Despite Consensus and Mounting Evidence, Challenges to Improved HIV–Reproductive Health Linkages Remain
In line with President Bush’s personal commitment, Congress recently voted to reauthorize the President’s Emergency Plan for AIDS Relief (PEPFAR). In addition to calling for a major increase in U.S. spending on international AIDS, tuberculosis and malaria activities, the new legislation supports linkages—either directly or by referral—with a long list of ancillary services that often affect AIDS-impacted individuals and families, including nutrition, access to safe water and sanitation, substance abuse and treatment services, and legal services. It also expands programs aimed at addressing the factors that drive the pandemic for women, including initiatives to reduce gender-based violence and empower women economically.
The new version of PEPFAR, with its broader development mission, has been hailed as a significant achievement and one of the most positive legacies of the Bush administration. Despite these impressive gains, there is one critical set of linkages that is lacking in U.S. global AIDS policy: linkages between HIV and reproductive health services. During the long reauthorization process, a diverse set of organizations—from CARE to the International Women's Health Coalition to the Elizabeth Glaser Pediatric AIDS Foundation—pushed for but ultimately failed to secure measures that would have strengthened the role of family planning service providers in providing HIV prevention services and would have encouraged the provision of contraceptive counseling, referral and even direct services in dedicated HIV programs (related article, page 2).
PEPFAR's silence on the importance of better linkages between HIV and reproductive health programming—often referred to as integration—is out-of-step with the rest of the world. Indeed, a broad consensus exists on the importance of better linkages between HIV and reproductive health care, and how increased integration can be achieved at the program level to advance the fight against AIDS (see box). Newly released research shows the clear benefits of linking HIV and reproductive health services—an approach that represents the kind of efficiency that should make it a priority. Yet, the fact remains that although progress may be taking place, integration is not widespread. Achieving better linkages between these two program areas has not been easy, and without the support of policymakers, the challenges are even more daunting.
Global Commitments for Integration
Support for better integration of HIV and reproductive health services stretches back to the 1994 International Conference on Population and Development (ICPD). Agreed to by more than 180 countries, the ICPD Program of Action articulated a dramatically new approach to population issues that emphasized a more comprehensive, client-centered approach to sexual and reproductive health, encompassing HIV prevention as well as services that traditionally fall under family planning.
Following ICPD, the continuing escalation of the AIDS epidemic heightened international interest in linking HIV and reproductive health. In 2004, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) convened meetings on HIV–reproductive health integration that brought together government ministers, policymakers, donors and leaders of nongovernmental organizations, as well as young people and people living with HIV. These meetings resulted in the Glion [Switzerland] Call to Action on Family Planning and HIV/AIDS in Women and Children and the New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health. Far-reaching in their scope, these documents represent consensus within the global community about the need for closer linkages between HIV and reproductive health services and consist of a series of recommendations for policy, programs and research.
More recently, the Political Declaration on HIV/AIDS, agreed to at the 2006 Review of the United Nations Special Session on HIV/AIDS, challenges the global health community to forge closer linkages between reproductive health and HIV services through better policy and program coordination. In addition, 65 representatives of global networks of people living with HIV met in 2007 to discuss how service integration can help support their sexual and reproductive health needs and rights. The Amsterdam Statement on the Sexual and Reproductive Health and Rights for People Living with HIV acknowledges that HIV-positive men and women have the right to decide whether and when to have children and to pursue a safe, consensual and satisfying sex life. It calls on international, regional and local governments, as well as other stakeholders, to acknowledge these needs and aspirations, and to meaningfully involve people living with HIV in policy and program design.
HIV–reproductive health integration also has the support of major AIDS donors worldwide. At the Group of Eight (G8) summit in July 2008, world leaders of the major industrialized nations endorsed a platform on development and Africa that includes integration: "The G8 will take concrete steps to work toward improving the link between HIV/AIDS activities and sexual and reproductive health and voluntary family planning programs, to improve access to health care, including preventing mother-to-child transmission, and to achieve the [Millennium Development Goals] by adopting a multisectoral approach and by fostering community involvement and participation."
