1. Sexual and Reproductive Health (SRH) and HIV Linkages
Making the Most of It:
Sexual and Reproductive Health (SRH) and HIV Linkages
Inter Agency Working Group on SRH and HIV Linkages
Established in Co-convened by UNFPA, WHO and IPPF.
Other partners include: UNAIDS, EngenderHealth, Family Health International (FHI), Guttmacher Institute (GI), Population Council, The Global AIDS Alliance (GAA), The Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM), The Global Network of People Living with HIV (GNP+), The World Bank (WB), UNDP and USAID.

2. Why should we link SRH and HIV?
Ask audience questions and brainstorm their understanding of SRH and HIV linkages.

3. Rationale for Linking SRH & HIV
Majority of HIV infections
sexually transmitted, or
associated with pregnancy, childbirth & breastfeeding
Common root causes
Poverty
Gender inequality
Gender-based violence
Human rights violations
Marginalisation of key populations
Stigma and discrimination
Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, WHO, IPPF,
UNAIDS, & UNFPA, 2005
There are clear reasons why it is important to link SRH and HIV (READ SLIDE)

4. 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.

5. What Do We Mean by “Linkages” & “Integration”*?
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. Principles for Linking
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.

7. SRH and HIV Linkages Agenda
Political Commitment
Priority Framework
Evidence Review
Rapid Assessment Tool
Indicators
On a number of levels there is a broad consensus on the importance of better linkages between HIV and sexual and reproductive health. These include:
- Political commitment: Glion Call to Action on Family Planning and HIV (2005), New York Call to Commitment (2005) and the UNGASS 2006
A priority framework was developed in 2005 highlighting key areas where HIV and SRH can be linked together
A systematic evidence review using Cochrane methods was conducted in 2008 and the results of the review are now widely available
A rapid assessment tool to support countries to assess the national situation in relation to linkages was developed in 2008 and the roll out at a country level has started

8. Conceptual Framework
This is just a starting point, a sampling of what is possible in a certain context. For example, sometimes STIs are considered HIV services, not SRH services. The categories aren’t rigid.
Bi-directionality is key: SRH interventions into HIV service delivery settings, and HIV interventions into SRH service delivery settings.
Not just around prevention—treatment too. SRH settings are increasingly delivering treatment services as well.
While all of the linkages look like services (integration) there are structural and policies concerns embedded within each one.
Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, WHO, IPPF, UNAIDS, & UNFPA, 2005.

9. Linkages: More Than Integration
Child marriage
Gender-based violence
Gender inequality
Human rights violations
Poor access to quality services
Coerced sex
Criminalization of HIV
Stigma and discrimination
Lack of empowerment/participation
Highlight that these are examples of the policy and human rights implications that go beyond integrated service delivery.
Need to recognise and think broadly about how SRH and HIV interact in people’s lives and all the different experiences and rights violations that have implications for both SRH and HIV.

10. Linkages: What Can Be Done
Examples
Joint Advocacy to End:
Child marriage
obstetric fistula, increased morbidity/ mortality, increased HIV risk…
Gender-based violence
Human rights violations, lack of access to education, increased HIV risk, violence against women living with HIV…
Criminalization of HIV
Human rights violations, adverse impact on women, forced disclosure of status…
Some examples on what can be done to act on the linkages are illustrated here.
Source: Ending Child Marriage: A Guide for Global Policy Action, IPPF, Young Positives, UNFPA, GCWA, 2006.
Verdict on a Virus: Public Health, Human Rights and Criminal Law, IPPF, GNP+, ICW, 2008.

11. Service Integration: What SRH Providers Can Do
HIV prevention information and services, including for people living with HIV;
Information to prevent unintended pregnancies and HIV/STIs (dual protection) through correct and consistent condom use; provision of male and female condoms
Nondirective, nonjudgmental and confidential counselling on SRH of people living with HIV;
HIV counselling and testing and ART as indicated;
Strengthen maternal and child health services by including elements of prevention of mother-to-child transmission services; and
Address the SRH needs of key populations, including men who have sex with men, people who use drugs, sex workers and their clients.
Not all sites may be able to provide all HIV and SRH services, for example:
They may not be able to provide the 4 elements of PMTCT but ideally they should at least facilitate access to all four elements.
STIs are not included on this list under the assumption that SRH providers are already addressing these issues, but this may not be true in all settings.
Key populations are defined as those populations for whom HIV risk and vulnerability converge. HIV epidemics can be limited by concentrating prevention efforts among key populations. The concept of key populations also recognizes that they can play a key role in responding to HIV. Key populations vary in different places depending on the context and nature of the local epidemic, but in most places, they include men who have sex with men, sex workers and their clients, and people who use or inject drugs.
Many women at risk of HIV—as well as those unaware that they are HIV positive—come into contact with the health care system seeking reproductive health services, which presents opportunities for providers to reach them with HIV prevention and treatment services, either directly or by referral.
Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008.

12. Service Integration: What HIV Providers Can Do
Address sexual and reproductive health of people living with HIV;
Prevent, diagnose and treat sexually transmitted infections other than HIV;
Refer for prenatal care and high quality obstetrical services;
Provide counselling on fertility desires and provide related services and commodities;
Better understand and respond to the SRH needs of key populations, including men who have sex with men, people who use drugs, and sex workers and their clients.
When integrating SRH services into existing HIV programmes is important not to overburden or compromise the quality of existing services.
HIV health providers can ensure the sexual and reproductive health needs of people living with HIV are addressed.
A positive HIV diagnosis does not have to mean an end to people’s sexual lives – including their desire whether or not to have children. Access to condoms and other contraceptives, high quality obstetrical care and the full spectrum of prevention of mother-to-child transmission (PMTCT) interventions are essential to both reproductive health and HIV prevention.
Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008.

