Kevin Osborne, Senior HIV Advisor Making the Most of It: Sexual and Reproductive Health (SRH) and HIV Linkages Kevin Osborne, Senior HIV Advisor

1.Why should we link SRH and HIV?

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.

Global Recognition Glion Call to Action on Family Planning and HIV/AIDS in Women and Children (May 2004) New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health (June 2004) UNAIDS policy position paper ‘Intensifying HIV prevention’ (June 2005) World Summit Outcome (September 2005) Call to Action: Towards an HIV-Free and AIDS-Free Generation (December 2005) UNGASS Political Declaration on HIV/AIDS (June 2006) Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services (November 2007) The Global Fund to Fight AIDS, Tuberculosis and Malaria – Technical Review Panel Recommendation (2008) Global Fund: In 2008, the independent Technical Review Panel of the Global Fund recommended that technical assistance to countries for proposal development place greater emphasis on potential opportunities for integration and synergy between sexual and reproductive health and HIV/AIDS, since HIV infection is acquired and transmitted largely through unprotected sexual intercourse or during pregnancy, childbirth and breastfeeding.

Terminology matters Linkages* - The bi-directional synergies in policy, programmes, services 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. Integration* - Different kinds of sexual and reproductive health and HIV services or operational programmes that can be joined together to ensure and perhaps maximize collective outcomes. This would include referrals from one service to another, for example. It is based on the need to offer comprehensive services. * Definitions agreed upon by the IAWG on Linkages As is so often the case when two programme areas are brought together, there is still confusion about the terms “linkages” and “integration.” Here, we attempt to explain these terms – which have been agreed by the IAWG on Linkages – and how increased linkages can advance the response to HIV and AIDS.  

2.How should we link SRH and HIV?

Some general principles Address structural determinants Focus on human rights and gender Promote a coordinated and coherent response Meaningfully involve PLHIV Foster community participation Reduce stigma and discrimination Recognise the centrality of sexuality Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

SRH and HIV Linkages Matrix There are a number of things that can be done at community level - These country report cards – currently available for 25 The pink row shows key HIV services while the green column shows key SRH services. Not only does this matrix show peer-reviewed studies in the top left-hand corner of each box, but also so called ‘promising practices’ in the bottom right-hand corner of each box. The areas shaded in grey were studies which were already reviewed elsewhere. The trend indicates that the majority of studies addresses the intersection between HIV prevention, education and condom programmes and key SRH services, and highlights possible research and programme areas for the future. Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

3. How do we know it works?

Kenya Site: Family Health Options Kenya Clinics Purpose: Providing a range of HIV services in a sexual and reproductive health setting such as VCT, PMTCT and ART. Results: Increased the number of young people seeking HIV testing in Nairobi Youth Centre by 35% between 2004 and 2005 Increased demand for SRH services as well as HIV services More men started using the clinics Linkages lessons: Providing a range of HIV services in SRH clinics attracts new clients and creates opportunities for promoting SRH to a wider population. Out of 9 clinics: Eight provide VCT All nine provide PMTCT as part of maternal health services Five provide ART to PLHIV 4 out of 9 clinics provided ART Nairobi Youth Centre 2003 - 1500 clients for VCT, 2004 – 2025 clients for VCT Source: Gateways to Integration: A case study from Kenya, WHO, UNFPA, UNAIDS, IPPF, 2008.

Haiti Site: Three GHESKIO Centres in Haiti Purpose: Voluntary counselling and testing as an entry point for comprehensive SRH services Results: 30-fold increase in the number of pregnant women seeking VCT between 1999 and 2004 when the PMTCT programme was introduced. Of 6,700 adults seeking VCT, 18% received treatment for an STI and 19% became new contraceptive users returning to the Centre for at least three family planning visits. Linkages lessons: Providing the opportunity to access other health services at the same time and under the same roof greatly enhances the uptake of HIV counselling and testing. The three centres are in Cite de Dieu, Cite Eternel and Cite Soleil Source: Gateways to Integration: A case study from Haiti, WHO, UNFPA, UNAIDS, IPPF, 2008.

Cambodia Site: Siem Reap District Purpose: Increasing utilization of VCT services and STI treatment for construction workers and sex workers Results: Increased services (3212 VCT and 3225 STI services provided) Empowered rural communities and sex workers Expanded HIV and STI prevention Linkages lessons: Partnerships with other NGOs and government services enabled peer-to-peer outreach and facilitated referrals

4. What is happening now?

Policy to practice Rapid Assessment Tool for SRH and HIV Linkages: A Generic Guide Assess HIV and SRH bi-directional linkages at the policy, systems, and service-delivery levels. Identify current critical gaps in policies and programmes. Contribute to the development of country-specific action plans to forge and strengthen these linkages. Focus primarily on the health sector. This tool was developed to help countries assess their current situation in relation to linkages. The purpose of this tool is (READ SLIDE) Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

Countries implementing the Rapid Assessment Tool Countries which have already implemented assessment Countries about to implement assessment Belize Lebanon Swaziland Benin Pakistan Tanzania Botswana Malawi Tunisia Burkina Faso Morocco Uganda Cote d’Ivoire Russian Federation Vietnam Kyrgyzstan Sudan Zimbabwe Afghanistan Jamaica Somalia Bangladesh Islamic Rep Iran St. Lucia Djibouti Lesotho Sri Lanka Ghana Namibia Surinam Granada Nepal Trinidad & Tobago Guyana Maldives Yemen India Nigeria Zambia Already implemented Zimbabwe Morocco

5. What key issues still remain?

What do the linkages between SRH and HIV look like in concentrated epidemics? Is integration of services cost effective? Does integration lead to stigma reduction? Does linkages help donors to avoid funding vertical programmes? How can we prove that particular integrated models work?

6. What are the take home messages?

Linkages is a dynamic and moving field Linkages is more than just the integration of SRH and HIV services Need to move linkages beyond the low hanging fruit Enabling factors: Increased political will Support from different funding mechanisms Disabling factors: Vertical programmes and funding streams Territorialism