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

Key issues and intersections in sexual and reproductive health and HIV integration Mobilizing for RH/HIV Integration Addis Ababa, Ethiopia 26-29 Feb. 2008. Manjula Lusti-Narasimhan Department of Reproductive Health and Research World Health Organization. 50. 45. 40. 35. 30. 25. 20. 15.

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

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  1. Key issues and intersections in sexual and reproductive health and HIV integrationMobilizing for RH/HIV IntegrationAddis Ababa, Ethiopia 26-29 Feb. 2008 Manjula Lusti-Narasimhan Department of Reproductive Health and Research World Health Organization Addis_GF-Mtg_25-02-08

  2. 50 45 40 35 30 25 20 15 10 5 0 27 years of responding to AIDS First cases of unusual immune deficiency are identified among gay men in the USA Global Fund to fight AIDS, Tuberculosis and Malaria In 1991-1993, HIV prevalence in Uganda and in Thailand begins to decrease 10 billion dollars for AIDS in developing countries The Human Immunodeficiency Virus (HIV) identified as cause of AIDS The UN General Assembly Special Session on HIV/AIDS Millions UN Political Declaration on HIV/AIDS Highly Active Antiretroviral Treatment launched Global Network of People living with HIV/AIDS (GNP+) WHO and UNAIDS launch the "3 x 5" initiative The World Health Organization launches the Global Programme on AIDS Brazil becomes the first developing country to provide antiretroviral therapy Evidence that male circumcision considerably reduces sexual transmission of HIV from women to men. The first HIV antibody test becomes available First regimen to reduce mother-to-child transmission of HIV President Bush announces PEPFAR Acquired Immune Deficiency Syndrome (AIDS) defined International AIDS Conference in Durban 2.3 million people on ART in the developing world The first therapy for AIDS — zidovudine, or AZT — is approved for use in the USA UNAIDS created Drug Access Initiative is launched in Africa A heterosexual AIDS epidemic is revealed in Africa 1980 ‘81 ‘82 ‘83 ‘84 ‘85 ‘86 ‘87 ‘88 ‘89 ‘90 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 2008 People living with HIV Children orphaned by AIDS in sub-Saharan Africa Addis_GFMtg_MLN_25-02-08

  3. Challenges to achieving health MDGs 4, 5 & 6and 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 healthWorld Health Report 2002 Addis_GFMtg_MLN_25-02-08

  4. Calls for linking sexual and reproductive healthand HIV have multiplied Addis_GFMtg_MLN_25-02-08

  5. The rationale for linkages: • Promote safe and responsible sexual behaviour • Have the potential to increase dual protection and condom use • Reduce mother to child transmission of HIV • Reduce stigma and discrimination in some settings • Minimize missed opportunities to increase access and coverage of services • Provide sexual and reproductive health services for people living with HIV which meet their needs Addis_GFMtg_MLN_25-02-08

  6. Operational definitions Integration: integration of services which emerged from ICPD based on the need to offer comprehensive SRH services that meet several needs simultaneouslyLinkages: linkages emerged to reflect alternative ways of combining services, including creating opportunities for systematic referrals within programmesSynergies:implies that outcomes of integrated or linked services are greater than the outcomes of individual services Addis_GFMtg_MLN_25-02-08

  7. Sexual and Reproductive Health Promote 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. Addis_GFMtg_MLN_25-02-08

  8. Key linkages between sexual and reproductive health and HIV/AIDS Addis_GFMtg_MLN_25-02-08

  9. 1. Learn HIV status • Support legal and policy reform to remove barriers to HIV testing and counselling, particularly for young people • Reorientate VCT/PITC services to better meet needs of young people and key populations • Provide basic sexual and reproductive health services (information on dual protection, counselling, access to condoms) in VCT/PITC programmes • Routinely offer HIV testing and counselling in STI services • Routinely offer HIV testing and counselling in family planning and antenatal care services (high prevalence settings) • Provide effective referral to treatment programmes Addis_GFMtg_MLN_25-02-08

  10. 2. Promote safer sex • Develop policies that support dual protection • Support policy development on comprehensive safer sex services for young people, PLWH and other key populations • Broaden sexual and reproductive health services to key populations • Promote condom use for dual protection within all family planning and HIV prevention programmes • Provide full range of sexual and reproductive health services (including prevention) for PLWH • Empower women and girls to negotiate safer sex and access sexual and reproductive health and HIV/AIDS services • Include services that address gender-based violence (counselling, emergency contraception, HIV post-exposure prophylaxis) Addis_GFMtg_MLN_25-02-08

  11. 3. Optimize connection between HIV/AIDS and STI services • Advocate for investment in STI management as a key strategy to reduce HIV transmission • Implement in STI programmes a package of HIV/AIDS services (safer sex information and counselling, routine offer of HIV testing and counselling, condoms) • Provide STI management to PLWH in all HIV/AIDS care and treatment services Addis_GFMtg_MLN_25-02-08

  12. 4. Integrate HIV/AIDS with maternal and infant health • Develop policies to provide appropriate HIV/AIDS management options for pregnant women, mothers, their infants and families • Ensure that all four prongs of the strategy for PMTCT of HIV are in place • Provide basic package of HIV/AIDS services in antenatal care settings • Integrate antenatal syphilis screening and treatment with PMTCT • Strengthen maternal health services for women living with HIV/AIDS (infant feeding counselling, family planning, access to HIV care, treatment and support) • Provide counselling on reproductive choices for PLWH and their partners Addis_GFMtg_MLN_25-02-08

  13. Helping countries to monitor progress towards universal access in sexual and reproductive health • WHO/UNFPA Technical Consultation,March 2007 • Contents • A recommended framework of indicators for priority aspects of sexual and reproductive health • Possible indicators of programmatic linkages between sexual and reproductive health services and HIV prevention, care, and treatment • Indicators Core – all countries should report onAdditional – could report, based on special needsExtended – contextual relevance Addis_GFMtg_MLN_25-02-08

  14. Family planning services STI prevention and control Condom promotion BCC HIV / AIDS services Proposed linkages Expected outcome Existing 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) Addis_GFMtg_MLN_25-02-08

  15. Indicators • Proportion of HIV/AIDS service delivery points offering condoms • Proportion of HIV/AIDS service sites incorporating BCC materials • Proportion of HIV-positive people offered treatment, and counselled on sexual and reproductive health • Proportion of HIV/AIDS service sites offering or referring for STI treatment • Reduced unmet need for family planning among HIV-positive people Addis_GFMtg_MLN_25-02-08

  16. Proposed linkages Expected outcome VCT - PITC Existing services Increased access to HIV treatment and prevention PMTCT ANCand delivery services Family planning Quality sexual and reproductive health services STI Male involvement Maternal health services(ANC intra and postpartum care) Addis_GFMtg_MLN_25-02-08

  17. Indicators • Proportion of ANC and delivery services promoting the four-pronged approach to the prevention of mother-to-child transmission of HIV • Proportion of ANC and delivery services users counselled and treated for STIs, including following up the male partner for treatment Addis_GFMtg_MLN_25-02-08

  18. Conclusion Sexual and reproductive health services expand entry points for accessing HIV prevention and care, increase efficiency and cost-effectiveness of programmes "What we have been doing is like mopping the floor while the roof is leaking" Maggwa N (2006) Addis_GFMtg_MLN_25-02-08

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