Mobilizing for Reproductive Health/HIV Integration Reducing HIV Vulnerability and Impact for Women, Young Women & Girls Addis Ababa, February 2008 Lynn Collins, UNFPA Based on collaborative work with EngenderHealth, GCWA, IPPF, YoungPositives, ICW, GNP+, IWHC, PopCouncil, WHO, UNICEF

Key Links – Priority Framework

Assessing priority linkages No ‘one size fits all’ model for linkages/integration Linkages are bi-directional Policy, systems, and service delivery considerations Less commonly considered as linkage policies and programmes are those addressing the structural determinants, particularly gender inequality Gender-based violence Economic empowerment of women Child marriage Legal/Policy barriers SRH Access Participation and Rights

Young Women and Girls: Vulnerability to HIV and Limits to Impact Mitigation Lack of economic opportunity Gender based violence/Coerced sex Biological susceptibility Lack of knowledge Femininity stereotypes Lack of empowerment Lack of access to sexual & reproductive health services & commodities Lower levels of education Inability to negotiate terms of sexual relations Trafficking Inability to exercise rights Harmful traditional practices Lower status Child marriage and early pregnancy

Know Your Epidemic – e.g. Report Cards “Know Your Epidemic” Inherent Complexity Report Cards: HIV Prevention for Girls and Young Women Covers legal, policy, availability, access, participation and rights aspects of HIV prevention strategies and services (23 countries, including Cameroon, Ethiopia, Mozambique, Nigeria)

2005 Country Progress toward UNGASS Declaration of Commitment 2001 Targets Percentage of youth aged who correctly identify ways of preventing HIV transmission and who reject major misconceptions about HIV transmission 2005 Global Target 90% Global Results 2005 Male 33% Female 20%

Paragraph 26 of the Political Declaration on HIV/AIDS 2006 “We, Heads of State and Government and representatives of States and Governments…Commit ourselves to addressing the rising rates of HIV infection among young people to ensure an HIV-free future generation through the implementation of comprehensive, evidence-based prevention strategies, responsible sexual behaviour, including the use of condoms, evidence- and skills-based, youth specific HIV education, mass media interventions, and the provision of youth friendly health services.” —

Sexuality education leads to safer sexual behaviour Strong evidence that school-based sexual health /HIV education does not encourage increased sexual activity. Quality sexual health education – delayed onset of sexual activity – reduced # sexual partners – reduce frequency of sexual activity – increased use of condoms Responsible & safe behaviour can be learned. Sexual health education is best started before the onset of sexual activity.

Evidence-informed Interventions for Young People Interventions graded as 'GO!' and 'Ready' for wide-spread implementation include: In schools: Curriculum-based interventions, led by adults, that are based on defined quality criteria, can have an impact on knowledge, skills and behaviour In health services: Increasing young people's use of services by training service providers, ensuring that facilities are 'adolescent-friendly' and creating demand through community support In the mass media: Behaviour change communications that employ a range of media and build on principles of good practice In communities: Working through existing organizations and stuctures to reach young people with interventions tailored to them. For young people most at-risk: Interventions that provide information and services to key groups through static and outreach facilities

Work in Progress  IPPF, UNFPA, WHO, and other partners, in consultation with the Cochrane Review Group, are conducting a systematic review of the linkages evidence  Purpose - identify, summarise and determine quality: a) rigorous evaluation research; b) promising practices  Which linkages will have the greatest impact and under what circumstances?  Are linkages cost effective?  How best to strengthen selected linkages in different programme settings?  How is availability, uptake and quality affected?  Outcome measures:  HIV and SRH-related  Individual and programme-level

Cost effectiveness of family planning Stover et al, 2003 Adding family planning to ongoing services for the prevention of vertical transmission of HIV in 14 high-prevalence countries could double the number of HIV-positive births averted, in addition to saving women’s lives and averting children’s deaths. Sweat et al Small reductions in maternal HIV prevalence or in unintended pregnancy among women with HIV had an impact on HIV incidence in infants which was equivalent to that of ARV intervention with nevirapine based on modeling in 8 countries in Africa. Reynolds et al, 2005 Family planning services in sub-Saharan Africa are preventing HIV infection in more infants than is the provision of nevirapine. Reynolds et al, 2006 – Expenditure of US$ to increase contraceptive services would prevent 88 HIV-positive births, whereas, for the same cost, the promotion and provision of nevirapine in antenatal care would prevent only 68 such births

Summary of evidence for comprehensive PMTCT Element 3 alone has a limited impact in resource-poor settings Small reductions in maternal HIV prevalence or in unintended pregnancy among women with HIV have an impact on HIV incidence in children equivalent to ARV intervention Family planning more cost effective than nevirapine Adding family planning to ongoing services (VCT, ARV) can double the number of HIV positive births averted Conclusion: UNGASS goals on reduction of HIV infection in infants cannot be met through current focus on element 3 alone