Documenting the Benefits
In light of global interest in HIV–reproductive health integration, researchers at the Institute for Global Health at the University of California, San Francisco, recently conducted a systematic review of the evidence to gain a clearer understanding of the effects of, as well as the optimal circumstances and best practices for, strengthening linkages. The analysis uncovered some 50,000 citations published between 1990 and 2007. Of these, 58 studies met the inclusion criteria: Twenty-nine reviewed programs integrating HIV services—usually HIV testing—into existing reproductive health services; 21 reviewed programs integrating reproductive health services into existing HIV services; and eight reviewed those that integrate HIV and reproductive health services concurrently.
The review found that, despite a diversity of settings and clients, the majority of programs studied showed improvements in all outcomes measured, and only a few showed mixed results. Many of the integrated programs increased condom or contraceptive use, improved the quality of services and/or increased uptake of HIV testing. In addition, some programs showed a decrease in the incidence of HIV and other sexually transmitted infections (STIs). Only a few studies measured cost-effectiveness, but those that did measure it suggested net savings.
Notably, the researchers observed a shift in focus of the studies over time. Whereas earlier studies often evaluated reproductive health programs that had added HIV services, later studies more often focused on HIV programs that had added reproductive health services. Moreover, earlier studies were more likely to address just one type of linkage, while later studies evaluated programs that were more comprehensive in scope, with five or more linkages. These trends over time probably indicate that programs are ahead of published research: Programs today may be more likely than in the past to focus on introducing reproductive health approaches into HIV programs and to address a broad range of integrated services. In addition, few studies included in the systematic review focused on integrated programs targeting males, either as partners of females or as clients in their own right. And few studies evaluated how well providers are addressing the sexual and reproductive health needs, aspirations and rights of people living with HIV—again, probably because until recently little attention has been given to meeting these needs.
Policy: Part of the Problem and the Solution
Clearly, policies at the global level recognize the importance of HIV–reproductive health linkages, and a growing body of evidence shows the potential benefits of integration. Promoting linkages between these two program areas is critical to reaching women at risk of HIV, to increasing efficiency and cost-effectiveness of AIDS programs, to improving the quality of services—including for people living with HIV—and to building a sustainable global HIV effort.
Nevertheless, major gaps in country policies remain, and as a result, integrated programs on the ground are not widespread. Just how important policy is to program implementation can be seen in a 2004 study conducted by the POLICY Project. According to this analysis of 16 countries with high HIV prevalence rates, despite some attempts at integration, HIV policies seldom acknowledge or mention the role of family planning. Any reference to family planning is usually reserved for discussions about equipping reproductive health providers with STI/HIV counseling facilities. As a result of not having a policy mandate or indicators on linking HIV and reproductive health services, many HIV-related programs in developing countries treat reproductive health as separate and unrelated.
Moreover, because service implementation is guided by policies at multiple levels—from donor country policies to recipient country policies, from national and state-level regulations and guidelines to local program service delivery protocols—policies at each level need to support linkages. Donor countries, for one, need to make clear to recipient governments and partners that HIV–reproductive health linkages are a priority. Germany and the United Kingdom, for example, have done just that in their global AIDS strategies by encouraging country partners to make use of opportunities to link HIV and reproductive health services in ways that respond better to people's needs. Similarly, recipient countries need policies, structures and guidelines in place that support linkages. Too often, HIV services and reproductive health services are separate and parallel programs, often resulting in sharp divisions within country governments and in frontline service provision. For linkages to work in a sustainable way, policies need to work together in concert at every level. And of course, policies supporting integration are just the first step: They must be backed by policies and funding that address a host of obstacles to better integration and to health care service delivery generally, such as staff shortages, inadequate training and the lack of basic supplies.
