SRH and HIV Linkages: An introduction to the big picture and the challenges Alejandra Trossero In collaboration with Janet Fleischman, Tamil Kendal and Lydia Mungherera

The international community agrees that the MDGs will not be achieved without also ensuring universal access to sexual and reproductive health and rights. So, why has it been so difficult to put an integrated approach into practice? Michel Sidibe, UNAIDS 26th Meeting of UNAIDS PCB, June 2010

Global Recognition: Political commitments: –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) –UNGASS Political Declaration on HIV /AIDS (June 2006) Donors priorities: –DFID RH & HIV strategy –Global Fund against HIV, TB and Malaria –US Global Health Initiative & PEPFAR II

A note on definitions * Linkages Bi-directional synergies in policy, programmes, services and advocacy between SRH and HIV. It refers to a broader human rights based approach, which service integration is a subset. Integration Different kinds of SRH & HIV services or operational programmes that can be joined together to ensure and maximize collective outcomes. This would include referrals. It’s based on the need to offer comprehensive and integrated services * * Definitions agreed upon by the IAWG on Linkages

 Allows continuity of care without the need for external referrals  Expands range of clinical services beyond ART  Reduces frequency and costs of medical appointments  Facilitates access of PLHIV to SRH services tailored to their needs  Reduces HIV–related stigma and discrimination  Provides greater coverage for key populations  Promotes an increased culture of rights Benefits of linkages for people living with HIV

Does the integration of HIV and SRH services offer a better model of care for women living with HIV?

Benefits of an integrated approach “It works for me this set up at [the hospital]. The fact that I can get everything here for my pregnancy needs and also the HIV treatment… say for instance I have the same appointment for a scan, checkup and also for treatment at the other side at the ART unit which is also the same appointment date at the TB unit and it works better than say I am at [a primary care site] and I have my scan appointment and there I have to get on a bus and go to another clinic for something else, like my TB…I think it is better this way” Female client, district hospital, Manzini, Swaziland Source: K. Church, 2010 (unpublished)

Models of integration (Kenya) HIV/AIDS ServicesSRH Services VCT+FP, ART, BCC, STI, Condoms FP+ ( V) CT, ART, BCC, STI, Condoms PMTCT, ART, BCC, FP, STI, TB screening, Condoms STI, PMTCT (V) CT, ART, BCC, FP, STI, Condoms (V) CT/PEP, ART, BCC, EC, Condoms (V) CT, BCC, FP, Condoms PMTCT+FP, ART, BCC, STI, Condoms BCC, STI, FP Condoms FP, STI, VCT Condoms ANC+ Delivery + ART+ Post-Partum+ BCC+ PAC/Abortion+ Post-rape+ STI+ Cervical Cancer screening+

Increased client load due to scale up of integrated services. Reluctance from health providers to increase workload and/or scope of care. Stigma and discrimination continues to be a barrier for accessing health services. Models used are based on women’s health – e.g. FP services inked to VCT or ART. Men are the weakest link in this approach. Limited evidence on linkages agenda in concentrated epidemics. Challenges

Recommendations Policy: –Ensure harmonization and coordination of efforts across sectors to support the delivery of a comprehensive model of care for people living with HIV. –Promote collaboration between ministries and departments beyond the health sector, e.g. education, judicial and law enforcement systems to address GBV, etc.

Recommendations Research: –Address some of the research gaps that have been identified, e.g. the integration of SRH and HIV services for people living with HIV and key populations; stigma reduction, gender based violence, linked services for men and boys living with HIV. –Gather evidence on the cost-effectiveness, cost-saving and efficiency of integrated programmes.

Recommendations Programmes: –Increase commitment to develop models addressing the SRH needs of key populations and marginalized populations and use them as a modality of stigma reduction. –Link health with development interventions to address some of the structural barriers that hinder HIV responses, particularly for young people living with HIV.

From Healthy, Happy and Hot: A young person’s guide to their rights, sexuality and living with HIV. IPPF.