1. Kevin Osborne, Senior HIV Advisor
Making the Most of It: Sexual and Reproductive Health (SRH) and HIV Linkages
Kevin Osborne, Senior HIV Advisor

2. 1.Why should we link SRH and HIV?

3. Benefits of linkages
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 scarce resources
better understanding and protection of individuals’ rights
mutually reinforcing complementarities in legal and policy frameworks
enhanced programme effectiveness and efficiency
better utilization of scarce human resources for health
Some of these benefits are well established and the current status of the evidence to support these benefits will be introduced later in this presentation.
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

4. Global Recognition
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)
UNAIDS policy position paper ‘Intensifying HIV prevention’ (June 2005)
World Summit Outcome (September 2005)
Call to Action: Towards an HIV-Free and AIDS-Free Generation (December 2005)
UNGASS Political Declaration on HIV/AIDS (June 2006)
Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services (November 2007)
The Global Fund to Fight AIDS, Tuberculosis and Malaria – Technical Review Panel Recommendation (2008)
Global Fund:
In 2008, the independent Technical Review Panel of the Global Fund recommended that technical assistance to countries for proposal development place greater emphasis on potential opportunities for integration and synergy between sexual and reproductive health and HIV/AIDS, since HIV infection is acquired and transmitted largely through unprotected sexual intercourse or during pregnancy, childbirth and breastfeeding.

5. Terminology matters
Linkages* - The bi-directional synergies in policy, programmes, services and advocacy between sexual and reproductive health and HIV.  It refers to a broader human rights based approach, of which service integration is a subset.
Integration* - Different kinds of sexual and reproductive health and HIV services or operational programmes that can be joined together to ensure and perhaps maximize collective outcomes. This would include referrals from one service to another, for example. It is based on the need to offer comprehensive services.
* Definitions agreed upon by the IAWG on Linkages
As is so often the case when two programme areas are brought together, there is still confusion about the terms “linkages” and “integration.” Here, we attempt to explain these terms – which have been agreed by the IAWG on Linkages – and how increased linkages can advance the response to HIV and AIDS.

6. 2.How should we link SRH and HIV?

7. Some general principles
Address structural determinants
Focus on human rights and gender
Promote a coordinated and coherent response
Meaningfully involve PLHIV
Foster community participation
Reduce stigma and discrimination
Recognise the centrality of sexuality
Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

8. SRH and HIV Linkages Matrix
There are a number of things that can be done at community level - These country report cards – currently available for 25 The pink row shows key HIV services while the green column shows key SRH services. Not only does this matrix show peer-reviewed studies in the top left-hand corner of each box, but also so called ‘promising practices’ in the bottom right-hand corner of each box. The areas shaded in grey were studies which were already reviewed elsewhere. The trend indicates that the majority of studies addresses the intersection between HIV prevention, education and condom programmes and key SRH services, and highlights possible research and programme areas for the future.
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

9. 3. How do we know it works?

10. Kenya Site: Family Health Options Kenya Clinics
Purpose: Providing a range of HIV services in a sexual and reproductive health setting such as VCT, PMTCT and ART.
Results:
Increased the number of young people seeking HIV testing in Nairobi Youth Centre by 35% between 2004 and 2005
Increased demand for SRH services as well as HIV services
More men started using the clinics
Linkages lessons: Providing a range of HIV services in SRH clinics attracts new clients and creates opportunities for promoting SRH to a wider population.
Out of 9 clinics:
Eight provide VCT
All nine provide PMTCT as part of maternal health services
Five provide ART to PLHIV
4 out of 9 clinics provided ART
Nairobi Youth Centre
clients for VCT,
2004 – 2025 clients for VCT
Source: Gateways to Integration: A case study from Kenya, WHO, UNFPA, UNAIDS, IPPF, 2008.

11. Haiti Site: Three GHESKIO Centres in Haiti
Purpose: Voluntary counselling and testing as an entry point for comprehensive SRH services
Results:
30-fold increase in the number of pregnant women seeking VCT between 1999 and 2004 when the PMTCT programme was introduced.
Of 6,700 adults seeking VCT, 18% received treatment for an STI and 19% became new contraceptive users returning to the Centre for at least three family planning visits.
Linkages lessons: Providing the opportunity to access other health services at the same time and under the same roof greatly enhances the uptake of HIV counselling and testing.
The three centres are in Cite de Dieu, Cite Eternel and Cite Soleil
Source: Gateways to Integration: A case study from Haiti, WHO, UNFPA, UNAIDS, IPPF, 2008.

12. Cambodia Site: Siem Reap District
Purpose: Increasing utilization of VCT services and STI treatment for construction workers and sex workers
Results:
Increased services (3212 VCT and 3225 STI services provided)
Empowered rural communities and sex workers
Expanded HIV and STI prevention
Linkages lessons: Partnerships with other NGOs and government services enabled peer-to-peer outreach and facilitated referrals

13. 4. What is happening now?

14. Policy to practice
Rapid Assessment Tool for SRH and HIV Linkages: A Generic Guide
Assess HIV and SRH bi-directional linkages at the policy, systems, and service-delivery levels.
Identify current critical gaps in policies and programmes.
Contribute to the development of country-specific action plans to forge and strengthen these linkages.
Focus primarily on the health sector.
This tool was developed to help countries assess their current situation in relation to linkages. The purpose of this tool is (READ SLIDE)
Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

15. Countries implementing the Rapid Assessment Tool
Countries which have already implemented assessment
Countries about to implement assessment
Belize
Lebanon
Swaziland
Benin
Pakistan
Tanzania
Botswana
Malawi
Tunisia
Burkina Faso
Morocco
Uganda
Cote d’Ivoire
Russian Federation
Vietnam
Kyrgyzstan
Sudan
Zimbabwe
Afghanistan
Jamaica
Somalia
Bangladesh
Islamic Rep Iran
St. Lucia
Djibouti
Lesotho
Sri Lanka
Ghana
Namibia
Surinam
Granada
Nepal
Trinidad & Tobago
Guyana
Maldives
Yemen
India
Nigeria
Zambia
Already implemented
Zimbabwe
Morocco

16. 5. What key issues still remain?

17. What do the linkages between SRH and HIV look like in concentrated epidemics?
Is integration of services cost effective?
Does integration lead to stigma reduction?
Does linkages help donors to avoid funding vertical programmes?
How can we prove that particular integrated models work?

18. 6. What are the take home messages?

19. Linkages is a dynamic and moving field
Linkages is more than just the integration of SRH and HIV services
Need to move linkages beyond the low hanging fruit
Enabling factors:
Increased political will
Support from different funding mechanisms
Disabling factors:
Vertical programmes and funding streams
Territorialism