1. Linking Sexual & Reproductive Health and HIV: Evidence Review and Recommendations Lucy Almers, Debbie Bain Brickley, Gail Kennedy, Laura Packel, Joy Mirjahangir, Alicen Spaulding, Caitlin Kennedy, Michael Mbizvo, Lynn Collins, Kevin Osborne

2. SRH & HIV Linkages Agenda Political Commitment Priority Framework Evidence Review Rapid Assessment Tool Indicators

3. 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

4. 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

5. 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?

6. Definitions  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.

7. 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 (1990-2007) — Rigorous evaluation study (pre-post or control group) — Conducted in any setting Promising practices — ‘Grey’ (non-peer-reviewed) literature (1990-2007) — Must report some evaluation results — Conducted in resource- limited settings only

8. Citations excluded from review (n=50,570) 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=167) 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=225) Citations identified through search strategy (n=50,797) Results

9. SRH-HIV Linkages Matrix

10. 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 —34 studies integrated HIV into existing SRH services (earlier studies) —14 studies integrated SRH into existing HIV services (later studies) —10 studies integrated HIV and SRH services concurrently

11. 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

12. 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: 7 studies, average rigour = 1.6  5 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

13. 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

14. 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

15. Gaps  Inadequately studied interventions —Linked services targeting men and boys —Gender-based violence prevention and management —Stigma and discrimination —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 —Stigma reduction —Cost-effectiveness —Trends in access to services

16. 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

17. 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

18. 2008 Linking SRH & HIV works Cochrane Evidence Review: 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 18

19. More information about linkages is available from:  www.igh.org/linkages  www.unaids.org  www.unfpa.org  www.ippf.org  www.who.int/reproductive-health/