Manjula Lusti-Narasimhan Department of Reproductive Health and Research World Health Organization

Addis_GF-Mtg_25-02-08

Key issues and intersections in Key issues and intersections in sexual and reproductive health sexual and reproductive health

and HIV integrationand HIV integration

Mobilizing for RH/HIV IntegrationMobilizing for RH/HIV IntegrationAddis Ababa, Ethiopia 26-29 Feb. 2008Addis Ababa, Ethiopia 26-29 Feb. 2008

Manjula Lusti-Narasimhan

Department of Reproductive Health and ResearchWorld Health Organization

Addis_GFMtg_MLN_25-02-08

People living with HIV Children orphaned by AIDS in sub-Saharan Africa

27 years of responding to AIDS27 years of responding to AIDS27 years of responding to AIDS27 years of responding to AIDS

First cases of unusual immune deficiency are identified among gay men in the USA

The Human Immunodeficiency Virus (HIV) identified as

cause of AIDS

First regimen to reduce mother-to-child

transmission of HIV

Brazil becomes the first developing country to provide antiretroviral

therapy

WHO and UNAIDS launch the "3 x 5" initiative

The first HIV antibody test becomes available

A heterosexual AIDS epidemic is revealed

in Africa

Highly Active Antiretroviral Treatment launched

The World Health Organization launches the Global Programme

on AIDS

Acquired Immune Deficiency Syndrome

(AIDS) definedThe first therapy for AIDS — zidovudine, or AZT —

is approved for use in the USA

Global Network of People living with HIV/AIDS (GNP+)

Drug Access Initiative is launched in Africa

International AIDS Conference

in Durban

Global Fund to fight AIDS, Tuberculosis and Malaria

The UN General Assembly Special Session on HIV/AIDS

In 1991-1993, HIV prevalence in Uganda and in Thailand begins to

decrease

UNAIDS created

Millions50

45

40

35

30

25

20

15

10

5

0

1980 ‘81 ‘05‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04

President Bush announces PEPFAR

‘06 ‘07 2008

UN Political Declaration on

HIV/AIDS

2.3 million people on ART in the

developing world

Evidence that male circumcision considerably

reduces sexual transmission of HIV

from women to men.

10 billion dollars for AIDS in developing

countries


Challenges to achieving health MDGs 4, 5 & 6

and Universal Access 536,000 maternal deaths 120 million couples have an unmet need for safe and effective

contraception 80 million unwanted pregnancies 68,000 deaths from unsafe abortion 3 million girls undergo FGM, with recent studies showing later

adverse delivery and newborn outcomes 340 million new curable sexually transmitted infections (STIs) 2.5 million people newly infected with HIV/AIDS 700,000 infants born with congenital syphilis 500,000 new cases of cancer of the cervix and 250,000 deaths

Unsafe sex is the second most important risk factor to health

World Health Report 2002


Calls for linking sexual and reproductive healthCalls for linking sexual and reproductive healthand HIV have multipliedand HIV have multiplied


The rationale for linkages:The rationale for linkages:

Promote safe and responsible sexual behaviourPromote safe and responsible sexual behaviour

Have the potential to increase dual protection Have the potential to increase dual protection and condom useand condom use

Reduce mother to child transmission of HIVReduce mother to child transmission of HIV

Reduce stigma and discrimination in some Reduce stigma and discrimination in some settings settings

Minimize missed opportunities to increase Minimize missed opportunities to increase access and coverage of servicesaccess and coverage of services

Provide sexual and reproductive health services Provide sexual and reproductive health services for people living with HIV which meet their needsfor people living with HIV which meet their needs


Operational definitionsOperational definitions

Integration: integration of services which emerged from ICPD based on the need to offer comprehensive SRH services that meet several needs simultaneously

Linkages: linkages emerged to reflect alternative ways of combining services, including creating opportunities for systematic referrals within programmes

Synergies: implies that outcomes of integrated or linked services are greater than the outcomes of individual services


Sexual and Reproductive HealthPromote and strengthen reproductive and sexual health services as the basis of the prevention and treatment of HIV/AIDS through: Family planning; Antenatal, childbirth and postpartum care;Control sexually transmitted infections; Promotion of safer sex;Prevention of mother-to-child transmission of HIV.


Key linkages between sexual and Key linkages between sexual and reproductive health and HIV/AIDSreproductive health and HIV/AIDS


1. Learn HIV status1. Learn HIV status

Support legal and policy reform to remove Support legal and policy reform to remove barriers to HIV testing and counselling, barriers to HIV testing and counselling, particularly for young peopleparticularly for young people

Reorientate VCT/PITC services to better meet Reorientate VCT/PITC services to better meet needs of young people and key populationsneeds of young people and key populations

Provide basic sexual and reproductive health Provide basic sexual and reproductive health services (information on dual protection, services (information on dual protection, counselling, access to condoms) in VCT/PITC counselling, access to condoms) in VCT/PITC programmesprogrammes

Routinely offer HIV testing and counselling in Routinely offer HIV testing and counselling in STI servicesSTI services

Routinely offer HIV testing and counselling in Routinely offer HIV testing and counselling in family planning and antenatal care services family planning and antenatal care services (high prevalence settings)(high prevalence settings)

Provide effective referral to treatment Provide effective referral to treatment programmesprogrammes


Develop policies that support dual protectionDevelop policies that support dual protection

Support policy development on comprehensive Support policy development on comprehensive safer sex services for young people, PLWH and safer sex services for young people, PLWH and other key populationsother key populations

Broaden sexual and reproductive health services Broaden sexual and reproductive health services to key populationsto key populations

Promote condom use for dual protection within all Promote condom use for dual protection within all family planning and HIV prevention programmesfamily planning and HIV prevention programmes

