On the integration of programs…

Luis Gutierrez Alberoni

PROPOSAL TO INTEGRATE PROPOSAL TO INTEGRATE SEXUAL AND REPRODUCTIVE SEXUAL AND REPRODUCTIVE

HEALTH PROMOTION HEALTH PROMOTION PROGRAMS AND SERVICES PROGRAMS AND SERVICES WITH THE HIV (AND STI) WITH THE HIV (AND STI)

RESPONSE RESPONSE

Rafael Mazín, MD; MPHRafael Mazín, MD; MPHLuis Gutierrez AlberoniLuis Gutierrez Alberoni

Quito, Ecuador. 29 October Quito, Ecuador. 29 October 20072007

BASIC PREMISESBASIC PREMISESEpidemiological evidence:Epidemiological evidence:

Dynamic of HIV epidemic closely associated with all unprotected sex (> 80% of the cases)

Infant mortality rate related to parental sexual behavior

STIs neglected in health agendas (50 million cases annually), 110,000 cases of congenital syphilis

Unsatisfactory efforts in prevention ( ∆12% in new cases in Latin America between 2004 and 2006)

Access to treatments at risk (6 new infections for each person in treatment)

BASIC PREMISESBASIC PREMISESEpidemiological evidence:Epidemiological evidence:

< 10% of acts of coitus at risk for HIV are protected by condoms

More than 85% of HIV+ individuals do not know their status

< 20% people with STIs seek professional care

< 20% of HIV+ pregnant women have access to prophylactic treatment

< 10% MSM have access to prevention and < 20% female SWs have access to prevention

Stigma, discrimination, homophobia, abuse are all still common in health services

BASIC PREMISESBASIC PREMISESContextual analysis:Contextual analysis:

General difficulty in dealing with sexuality

Neglect of masculinity, sexual orientation, attraction, pleasure, and power

Sexual health reduced to reproductive dimension

Sexual health linked with reproductive health, but not always with mental health, other areas

Responses almost exclusively through health

“Medicalization” (i.e., prevalance of a curative paradigm)

BASIC PREMISESBASIC PREMISESAnalysis of the responses:Analysis of the responses:

HIV programs have “tubular” structureHIV programs have “tubular” structure

Interventions focused on sporadic eventsInterventions focused on sporadic events

Services and activities focused on populations of Services and activities focused on populations of childbearing agechildbearing age

Lack of access to SRH promotion and care for especially Lack of access to SRH promotion and care for especially vulnerable populationsvulnerable populations

Lack of interest in non-routine interventionsLack of interest in non-routine interventions

BASICBASIC PREMISESPREMISES Sexuality, Health, and Well-beingSexuality, Health, and Well-being

Reproduction

SRHSRH 1. Know HIV status

2. Promote safer sex

3. Optimize the

connection betweenHIV/AIDS services and STI services

4. Integrate HIV/AIDS with maternal and child health

Family planning Maternal and child care STI management Management of other SRH problems

HIV/AIDS

Prevention

Treatment

Care

Support

Key Links

Integration: High potential for benefits

Source: SSR y VIH/SIDA. Un marco de referencia para establecer vínculos prioritarios. (WHO, UNFPA, UNAIDS, IPPF, 2005)

THE CASE OF NEW ZEALAND:THE CASE OF NEW ZEALAND:

HIV/AIDS Action Plan: Sexual andHIV/AIDS Action Plan: Sexual and Reproductive Health StrategyReproductive Health Strategy

THE CASE OF NEW ZEALAND:THE CASE OF NEW ZEALAND:

HIV/AIDS Action Plan: Sexual andHIV/AIDS Action Plan: Sexual and Reproductive Health StrategyReproductive Health Strategy

FOUR STRATEGIC AREAS INFOUR STRATEGIC AREAS IN THE THE ACTION PLANACTION PLAN

Attitudes, values, and social behavior: Greater Attitudes, values, and social behavior: Greater notification and understanding of the causes and impact ofnotification and understanding of the causes and impact of HIV/AIDS, with greater commitment to prevent and reduce HIV/AIDS, with greater commitment to prevent and reduce impactimpact

Individual knowledge, skills, and behavior: People in Individual knowledge, skills, and behavior: People in vulnerable groups have knowledge,vulnerable groups have knowledge, skills, self-esteem, and skills, self-esteem, and motivation to protect themselvesmotivation to protect themselves

Programs and services: Effective and accessible Programs and services: Effective and accessible programs and services with integrated SRH activities and programs and services with integrated SRH activities and prevention and reduction of HIV/AIDS impactprevention and reduction of HIV/AIDS impact

Information: Information and evidence base for Information: Information and evidence base for sustaining policies, program development, monitoring, and sustaining policies, program development, monitoring, and decision-makingdecision-making

