ally positive results of linking HIV/AIDS and SRH service needs, indicators of readiness to provide programs. However, few rigorous evaluations exist integrated services, provider readiness to offer leaving significant research gaps. Most of the recent integrated services, and compared provider and studies were noted to be of SRH integration into HIV client reports of services provided and received. programs due to the abundance of funding for the latter. More resources, therefore, will need to be Results: directed to investigating the best ways for integrating Findings revealed that many women using HIV HIV into SRH programs. counseling and testing services (CT), and care Table 1. Factors Promoting or Inhibiting Effective Linkages Promoting Factors Inhibiting Factors Positive attitudes and good practices among provid- Lack of commitment from stakeholders ers and staff Non-sustainable funding Ongoing capacity building Clinics understaffed/low morale/high turnover/inad- Involvement of the community and government dur- equate training ing planning and implementation Inadequate infrastructure, equipment, and commodities Simple, easily applied additional services which add Lack of male partner participation no costs to existing services Women not sufficiently empowered to make SRH decisions Non-stigmatizing services Cultural and literacy issues Male partner inclusion Adverse social events/domestic violence incidence Engagement of key populations Poor program management and supervision Stigma preventing clients from utilizing services Examples of integration of HIV/AIDS and family planning (FP) Service delivery elements that comprise the minimum essential package of integrated FP/HIV services are in purple in the table below. Integration of HIV services into FP services Integration of FP services into HIV services HIV services that can be integrated into the FP service FP services that can be integrated into the HIV service include: include: If HIV status is unknown: Screening clients for risk of unintended pregnancy* HIV/STI prevention education including risk- reduction Referrals to FP services for clients at risk of unintended counseling, condom demonstration and promotion, pregnancy. If no reliable FP services exist in the area, and counseling on dual protection and dual method the facility and its provider should strive to provide use* some methods, such as condoms, pills and injectables, on-site.* Assessment of HIV status and counseling on the ben- efits of knowing one's status* For HIV+ clients desiring pregnancy, referrals to PMTCT services* Screening for risk of HIV infection* Promotion and provision of condom use for dual pro- Referrals to counseling and testing (CT) services for tection and condom demonstration* clients at risk for HIV infection* Informed choice counseling on the full range of avail- HIV counseling and testing (provider- or client-initiated) able FP methods and where to access them, including discussion of method effectiveness, side effects, and If HIV+ status is known: non-contraceptive benefits; potential drug interactions Counseling on reproductive choices and contraceptive with hormonal contraceptives if client is on ARVs; options for women and couples with HIV* capacity of FP methods to prevent STI/HIV infection; Referrals to HIV care and treatment services* dual method use Referrals to care and support programs for people For HIV+ clients desiring pregnancy, provision of living with HIV* information on the risk of transmission to children and uninfected partners, assessment of health status as it re- For HIV+ clients desiring pregnancy, referrals to lates to pregnancy, and counseling on safer pregnancy PMTCT services* and infant feeding options Counseling on healthy timing and spacing of pregnan- For HIV+ clients desiring pregnancy, provision of cy, fertility return, LAM, and exclusive breastfeeding information on the risk of transmission to children and through six months uninfected partners, assessment of health status as it re- lates to pregnancy, and counseling on safer pregnancy Provision of oral contraceptive pills, injectable hormon- al contraceptives, intrauterine device (IUD), and/or and infant feeding options hormonal implants with instructions for use, and male Couple counseling on risk reduction for sero-concor- and female condoms dant and sero-discordant couples Provision of method re-supply and follow-up care, as Counseling on disclosure strategies for people diag- necessary nosed with HIV/AIDS and referrals for their partners for counseling and testing Provision of tubal ligation and vasectomy Specific HIV information and services for key popula- Referral for methods not offered on-site, preferably through a referral mechanism that guarantees same- tions, such as youth, MSM, sex workers, and injection day uptake of method drug users Psycho-social support for people living with HIV Referrals to other HIV services not offered on-site * Minimum essential package Research gaps tive use, etc.), stigma reduction, cost-effectiveness, and trends in access to services. The lack of experience and corresponding lack of 3. Direct research towards areas of integra- evaluations of programs linking HIV/AIDS and SRH tion that are currently understudied, notably makes evident the need for more study of efforts in integrating SRH services with HIV services this field. Recommendations to fill these research for PLWHA, including clinical and psychosocial gaps include: care, contraception and pre-conception planning if pregnancy is desired, gender-based violence reduc- 1. Design rigorous studies to evaluate integrated tion and linked services for men and boys. HIV and SRH services including processes and im- 4. Foster community participation in re- pact, particularly comparative assessments of search to ensure that all research on linkages has integrated delivery of services versus non- relevant outcomes for clients. integrated delivery of the same services. 