HIV and Reproductive Health? William Stones

Questions What is reproductive health? Is HIV best approached as a RH topic? What are the pros and cons of making the link? What are the research questions?

RH Definition- ICPD 1994 Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.

Reproductive Health Topics- WHO Adolescence Ageing Cancers Family planning FGM/Harmful practices Infertility Maternal and newborn health Prevention of unsafe abortion RTIs, STIs, HIV/AIDS NOT child health

Associated ICPD statements Reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems It also includes sexual health, the purpose of which is the enhancement of life and personal relations and not merely counselling and care related to reproduction and sexually transmitted diseases

New perspective: WHO 2004 …sexual health is broader and more encompassing than reproductive health. Rather than being a component, sexual health should in fact be seen as a necessary underlying condition for reproductive health, while at the same time being relevant throughout the life span and not only during the reproductive years

Includes… STIs, including HIV, and reproductive tract infections (RTIs) Unintended pregnancy and unsafe abortion Infertility Sexual well-being (including sexual satisfaction, pleasure and dysfunction) Violence related to gender and sexuality Certain aspects of mental health The impact of physical disabilities and chronic illnesses on sexual health Female genital mutilation.

Underlying issues Gender inequality Poverty Unequal access to education Rights

HIV/AIDS Domains (WHO) Antiretroviral Therapy Blood Safety Condom Promotion Harm Reduction Approaches to Injecting Drug Use Microbicides Nutritional Support Palliative Care Post Exposure Prophylaxis Preventing HIV Infection in Infants and Young Children Preventing HIV-Related Infections Psychosocial Support Second Generation Surveillance Sexually Transmitted Infections Sexually Transmitted Infections Surveillance Testing and Counselling Tuberculosis and HIV Universal Precautions Vaccines

Obvious links Clinical aspects –PMTCT, AN Screening, Cervical screening, STI testing and treatment, Family planning Condom promotion Microbicides Social aspects –Gender –Sexuality –Poverty –Education

Less clear… IV drug use Blood transfusion Men Nutrition TB Care and support Long term ART

Madhya Pradesh Uttar Pradesh Variables Aware of HIV Knowledge that HIV can be avoided Correct knowledge about HIV transmission Aware of HIV Aware that HIV can be avoided Correct knowledge HIV transmission Age group Y Y Y Y × Y Education Y Y × Y Y × Work Y Y × Y × × Religion Y × × Y Y × Caste Y × Y Y × × Standard of living Index Y Y Y Y × × Place of residence Y × × Y × Y Watch TV once a week Y Y Y Y Y × FP worker visited × × Y × × × Discussed FP with partner Y Y × Y Y × Everuse of F P Y Y × Y Y Y Media __ Y × - Y Y Vulnerable women groups in North Older Poor Less educated Not having access to TV Non-users of FP Lack of integration of FP with HIV

Impact in rural areas: TYPICAL PATTERN HUSBAND GET THE INFECTION FIRST USES FAMILY RESOURCES FOR TREATENT WIFE BECOMES HIV + WIDOW (WITH CHILDREN) DRIVEN OUT OF HUSBAND’S HOUSE TAKE SHELTER AT NATAL HOME BECOME A DESTITUTE

Microbicides Acceptability at individual, couple and community levels ? Best taken forward through social marketing rather than through health service channels Not contraceptive (at present)

HIV dimension in RH programmes Large scale component of public health –Antenatal and delivery care –Family planning In high prevalence settings, most women are not HIV positive HIV positive men and women need access to family planning and women need maternity services