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Making the Most of It: Sexual and Reproductive Health (SRH) and HIV Linkages Inter Making the Most of It: Sexual and Reproductive Health (SRH) and HIV Linkages Inter Agency Working Group on SRH and HIV Linkages Established in 2008. Co-convened by UNFPA, WHO and IPPF. Other partners include: UNAIDS, Engender. Health, 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.

Why should we link SRH and HIV? Why should we link SRH and HIV?

Rationale for Linking SRH & HIV § Majority of HIV infections § sexually transmitted, 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

Benefits of Linkages § improved access to and uptake of key HIV and SRH 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 Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

What Do We Mean by “Linkages” & “Integration”*? § Linkages - The bi-directional synergies 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

Principles for Linking § § § § Address structural determinants Focus on human rights 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.

SRH and HIV Linkages Agenda Political Commitment Priority Framework Evidence Review Rapid Assessment Tool SRH and HIV Linkages Agenda Political Commitment Priority Framework Evidence Review Rapid Assessment Tool Indicators

Conceptual Framework Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, Conceptual Framework Source: Sexual and Reproductive Health & HIV/AIDS: A Framework for Priority Linkages, WHO, IPPF, UNAIDS, & UNFPA, 2005.

Linkages: More Than Integration § § § § § Child marriage Gender-based violence Gender 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

Linkages: What Can Be Done Examples Joint Advocacy to End: § Child marriage Ø Linkages: What Can Be Done Examples Joint Advocacy to End: § Child marriage Ø obstetric fistula, increased morbidity/ mortality, increased HIV risk… § Gender-based violence Ø Human rights violations, lack of access to education, increased HIV risk, violence against women living with HIV… § Criminalization of HIV Ø Human rights violations, adverse impact on women, forced disclosure of status… 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.

Service Integration: What SRH Providers Can Do § HIV prevention information and services, including 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. Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008.

Service Integration: What HIV Providers Can Do § Address sexual and reproductive health of 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 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. Source: Gateways to Integration Case Studies for Haiti, Kenya and Serbia, WHO, UNFPA, UNAIDS, IPPF, 2008.

Service Integration: PMTCT What Can Be Done § Deliver comprehensive package § Screen and Service Integration: PMTCT What Can Be Done § Deliver comprehensive package § Screen and treat for syphilis and of PMTCT services other STIs § Integrate HIV counselling & § Develop appropriate guidelines, testing into SRH tools & competencies for SRH people living with HIV in the § Provide high quality SRH to context of PMTCT women living with HIV § Integrate SRH into ART centres or strengthen referrals § Provide family planning counselling and services during antenatal and post-partum care 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.

SRH & Human Rights of People Living with HIV Source: Advancing the Sexual and SRH & Human Rights of People Living with HIV 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.

Community Engagement Source: HIV Prevention Report Cards for Young Women and Girls, IPPF, UNFPA, Community Engagement Source: HIV Prevention Report Cards for Young Women and Girls, IPPF, UNFPA, GCWA, Young Positives, 2006 -2009.

The Evidence § A systematic review showed that linking SRH and HIV services is 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 Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

SRH-HIV Linkages Matrix Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & SRH-HIV Linkages Matrix Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

Key Recommendations: Policy Makers § Develop, adopt, modify and strengthen relevant policies, HIV and 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. Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

Key Recommendations: Programme Managers Strengthen linked SRH and HIV responses in both directions through: 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 Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

Key Recommendations: Researchers § Design rigorous studies to evaluate integrated SRH and HIV services, 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: ü Health, Stigma reduction, Cost-effectiveness ü 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) Source: Sexual & Reproductive Health and HIV Linkages: Evidence Review & Recommendations, IPPF, UCSF, : UNAIDS, UNFPA, WHO, 2009.

Rapid Assessment Tool for SRH and HIV Linkages: A Generic Guide § Assess HIV 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. Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

Implementing the Rapid Assessment Tool § Stand-alone activity or part of a larger review 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 Source: Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A generic guide, IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW, Young Positives, 2009.

The Way Forward § Measuring linkages progress § Strengthening joint advocacy between SRH and The Way Forward § Measuring linkages progress § Strengthening joint advocacy between SRH and HIV e. g. maternal health initiatives / PMTCT § Evolving dynamic field 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.