This document summarizes a review of evidence on linking sexual and reproductive health and HIV services. The review found that integrating these services generally led to improved outcomes, including increased uptake of HIV testing and improved quality of services. However, there were still gaps in studying interventions targeting men/boys, gender-based violence, and services for people living with HIV. The review recommended that policymakers and program managers strengthen integrated SRH-HIV programs and monitor them closely, while researchers address gaps in integration research.

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