5. Ensure strengthened collaboration be- 2. Evaluate key outcomes, such as: health indi- tween the HIV and SRH research commu- cators (unintended pregnancies prevented, HIV+ nities through the development of a collective births averted, increase/continuance in contracep- linkages research agenda. References Adamchak S, Reynolds H, Janowitz B, Grey T, Keyes E, FP and HIV/AIDS Integration: Findings from 5 Countries, World Bank Strengthening HIV/AIDS and SRH Linkages BBL Presentation on November 19, 2008, FHI/USAID, November 2008. Available at: http://go.worldbank.org/N8GFJMIDP0 Cates W, SRH/HIV Linkages: What's the Rationale? World Bank Strengthening HIV/AIDS and SRH Link- ages BBL Presentation on November 19, 2008, FHI/USAID, November 2008. Available at: http:// go.worldbank.org/N8GFJMIDP0 Interagency Working Group on FP/HIV Integration, Programmatic Considerations for Strengthening the Integration of Family Planning and HIV Service Delivery Programs, to be published in 2009. http:// www.hivandsrh.org/ Kennedy C. Linking Sexual & Reproductive Health and HIV: Evidence Review and Recommendations, World Bank Strengthening HIV/AIDS and SRH Linkages BBL Presentation on November 19, 2008, The Cochrane/WHO/IPPF/UNFPA, November 2008. Available at: http://go.worldbank.org/N8GFJMIDP0 Population Council. Women living with HIV have unmet family planning needs. FRONTIERS Operations Research Summary, No 75. 2008. Available at http://pdf.usaid.gov/pdf_docs/PNADL834.pdf The African Union, Maputo Plan Of Action for the Operationalisation of the Continental Policy Framework for Sexual And Reproductive Health And Rights 2007­2010, Special Session of the African Union Conference of Ministers of Health, Maputo, Mozambique, 18­22 September 2006. Available at: http://www.unfpa.org/africa/newdocs/maputo_eng.pdf The Lancet HIV Prevention Series, Volume 372, August 2008. http://www.thelancet.com/series/hiv-prevention UNFPA, The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health, June 4, 2004 Meeting, Rockefeller Foundation, New York, NY, 2004. Available at: http://www.unfpa.org/ upload/lib_pub_file/321_filename_New%20York%20Call%20to%20Commitment.pdf WHO, The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, May 3­5, 2004. Available at: http://www.who.int/reproductive-health/stis/docs/glion_cal_to_action.pdf WHO/HIV/2005.05: WHO/UNFPA/UNAIDS/IPPF. Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages, October 2005. Available at: http://www.who.int/hiv/pub/prev_ care/A%20Framework%20for%20Priority%20Linkages%20FINAL.pdf WHO, Strengthening Linkages between Sexual and Reproductive Health and HIV, HIV Technical Briefs, April 3, 2007. Accessed on October 2, 2008. http://www.who.int/reproductive-health/hiv/hiv_ tecbrief_srhhiv.pdf WHO, UNAIDS, UNFPA, IPPF, GNP+, ICW, and Young Positives, Rapid Assessment Tool for SRH and HIV Linkages: A Generic Guide, 2008 http://www.who.int/reproductive-health/hiv/linkages_rapid_assmnt_ tool.pdf WHO-HIV/UNFPA/IPPF-HIV/UNAIDS/UCSF, Sexual and Reproductive Health and HIV Linkages: Evidence Review and Recommendations, 2008. Available at: http://www.who.int/reproductive-health/hiv/link- ages_evidence_review.pdf Other Useful Resources FHI/Kenyan Ministry of Health, Integrating Family Planning into HIV Voluntary Counseling and Test- ing Services in Kenya: Progress to Date and Lessons Learned, FHI/USAID, 2006. Available at: http://www.fhi.org/NR/rdonlyres/es5cvy4xltapkfligen2lj32zvkcv2fpdv4ellln6c4viqcjbpaamdhkc- stld3n25fixj6uhgomyuc/FPVCTintegrationKenyalessons.pdf FHI/EngenderHealth, Increasing Access to Contraception for Clients with HIV: A Toolkit, FHI/USAID, 2008. Available at: http://www.fhi.org/training/en/modules/FPHIV_toolkit/interface.pdf Pathfinder International, Quality of Care for Integrated Services: A Facility Assessment Tool, 2003. http:// www.pathfind.org/site/DocServer/QOC_document_oct_6.pdf?docID=1581 UNAIDS, Intensifying HIV Prevention: A UNAIDS Position Paper, 2005. Available at: http://data.unaids. org/publications/irc-pub06/jc1165-intensif_hiv-newstyle_en.pdf Yoder P, Amare Y. Integrated Family Planning and VCT Services in Ethiopia: Experiences of Health Care Providers. Measure DHS/USAID, 2008. Available at: http://pdf.usaid.gov/pdf_docs/PNADN519.pdf Websites http://www.hivandsrh.org/ http://www.fhi.org/en/Topics/FPHIV.htm http://www.who.int/reproductive-health/hiv/index.html http://www.unfpa.org/publications/detail.cfm?ID=382&filterListType= http://go.worldbank.org/RQU0H5VGJ0 Prepared in technical collaboration the Interagency Working Group on FP/HIV Integration