In two closely interrelated ways, U.S. policies remain a major obstacle to moving the global HIV–reproductive health integration agenda forward. As the single largest donor to global AIDS programming, this country's failure to join and actively support the global integration consensus is a serious problem in and of itself. Compounding that problem is the fact that even as U.S. commitment to global AIDS efforts has risen exponentially under the Bush administration, so has its support for family planning eroded. Since its apex in 1995, U.S. government support for international family planning assistance has dropped in inflation-adjusted terms by 39% to $461 million in the current fiscal year. In his final budget to Congress, President Bush requested yet another deep cut—to $327 million in FY 2009.
To date, securing political support for HIV–reproductive health integration has been a challenge to say the least. During the reauthorization of PEPFAR, the debate reached a low point when congressional conservatives argued that proposals to add HIV testing and counseling services to family planning programs would somehow turn PEPFAR into an abortion-promotion program, and administration officials asserted that providing contraceptive services to HIV-positive women wishing to avoid unplanned pregnancies is somehow "antilife." Now that PEPFAR has been reauthorized, it is high time for policymakers of all political stripes to move beyond this ideological debate in favor of proven, evidence-based interventions promoting linkages between HIV and reproductive health services. Failure to do so only foregoes a key weapon in the fight against AIDS.
What Is Integration Between HIV and Reproductive Health Services?
A broad consensus exists on the importance of better integration between HIV services and reproductive health services. Global commitments by the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO), the United Nations Population Fund (UNFPA), service providers, networks of people living with HIV and others have stressed how critical these two program areas are, together, in the fight against AIDS.
The goal of better integration is simple: To ensure that individual men and women—whether they are atrisk of HIV or HIV-positive—are provided with a continuum of HIV and reproductive health services that meets their needs. This does not mean that all of these services can or even should be provided by the same clinician or even in the same setting; rather, it means that there is a mechanism in place, so that every person has access to the HIV and reproductive health services he or she needs, either directly or by referral.
Recognizing that there is still confusion about the terms “integration” and “linkages,” UNAIDS, WHO, UNFPA and the International Planned Parenthood Federation defined these terms in a 2008 report, emphasizing the need for joint operations, referrals and synergies. At the core of these definitions is an understanding that integration is a two-way street.
What HIV Service Providers Can Do
Most women at risk of HIV are also at risk of unintended pregnancy, and a positive HIV diagnosis does not mean an end to most people’s sexual lives or to their desire to achieve, time or prevent pregnancies and births. While condom use prevents horizontal HIV transmission from partner to partner, it also prevents unintended pregnancy—the primary motivating factor behind most young people’s use of condoms. All contraceptive methods, including condoms, reduce the incidence of vertical transmission from mother to child, by helping HIV-positive women avoid unintended, high risk pregnancies. Safe abortion, high quality obstetrical care and dedicated prevention of mother-to-child transmission (PMTCT) interventions are also services essential to both reproductive health and HIV prevention.
Providers of HIV prevention and treatment services can start by providing:
• nondirective, nonjudgmental and confidential counseling on reproductive options;
• voluntary contraceptive services;
• prevention, diagnosis and treatment of sexually transmitted infections other than HIV;
• referral for prenatal care and high quality obstetrical services; and
• referral for safe, legal abortion services and for postabortion care for HIV-positive women with unwanted pregnancies.
What Reproductive Health Providers Can Do
Many women at risk of HIV—as well as those unaware that they are HIV positive—come into contact with the health care system seeking reproductive health services, which presents opportunities for providers to reach them with HIV prevention services and referral for treatment when necessary. Reproductive health providers have the knowledge and skills upon which stepped-up interventions for HIV prevention can be built.
Reproductive health providers can start by providing:
• HIV prevention information and counseling, including information on dual protection and the importance of correct and consistent condom use;
• HIV testing and referral for HIV treatment as indicated; and
• referral for prevention of mother-to-child transmission services for HIV positive women who are already pregnant and intend to continue their pregnancies.