13. Service Integration: PMTCT What Can Be Done
Deliver comprehensive package of PMTCT services
Integrate HIV counselling & testing into SRH
Provide high quality SRH to women living with HIV
Integrate SRH into ART centres or strengthen referrals
Provide family planning counselling and services during antenatal and post-partum care
Screen and treat for syphilis and other STIs
Develop appropriate guidelines, tools & competencies for SRH people living with HIV in the context of PMTCT
PMTCT is a key entry point for integrating HIV and SRH services. A recent Guidance on Global Scale-Up of the Prevention of Mother-to-Child Transmission of HIV: Towards universal access for women, infants and young children and eliminating HIV and AIDS among children released by the Inter-Agency Task Team (IATT) on Prevention of HIV Infection in Pregnant women, Mothers and their Children highlights the need to implement a comprehensive approach to PMTCT that include the following four elements:
Primary prevention of HIV for women of childbearing age
Preventing unintended pregnancies among women living with HIV
Preventing HIV transmission from a woman living with HIV to their infants; and
Providing appropriate treatment, care and support to mothers living with HIV, their children and families
Source: Guidance on Global Scale-Up of the Prevention of Mother-to-Child Transmission of HIV, IATT on Prevention of HIV Infection in Pregnant women, Mothers and their Children, 2007.

14. SRH & Human Rights of People Living with HIV
This publication, recently produced by the Global Network of People living with HIV, Young positives, the International Community of women living with HIV, Engender health, IPPF and UNAIDS, was developed by HIV positive people and highlights important issues and areas where more action is needed in order to address their sexual and reproductive health.
Source: Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV: A Guidance Package, GNP+, ICW, Young Positives, Engender Health, IPPF, UNAIDS, 2009.

15. Community Engagement
There are a number of things that can be done at community level - These country report cards – currently available for 25 countries – are an example of how the global commitments are monitored at country level.
Source: HIV Prevention Report Cards for Young Women and Girls, IPPF, UNFPA, GCWA, Young Positives,

16. The Evidence
A systematic review showed that linking SRH and HIV services is beneficial and feasible:
Increases access to and uptake of services
Improves health and behavioural outcomes, including condom use
Increases knowledge of HIV and other STIs
Improves quality of services
A growing body of evidence shows the potential benefits of linkages. In 2008, a systematic review of some 50,000 citations was conducted to gain a clearer understanding of the effects of strengthening linkages. The analysis found that the majority of programmes studied showed improvements in all outcomes measured: Many of the integrated programmes increased condom or contraceptive use, improved the quality of services and/or increased uptake of HIV testing. In addition, some programmes showed a decrease in the incidence of STIs and to some extent HIV. Only a few studies measured cost-effectiveness, but those that did measure it suggested net savings.
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

17. SRH-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.

18. Key Recommendations: Policy Makers
Develop, adopt, modify and strengthen relevant policies, HIV and SRH strategic plans and coordination mechanisms to foster effective linkages.
Advocate for sufficient funding for service delivery, operations research and other activities to further the linkages agenda.
Ensure the implementation of a collective human rights and gender-sensitive approach to SRH and HIV linkages, including through the meaningful involvement of civil society and groups representing people living with HIV.
The evidence review made some key recommendations to policy makers (READ SLIDE)
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

19. Key Recommendations: Programme Managers
Strengthen linked SRH and HIV responses in both directions through:
Stakeholder commitment
Human resources and planning
Health provider training
Client education involvement
Quality of services
Infrastructure
Supply management including commodity security
Programme managers
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

20. Key Recommendations: Researchers
Design rigorous studies to evaluate integrated SRH and HIV services, particularly comparative assessments of integrated delivery of services versus non-integrated delivery of the same services.
Evaluate key outcomes, such as:
Health, Stigma reduction, Cost-effectiveness
Trends in access to services
Direct research toward areas that are under-studied
(linked services targeting men and boys, comprehensive SRH services for people living with HIV, gender-based violence prevention)
And researchers
Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, UNAIDS, UNFPA, WHO, 2009.

21. 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.

22. Implementing the Rapid Assessment Tool
Stand-alone activity or part of a larger review of national response
Includes desk reviews & individual/group interviews
Ensure at a minimum the assessment team includes:
national government SRH and HIV units
networks of people living with HIV
key populations
civil society
UN organizations
donors
Estimated timeframe: 3 months
Appendix 3. Budget Outline for Estimating Cost: USD 30,000 – 50,000
Appendix 5. List of Selected Possible Next Steps for Utilization of the Assessment Findings
Key elements of the Rapid Assessment include the following (READ SLIDE)
Note: please highlight the need to involve all stakeholders, particularly the HIV and SRH units, networks of people living with HIV, local NGOs and UN agencies.
Appendix 3 offers information on the key elements to consider when preparing the budget
Appendix 5 presents some ideas on how to use the findings.
Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

23. The Way Forward Measuring linkages progress
Strengthening joint advocacy between SRH and HIV e.g. maternal health initiatives / PMTCT
Evolving dynamic field
While a lot of progress has been made in the last five years to promote the linkages agenda there are a number of areas that will require our attention. These include:
Finding concise indicators to measure progress
Continuing to foster and build partnerships between the SRH and HIV communities.
An acknowledgment that integration is happening in places far and wide.
The SRH/HIV linkages agenda is part of a wider conversation and needs to address health systems strengthening, multi-sectoral approaches and global financing for health etc
We need to stay vigilant to ensure human rights are promoted and protected.
Source: Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators, UNAIDS, 2009.
National-Level Monitoring of the Achievement of Universal Access to Reproductive Health, WHO, UNFPA, 2007.