THE CASE OF GREAT BRITAIN:THE CASE OF GREAT BRITAIN:

The National Strategy for SexualThe National Strategy for Sexual Health and HIVHealth and HIV

GOALS:GOALS:

- - a)a) Improve information, services, and supportImprove information, services, and support- b) Reduce inequities in sexual health - b) Reduce inequities in sexual health - c) Improve health, sexual health, and well-being- c) Improve health, sexual health, and well-being

PRINCIPLES: PRINCIPLES: Appropriate services for individuals, their families, and Appropriate services for individuals, their families, and

their health care providerstheir health care providers Integrated actionsIntegrated actions Focus on maintaining health and reducing inequitiesFocus on maintaining health and reducing inequities Services “without interruptions”Services “without interruptions” Adaptation to specific needsAdaptation to specific needs Ongoing improvement of servicesOngoing improvement of services Respect for confidentiality and availability of Respect for confidentiality and availability of

information on services and treatmentsinformation on services and treatments

THREE PILLARS OF THE STRATEGY THREE PILLARS OF THE STRATEGY I. BETTER PREVENTIONI. BETTER PREVENTIONPublic Public informationinformationGuide on the use of evidence Guide on the use of evidence Clear goals in prevention (new HIV infections, unprotected sex, measured by STI Clear goals in prevention (new HIV infections, unprotected sex, measured by STI rates including rectal gonorrhea) rates including rectal gonorrhea) General goals at the national level General goals at the national level

II. BETTER SERVICESII. BETTER SERVICESChlamydia detection in certain groups Chlamydia detection in certain groups Reinforce role of PHC Reinforce role of PHC Improve skills of PHC providersImprove skills of PHC providersIncrease HBV vaccination coverage Increase HBV vaccination coverage

III. BETTER MANAGEMENTIII. BETTER MANAGEMENT

Local commissions with various agencies and sectors representedLocal commissions with various agencies and sectors representedLocal goals linked to national goalsLocal goals linked to national goalsPlanning based on study of local needsPlanning based on study of local needsForging of professional partnerships and participationForging of professional partnerships and participationParticipation of families and communitiesParticipation of families and communities

From Montevideo I and II to Montevideo III: From Montevideo I and II to Montevideo III: Scope of the Integration StrategyScope of the Integration Strategy

GOAL:GOAL: Sexual well-being of people, families, andSexual well-being of people, families, and

communitiescommunities

• Integration of SRH and responses to HIV/STIs into national Integration of SRH and responses to HIV/STIs into national and local programsand local programs• SRH policies on risk and damage control associated with SRH policies on risk and damage control associated with sexual behavior and reproduction or with values, attitudes sexual behavior and reproduction or with values, attitudes and beliefs related to theseand beliefs related to these• Integrated health services for young people and adultsIntegrated health services for young people and adults• Development of professional skills in SRHDevelopment of professional skills in SRH

Linkage of health care actions with those in homes, Linkage of health care actions with those in homes, schools, communitiesschools, communities

From Montevideo I and II to Montevideo III: From Montevideo I and II to Montevideo III: Areas for IntegrationAreas for Integration

Emphasis on PreventionEmphasis on Prevention Emphasis on Risk and VulnerabilityEmphasis on Risk and Vulnerability Redimension STIsRedimension STIs Opportunities for concrete achievementsOpportunities for concrete achievements Gender, masculinity, and powerGender, masculinity, and power Integrating role of the health sectorIntegrating role of the health sector

From Montevideo I and II to Montevideo III:From Montevideo I and II to Montevideo III: Proposals for ActionProposals for Action

Political commitmentPolitical commitment Integration among sectorsIntegration among sectors Promotion of gender agendaPromotion of gender agenda SRH care for men and womenSRH care for men and women STI ProgramsSTI Programs Community ParticipationCommunity Participation Comprehensive sex educationComprehensive sex education Training in sexuality and sexual healthTraining in sexuality and sexual health

From Montevideo I and II to Montevideo III: From Montevideo I and II to Montevideo III: Suggested Key StrategiesSuggested Key Strategies

Comprehensive information for decision-makingComprehensive information for decision-making

Health services that are accessible, inclusive, Health services that are accessible, inclusive, integrated, and effectiveintegrated, and effective

Promotion of sexual and reproductive health and well-Promotion of sexual and reproductive health and well-being for the populationbeing for the population

Integrated, efficient management and administration to Integrated, efficient management and administration to

carry out the integration strategycarry out the integration strategy

Montevideo III: Montevideo III: Next StepsNext Steps

Review the Strategic ProposalReview the Strategic Proposal

Review and articulate with other potential Review and articulate with other potential membersmembers

Construction of matrix of actions and Construction of matrix of actions and interventionsinterventions

Presentation of Family and Community Health Presentation of Family and Community Health strategy as an examplestrategy as an example