Linking Sexual & Reproductive Health and HIV: Evidence Review and Recommendations

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. Results 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 included in review(n=227) Citations identified through search strategy (n=50,799) 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)

8. SRH-HIV Linkages Matrix Element 3 of PMTCT HIV prevention, education & condoms HIV counselling & testing Clinical care for PLHIV Peer-Reviewed Studies Promising Practices Psychosocial & other services for PLHIV 1 4 6 16 2 5 Family planning 6 5 54 25 15 10 7 10 Maternal & child health care 2 3 1 4 1 2 1 2 4 10 GBV prevention & management 1 1 0 1 9 10 4 2 129 23 1 2 STI prevention & management 5 2 0 5 0 1 2 0 1 0 Other SRH services 1 2

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