Provide full range of sexual and reproductive Provide full range of sexual and reproductive health services (including prevention) for PLWHhealth services (including prevention) for PLWH

Empower women and girls to negotiate safer sex Empower women and girls to negotiate safer sex and access sexual and reproductive health and and access sexual and reproductive health and HIV/AIDS servicesHIV/AIDS services

Include services that address gender-based Include services that address gender-based violence (counselling, emergency contraception, violence (counselling, emergency contraception, HIV post-exposure prophylaxis)HIV post-exposure prophylaxis)

2. Promote safer sex2. Promote safer sex


Advocate for investment in STI Advocate for investment in STI management as a key strategy to management as a key strategy to reduce HIV transmissionreduce HIV transmission

Implement in STI programmes a Implement in STI programmes a package of HIV/AIDS services (safer package of HIV/AIDS services (safer sex information and counselling, sex information and counselling, routine offer of HIV testing and routine offer of HIV testing and counselling, condoms)counselling, condoms)

Provide STI management to PLWH in Provide STI management to PLWH in all HIV/AIDS care and treatment all HIV/AIDS care and treatment servicesservices

3. Optimize connection between 3. Optimize connection between HIV/AIDS and STI servicesHIV/AIDS and STI services


Develop policies to provide appropriate Develop policies to provide appropriate HIV/AIDS management options for pregnant HIV/AIDS management options for pregnant women, mothers, their infants and familieswomen, mothers, their infants and families

Ensure that all four prongs of the strategy for Ensure that all four prongs of the strategy for PMTCT of HIV are in place PMTCT of HIV are in place

Provide basic package of HIV/AIDS services in Provide basic package of HIV/AIDS services in antenatal care settingsantenatal care settings

4. Integrate HIV/AIDS with 4. Integrate HIV/AIDS with maternal and infant healthmaternal and infant health

Integrate antenatal syphilis screening and treatment with PMTCTIntegrate antenatal syphilis screening and treatment with PMTCT

Strengthen maternal health services for women living with Strengthen maternal health services for women living with HIV/AIDS (infant feeding counselling, family planning, access to HIV/AIDS (infant feeding counselling, family planning, access to HIV care, treatment and support)HIV care, treatment and support)

Provide counselling on reproductive choices for PLWH and their Provide counselling on reproductive choices for PLWH and their partnerspartners


Helping countries to monitor progress towards Helping countries to monitor progress towards universal access in sexual and reproductive healthuniversal access in sexual and reproductive health

WHO/UNFPA Technical Consultation,WHO/UNFPA Technical Consultation,March 2007March 2007

ContentsContents

A recommended framework of indicators forA recommended framework of indicators forpriority aspects of sexual and reproductive priority aspects of sexual and reproductive

healthhealth

Possible indicators of programmatic linkagesPossible indicators of programmatic linkagesbetween sexual and reproductive health between sexual and reproductive health

servicesservicesand HIV prevention, care, and treatmentand HIV prevention, care, and treatment

IndicatorsIndicators

Core Core –– all countries should report onall countries should report onAdditionalAdditional –– could report, based on special could report, based on special needsneedsExtendedExtended –– contextual relevancecontextual relevance


HIV / AIDS servicesHIV / AIDS services

Expected Expected outcomeoutcome

BCC

Condom promotion

STI prevention and control

Family planning services

Improved access to and coverage of sexual and

reproductive health services

VCT/PITC + PMTCT + ART +

BCC programmes§

§voluntary counselling and testing (VCT)/provider-initiated testing and counselling (PITC); prevention of mother-to- child transmission (PMTCT); antiretroviral treatment (ART); behaviour change communication (BCC)

Proposed Proposed linkageslinkages

Existing Existing servicesservices


IndicatorsIndicators Proportion of HIV/AIDS service delivery points Proportion of HIV/AIDS service delivery points

offering condomsoffering condoms

Proportion of HIV/AIDS service sites incorporating Proportion of HIV/AIDS service sites incorporating BCC materialsBCC materials

Proportion of HIV-positive people offered treatment, Proportion of HIV-positive people offered treatment, and counselled on sexual and reproductive healthand counselled on sexual and reproductive health

Proportion of HIV/AIDS service sites offering or Proportion of HIV/AIDS service sites offering or referring for STI treatmentreferring for STI treatment

Reduced unmet need for family planning among HIV-Reduced unmet need for family planning among HIV-positive peoplepositive people


Expected Expected outcomeoutcomeIncreased

access to HIV treatment and

prevention

Quality sexual and

reproductive health services

Maternal health services(ANC intra and postpartum care)

ANC and delivery services

Existing services

STI

Family planning

Male involvement

PMTCT

VCT - PITC

Proposed Proposed linkageslinkages


IndicatorsIndicators

Proportion of ANC and delivery services promoting Proportion of ANC and delivery services promoting the four-pronged approachthe four-pronged approach to the prevention of to the prevention of mother-to-child transmission of HIVmother-to-child transmission of HIV

Proportion of ANC and delivery services users Proportion of ANC and delivery services users counselled and treated for STIs, including following up counselled and treated for STIs, including following up the male partner for treatmentthe male partner for treatment


ConclusionConclusion

Sexual and reproductive health Sexual and reproductive health

services expand entry points services expand entry points

for accessing HIV prevention for accessing HIV prevention

and care, increase efficiency and care, increase efficiency

and cost-effectiveness of and cost-effectiveness of

programmesprogrammes

"What we have been doing is like mopping the floor while the roof is leaking"Maggwa N (2006)

Documents

Manjula Lusti-Narasimhan Department of Reproductive Health and Research World Health Organization