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Gender and Health
1. Linking Sexual & Reproductive Health
and HIV:
Evidence Review and
Recommendations
Caitlin Kennedy
November 19, 2008
2. Objectives
The international community agrees that the Millennium
Development Goals will not be achieved without ensuring
universal access to sexual & reproductive health (SRH)
and HIV prevention, treatment, care and support
In order to gain a clearer understanding of the
effectiveness, optimal circumstances, and best practices
for strengthening SRH and HIV linkages, a systematic
review of the literature was conducted
3. Potential Benefits
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 resources
Better understanding and protection of individual rights
Mutually reinforcing complementarities in legal and policy
frameworks
Enhanced programme effectiveness and efficiency
Better utilization of scarce human resources for health
4. Key Research Questions
What linkages are currently being evaluated?
What are the outcomes of these linkages?
What types of linkages are most effective and in what
context?
What are the current research gaps?
How should policies and programmes be strengthened?
5. Definitions
Linkages: Policy, programmatic, services and advocacy
bi-directional synergies between SRH and HIV/AIDS
services
Integration: Different kinds of SRH and HIV services or
operational programmes joined together to ensure and
perhaps maximize collective outcomes
6. Methods
Systematic review
—Comprehensive online search of scientific databases, program
websites, and consultation with experts
—Systematic methods used for screening, data extraction, and
quality assessment of studies
Inclusion criteria
Peer-reviewed studies
— Published in peer-reviewed
journal (1990-2007)
— Rigorous evaluation study
(pre-post or control group)
— Conducted in any setting
Promising practices
— ‘Grey’ (non-peer-
reviewed) literature (1990-
2007)
— Must report some
evaluation results
— Conducted in resource-
limited settings only
7. Citations excluded from review (n=50,572)
• Did not meet inclusion criteria
• Interventions with element 3 of PMTCT (matrix column
3, row 2) were reviewed elsewhere (see full report)
Citations not retained for analysis (n=169)
• Interventions linking HIV prevention, education
and condoms with SRH services (matrix
column 1) were reviewed elsewhere (see full report)
Citations included in
analysis
(n=58)
Citations included
in review
(n=227)
Citations identified
through search
strategy
(n=50,799)
Result
s
8. SRH-HIV Linkages Matrix
Element 3 of
PMTCT
HIV
prevention,
education &
condoms
HIV
counselling
&
testing
Maternal & child
health care
7
10
15
10
STI prevention &
management
129
23
9
10
1
2
Other SRH services 0
5
1
2
0
1
GBV prevention &
management
4
10
1
2
1
2
Family planning 54
25
6
16
2
5
Clinical care
for PLHIV
2
3
4
2
2
0
1
1
1
4
Psychosocial
& other
services for
PLHIV
1
4
5
2
1
0
0
1
6
5
Peer-Reviewed
Studies
Promising
Practices
9. Key Study Characteristics
58 studies included in analysis
— 35 peer-reviewed studies
— 23 promising practices
6 of 58 studies used a randomized control design
Region
— 36 Africa (80% of promising practices were in Africa)
— 11 United Kingdom and United States of America
— 11 Asia, Eastern Europe, Latin America and the Caribbean
Direction of linkages
— 29 studies integrated HIV into existing SRH services (earlier studies)
— 21 studies integrated SRH into existing HIV services (later studies)
— 8 studies integrated HIV and SRH services concurrently
10. Key Study Characteristics
Populations
— Most interventions targeted pregnant/postpartum women, or adults of
reproductive age
— 3 studies specifically targeted youth/adolescents
2 peer-reviewed studies providing HIV testing in STI clinics
1 promising practice providing HIV testing in youth centres
Several other studies did not specifically target youth, but youth were among
the clients/beneficiaries
Settings
— Antenatal care clinics adding HIV services (n=16)
— HIV counseling & testing centres adding SRH services (n=3)
— Family planning clinics adding HIV services (n=6)
— HIV clinics adding SRH services (n=5)
— STI clinics adding HIV services (n=3)
— Primary health care clinics adding HIV and/or SRH services (n=10)
11. Key Outcomes
Health
—HIV incidence: 2 studies, average rigour = 4
1 positive effect, 1 no effect
—STI incidence: 2 studies, average rigour = 6.5
Both positive effect
Behavioural
—Condom use: 13 studies, average rigour = 3.8
8 positive effect, 3 mixed effect, 2 no effect
—Contraceptive use (other than condoms): 6 studies, average
rigour = 3.3
4 positive effect, 2 mixed effect
12. Key Outcomes
Process
—Uptake of HIV testing: 12 studies, average rigour = 2.2
All positive effect
—Quality of services: 7 studies, average rigour = 2.7
5 positive effect, 2 no effect
Other
—Stigma: 0 studies
—Cost: 5 studies, average rigour = 1.6
3 studies presented costing data only (absolute cost per unit)
2 studies presented cost-effectiveness; Both suggested net savings
from HIV/STI prevention integrated into MCH services
13. Promoting and Inhibiting Factors
Promoting
—Stakeholder involvement
—Capacity building
—Positive staff attitudes and non-stigmatizing services
—Engagement of key populations
Inhibiting
—Lack of sustainable funding and stakeholder commitment
—Staff shortages, high turnover or inadequate training
—Poor programme management and supervision
—Inadequate infrastructure, equipment, and commodity supply
—Client barriers to service utilization, including low literacy, lack of
male partner involvement, stigma, and lack of women’s
empowerment to make SRH decisions
14. Overall Findings
The majority of studies showed improvements in all outcomes
measured
— A few mixed results
— Very few negative findings
Linking SRH and HIV services was considered beneficial and
feasible, especially in:
— Family planning clinics
— HIV counselling and testing centres
— HIV clinics
Promising practices tended to evaluate more recent and more
comprehensive programmes
— 71% of peer-reviewed studies reported only one type of linkage
— 57% of promising practices reported five or more linkages, while just 9%
had only one type of linkage
15. Gaps
Inadequately studied interventions
— Linked services targeting men and boys
— Gender-based violence prevention and management
— Comprehensive SRH services for people living with HIV, including
addressing unintended pregnancies and planning for safe pregnancies, if
desired
Infrequently used study designs & research
questions
— Research questions that specifically address SRH and HIV service
integration
— Study designs that compare integrated services to the same services
offered separately
Insufficiently reported outcomes
— Health
— Cost
— Stigma
16. Strengths and Limitations
Strengths
—Broad scope of review
—Systematic methodology
Limitations
—Difficult to synthesize data due to heterogeneity in:
Interventions
Populations
Research questions/objectives
Study designs/rigour
Measured outcomes
—May not have captured all promising practices
17. 3 of 15 Key Recommendations
Policy makers: Advocate and support SRH and HIV
linkages at the policy, systems and service levels since
they are demonstrated to improve outcomes
Programme managers: Strengthen linked SRH and
HIV responses in both directions and rigorously monitor
and evaluate integrated programmes during all phases
of implementation
Researchers: Direct rigourous research towards areas
of integration that are currently understudied, evaluate
key outcomes, and disseminate findings
18. Acknowledgements
The Cochrane/WHO/IPPF/UNFPA SRH-HIV linkages
review team
—Gail Kennedy, Alicen Spaulding, Lucy Almers, Debbie Bain
Brickley, Laura Packel, Joy Mirjahangir, Michael Mbizvo, Lynn
Collins, Kevin Osborne