Linking Sexual & Reproductive Health and HIV: Evidence Review and Recommendations Caitlin Kennedy November 19, 2008

Objectives  The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to sexual & reproductive health (SRH) and HIV prevention, treatment, care and support  In order to gain a clearer understanding of the effectiveness, optimal circumstances, and best practices for strengthening SRH and HIV linkages, a systematic review of the literature was conducted

Potential Benefits  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 resources  Better understanding and protection of individual rights  Mutually reinforcing complementarities in legal and policy frameworks  Enhanced programme effectiveness and efficiency  Better utilization of scarce human resources for health

Key Research Questions  What linkages are currently being evaluated?  What are the outcomes of these linkages?  What types of linkages are most effective and in what context?  What are the current research gaps?  How should policies and programmes be strengthened?

Definitions  Linkages: Policy, programmatic, services and advocacy bi-directional synergies between SRH and HIV/AIDS services  Integration: Different kinds of SRH and HIV services or operational programmes joined together to ensure and perhaps maximize collective outcomes

Methods  Systematic review —Comprehensive online search of scientific databases, program websites, and consultation with experts —Systematic methods used for screening, data extraction, and quality assessment of studies  Inclusion criteria Peer-reviewed studies — Published in peer-reviewed journal ( ) — Rigorous evaluation study (pre-post or control group) — Conducted in any setting Promising practices — ‘Grey’ (non-peer-reviewed) literature ( ) — Must report some evaluation results — Conducted in resource- limited settings only

Citations excluded from review (n=50,572) Did not meet inclusion criteria Interventions with element 3 of PMTCT (matrix column 3, row 2) were reviewed elsewhere (see full report) Citations not retained for analysis (n=169) Interventions linking HIV prevention, education and condoms with SRH services (matrix column 1) were reviewed elsewhere (see full report) Citations included in analysis (n=58) Citations included in review (n=227) Citations identified through search strategy (n=50,799) Results

SRH-HIV Linkages Matrix Element 3 of PMTCT HIV prevention, education & condoms HIV counselling & testing Maternal & child health care STI prevention & management Other SRH services GBV prevention & management Family planning Clinical care for PLHIV Psychosocial & other services for PLHIV Peer-Reviewed Studies Promising Practices

Key Study Characteristics  58 studies included in analysis —35 peer-reviewed studies —23 promising practices  6 of 58 studies used a randomized control design  Region —36 Africa (80% of promising practices were in Africa) —11 United Kingdom and United States of America —11 Asia, Eastern Europe, Latin America and the Caribbean  Direction of linkages —29 studies integrated HIV into existing SRH services (earlier studies) —21 studies integrated SRH into existing HIV services (later studies) —8 studies integrated HIV and SRH services concurrently

Key Study Characteristics  Populations —Most interventions targeted pregnant/postpartum women, or adults of reproductive age —3 studies specifically targeted youth/adolescents  2 peer-reviewed studies providing HIV testing in STI clinics  1 promising practice providing HIV testing in youth centres  Several other studies did not specifically target youth, but youth were among the clients/beneficiaries  Settings —Antenatal care clinics adding HIV services (n=16) —HIV counseling & testing centres adding SRH services (n=3) —Family planning clinics adding HIV services (n=6) —HIV clinics adding SRH services (n=5) —STI clinics adding HIV services (n=3) —Primary health care clinics adding HIV and/or SRH services (n=10)

Key Outcomes  Health —HIV incidence: 2 studies, average rigour = 4  1 positive effect, 1 no effect —STI incidence: 2 studies, average rigour = 6.5  Both positive effect  Behavioural —Condom use: 13 studies, average rigour = 3.8  8 positive effect, 3 mixed effect, 2 no effect —Contraceptive use (other than condoms): 6 studies, average rigour = 3.3  4 positive effect, 2 mixed effect

Key Outcomes  Process —Uptake of HIV testing: 12 studies, average rigour = 2.2  All positive effect —Quality of services: 7 studies, average rigour = 2.7  5 positive effect, 2 no effect  Other —Stigma: 0 studies —Cost: 5 studies, average rigour = 1.6  3 studies presented costing data only (absolute cost per unit)  2 studies presented cost-effectiveness; Both suggested net savings from HIV/STI prevention integrated into MCH services

Promoting and Inhibiting Factors  Promoting —Stakeholder involvement —Capacity building —Positive staff attitudes and non-stigmatizing services —Engagement of key populations  Inhibiting —Lack of sustainable funding and stakeholder commitment —Staff shortages, high turnover or inadequate training —Poor programme management and supervision —Inadequate infrastructure, equipment, and commodity supply —Client barriers to service utilization, including low literacy, lack of male partner involvement, stigma, and lack of women’s empowerment to make SRH decisions

Overall Findings  The majority of studies showed improvements in all outcomes measured —A few mixed results —Very few negative findings  Linking SRH and HIV services was considered beneficial and feasible, especially in: —Family planning clinics —HIV counselling and testing centres —HIV clinics  Promising practices tended to evaluate more recent and more comprehensive programmes —71% of peer-reviewed studies reported only one type of linkage —57% of promising practices reported five or more linkages, while just 9% had only one type of linkage

Gaps  Inadequately studied interventions —Linked services targeting men and boys —Gender-based violence prevention and management —Comprehensive SRH services for people living with HIV, including addressing unintended pregnancies and planning for safe pregnancies, if desired  Infrequently used study designs & research questions —Research questions that specifically address SRH and HIV service integration —Study designs that compare integrated services to the same services offered separately  Insufficiently reported outcomes —Health —Cost —Stigma

Strengths and Limitations  Strengths —Broad scope of review —Systematic methodology  Limitations —Difficult to synthesize data due to heterogeneity in:  Interventions  Populations  Research questions/objectives  Study designs/rigour  Measured outcomes —May not have captured all promising practices

3 of 15 Key Recommendations  Policy makers: Advocate and support SRH and HIV linkages at the policy, systems and service levels since they are demonstrated to improve outcomes  Programme managers: Strengthen linked SRH and HIV responses in both directions and rigorously monitor and evaluate integrated programmes during all phases of implementation  Researchers: Direct rigourous research towards areas of integration that are currently understudied, evaluate key outcomes, and disseminate findings

Acknowledgements  The Cochrane/WHO/IPPF/UNFPA SRH-HIV linkages review team —Gail Kennedy, Alicen Spaulding, Lucy Almers, Debbie Bain Brickley, Laura Packel, Joy Mirjahangir, Michael Mbizvo, Lynn Collins, Kevin Osborne