On the integration of programs… Luis Gutierrez Alberoni

PROPOSAL TO INTEGRATE SEXUAL AND REPRODUCTIVE HEALTH PROMOTION PROGRAMS AND SERVICES WITH THE HIV (AND STI) RESPONSE Rafael Maz í n, MD; MPH Rafael Maz í n, MD; MPH Luis Gutierrez Alberoni Quito, Ecuador. 29 October 2007

BASIC PREMISES Epidemiological evidence: Dynamic of HIV epidemic closely associated with all unprotected sex (> 80% of the cases) Infant mortality rate related to parental sexual behavior STIs neglected in health agendas (50 million cases annually), 110,000 cases of congenital syphilis Unsatisfactory efforts in prevention ( ∆12% in new cases in Latin America between 2004 and 2006) Access to treatments at risk (6 new infections for each person in treatment)

BASIC PREMISES Epidemiological evidence: < 10% of acts of coitus at risk for HIV are protected by condoms More than 85% of HIV+ individuals do not know their status < 20% people with STIs seek professional care < 20% of HIV+ pregnant women have access to prophylactic treatment < 10% MSM have access to prevention and < 20% female SWs have access to prevention Stigma, discrimination, homophobia, abuse are all still common in health services

BASIC PREMISES Contextual analysis: General difficulty in dealing with sexuality Neglect of masculinity, sexual orientation, attraction, pleasure, and power Sexual health reduced to reproductive dimension Sexual health linked with reproductive health, but not always with mental health, other areas Responses almost exclusively through health “Medicalization” (i.e., prevalance of a curative paradigm)

BASIC PREMISES Analysis of the responses: HIV programs have “tubular” structure HIV programs have “tubular” structure Interventions focused on sporadic events Interventions focused on sporadic events Services and activities focused on populations of childbearing age Services and activities focused on populations of childbearing age Lack of access to SRH promotion and care for especially vulnerable populations Lack of access to SRH promotion and care for especially vulnerable populations Lack of interest in non-routine interventions Lack of interest in non-routine interventions

BASIC PREMISES Sexuality, Health, and Well-being Sexuality, Health, and Well-being Reproduction

SRH 1. Know HIV status 2. Promote safer sex 3. Optimize the connection between HIV/AIDS services and STI services 4. Integrate HIV/AIDS with maternal and child health  Family planning  Maternal and child care  STI management  Management of other SRH problems HIV/AIDS  Prevention  Treatment  Care  Support Key Links Integration: High potential for benefits Source: SSR y VIH/SIDA. Un marco de referencia para establecer vínculos prioritarios. (WHO, UNFPA, UNAIDS, IPPF, 2005)

THE CASE OF NEW ZEALAND: HIV/AIDS Action Plan: Sexual and Reproductive Health Strategy

FOUR STRATEGIC AREAS IN THE ACTION PLAN Attitudes, values, and social behavior: Greater notification and understanding of the causes and impact of HIV/AIDS, with greater commitment to prevent and reduce impact Attitudes, values, and social behavior: Greater notification and understanding of the causes and impact of HIV/AIDS, with greater commitment to prevent and reduce impact Individual knowledge, skills, and behavior: People in vulnerable groups have knowledge, skills, self-esteem, and motivation to protect themselves Individual knowledge, skills, and behavior: People in vulnerable groups have knowledge, skills, self-esteem, and motivation to protect themselves Programs and services: Effective and accessible programs and services with integrated SRH activities and prevention and reduction of HIV/AIDS impact Programs and services: Effective and accessible programs and services with integrated SRH activities and prevention and reduction of HIV/AIDS impact Information: Information and evidence base for sustaining policies, program development, monitoring, and decision-making Information: Information and evidence base for sustaining policies, program development, monitoring, and decision-making

THE CASE OF GREAT BRITAIN: The National Strategy for Sexual Health and HIV

GOALS: - a) Improve information, services, and support - b) Reduce inequities in sexual health - c) Improve health, sexual health, and well-being PRINCIPLES: Appropriate services for individuals, their families, and their health care providers Appropriate services for individuals, their families, and their health care providers Integrated actions Integrated actions Focus on maintaining health and reducing inequities Focus on maintaining health and reducing inequities Services “without interruptions” Services “without interruptions” Adaptation to specific needs Adaptation to specific needs Ongoing improvement of services Ongoing improvement of services Respect for confidentiality and availability of information on services and treatments Respect for confidentiality and availability of information on services and treatments

THREE PILLARS OF THE STRATEGY I. BETTER PREVENTION Public information Guide on the use of evidence Clear goals in prevention (new HIV infections, unprotected sex, measured by STI rates including rectal gonorrhea) General goals at the national level II. BETTER SERVICES Chlamydia detection in certain groups Reinforce role of PHC Improve skills of PHC providers Increase HBV vaccination coverage III. BETTER MANAGEMENT THREE PILLARS OF THE STRATEGY I. BETTER PREVENTION Public information Guide on the use of evidence Clear goals in prevention (new HIV infections, unprotected sex, measured by STI rates including rectal gonorrhea) General goals at the national level II. BETTER SERVICES Chlamydia detection in certain groups Reinforce role of PHC Improve skills of PHC providers Increase HBV vaccination coverage III. BETTER MANAGEMENT Local commissions with various agencies and sectors represented Local goals linked to national goals Planning based on study of local needs Forging of professional partnerships and participation Participation of families and communities

From Montevideo I and II to Montevideo III: Scope of the Integration Strategy GOAL: Sexual well-being of people, families, and communities Integration of SRH and responses to HIV/STIs into national and local programs Integration of SRH and responses to HIV/STIs into national and local programs SRH policies on risk and damage control associated with sexual behavior and reproduction or with values, attitudes and beliefs related to these SRH policies on risk and damage control associated with sexual behavior and reproduction or with values, attitudes and beliefs related to these Integrated health services for young people and adults Integrated health services for young people and adults Development of professional skills in SRH Development of professional skills in SRH Linkage of health care actions with those in homes, schools, communities Linkage of health care actions with those in homes, schools, communities

From Montevideo I and II to Montevideo III: Areas for Integration Emphasis on Prevention Emphasis on Prevention Emphasis on Risk and Vulnerability Emphasis on Risk and Vulnerability Redimension STIs Redimension STIs Opportunities for concrete achievements Opportunities for concrete achievements Gender, masculinity, and power Gender, masculinity, and power Integrating role of the health sector Integrating role of the health sector

From Montevideo I and II to Montevideo III: Proposals for Action Political commitment Political commitment Integration among sectors Integration among sectors Promotion of gender agenda Promotion of gender agenda SRH care for men and women SRH care for men and women STI Programs STI Programs Community Participation Community Participation Comprehensive sex education Comprehensive sex education Training in sexuality and sexual health Training in sexuality and sexual health

From Montevideo I and II to Montevideo III: Suggested Key Strategies Comprehensive information for decision-making Comprehensive information for decision-making Health services that are accessible, inclusive, integrated, and effective Health services that are accessible, inclusive, integrated, and effective Promotion of sexual and reproductive health and well- being for the population Promotion of sexual and reproductive health and well- being for the population Integrated, efficient management and administration to carry out the integration strategy Integrated, efficient management and administration to carry out the integration strategy

Montevideo III: Next Steps Review the Strategic Proposal Review the Strategic Proposal Review and articulate with other potential members Review and articulate with other potential members Construction of matrix of actions and interventions Construction of matrix of actions and interventions Presentation of Family and Community Health strategy as an example Presentation of Family and Community Health strategy as an example