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Memorandum submitted by the International Planned Parenthood Federation (IPPF) to the International Development Committee of the UK Parliament
Summary of recommendations 1. IPPF recommends that existing SRH infrastructure is used to deliver ARVs 2. IPPF recommends that International Funding Structures recognise the role that SRH organizations can play in ARV delivery (in particular) and in health system strengthening 3. IPPF recommends that there is greater control over the quality of ARVs provided 4. IPPF recommends that donors ensure there is a continuous supply of ARVs 5. IPPF recommends that all prevention and treatment activities need to account for those who are HIV positive 6. IPPF recommends that all prevention activities need to be evidence based when targeting vulnerable populations 7. IPPF recommends that ABC as a prevention strategy is revised 8. IPPF recommends that prevention and treatment are seen as linked and mutually supporting activities
Background on the International Planned Parenthood Federation 1.1 The International Planned Parenthood Federation (IPPF) is a global network of 149 Member Associations working in 183 countries and is the world's foremost voluntary, non-governmental provider and advocate of sexual and reproductive health and rights.
1.2 IPPF aims to improve the quality of life of individuals by campaigning for sexual and reproductive health (SRH) and rights through advocacy and services, especially for poor and vulnerable people. We defend the right of all young people to enjoy their sexual lives free from ill-health, unwanted pregnancy, violence and discrimination. We support a woman's right to choose to terminate her pregnancy legally and safely. We strive to eliminate sexually transmitted infections and reduce the spread and impact of HIV/AIDS.
1.3 IPPF's strategy on HIV/AIDS aims to reduce the global incidence of HIV/AIDS and to protect the rights of those infected and affected. The four specific objectives towards delivering this strategy are 1) to reduce social, religious, cultural, economic, legal and political barriers that make people vulnerable to HIV/AIDS, 2) to increase access to interventions for prevention of HIV/AIDS/STIs through integrated, gender-sensitive and rights-based SRH programmes, 3) to increase access to care, support and treatment for people infected and support for those affected by HIV/AIDS, and 4) to strengthen the programmatic and policy linkages between SRH and HIV/AIDS.
We therefore submit this Memorandum to highlight issues and recommendations gained through our experience.
IPPF's Response to the Call for Evidence
Addressing the HIV/AIDS Pandemic: what are the priorities in 2006?
2 The importance of the policy and programmatic linkages between SRH and HIV/AIDS needs to be reflected in any response to the HIV/AIDS pandemic. The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. The interactions between SRH and HIV/AIDS are now widely recognised by the international community[1]. In addition, sexual and reproductive ill-health and HIV/AIDS share root causes, including poverty, gender inequality and social marginalization of the most vulnerable populations. The international community agrees that the Millennium Development goals will not be achieved without ensuring access to SRH services and an effective global response to HIV/AIDS.
Issue: The delivery of ARVs in Resource-poor settings
IPPF recommendations:
3 EXISTING SRH INFRASTRUCTURE 3.1 Resource poor-settings frequently lack the existing infrastructure to be able to deliver ARVs (both clinics and staff) and a further consequence of being resource-poor is that they are unable to build new infrastructure.
3.2 IPPF urges the UK Government to support the ARV capacity of SRH organisations. Many resource poor countries, especially in Sub-Saharan Africa, already have an existing network of Family Planning clinics and Associations (as part of the global IPPF network) that provides an under-utilised resource capable of providing ARV delivery. Current work by our IPPF Member Associations in Kenya[2] (the Family Planning Association of Kenya) and the Dominican Republic (Associacion Dominicana Pro-Bienestar de la Familia) demonstrates how this existing infrastructure and personnel can be used to great effect in the delivery of ARV programmes within an SRH setting.
This forms part of wider recognition within the SRH and HIV/AIDS communities about the benefits of integration of SRH and HIV/AIDS policy and programmes[3]. DFID documents recognise the importance of these linkages[4] in tackling the HIV/AIDS epidemic and in supporting SRH services generally[5]. The UK Government should apply this principle of linking SRH and HIV/AIDS to delivering ARVs.
IPPF recommends that existing SRH infrastructure is used to deliver ARVs
4 INTERNATIONAL FUNDING STRUCTURES 4.1 International HIV/AIDS funding structures, like the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) do not act on the linkages between SRH and HIV/AIDS. We recommend making SRH issues a requirement of the GFATM funding proposals would ensure stronger linkages between the two sectors.
Recent research by IPPF has highlighted the difficulties our Member Associations (SRH clinics) face in becoming involved in the country level bodies of the GFATM - because they are seen by some as not 'conventional' HIV/AIDS (i.e. organisations that solely focus on HIV/AIDS or have been heavily associated with HVI/AIDS in the past) organisations or as 'competition'.
4.2 IPPF urges the UK Government to advocate for the greater involvement of, and access to, SRH organisations within international funding structures like the GFATM (This could be through advocating for the inclusion of SRH as a requirement (not a recommendation) for funding).
IPPF recommends that International Funding Structures recognise the role that SRH organizations can play in ARV delivery (in particular) and in health system strengthening
5 QUALITY OF ARVS 5.1 In some contexts Governments are purchasing supplies of ARVs based solely on cost considerations rather than quality considerations. These concerns have been noted in Argentina, Venezuela and Brazil. This can lead to ineffective drugs being supplied to People Living With HIV/AIDS (PLWHA).
5.2 IPPF urges the UK Government to advocate for greater control over the quality of ARV drugs supplied in resource-poor settings
IPPF recommends that there is greater control over the quality of ARVs provided
6 A CONTINOUS SUPPLY OF ARVs 6.1 Concerns have been expressed over the lack of continuous supply of ARV drugs in some resource-poor settings. Inadequate donor funding can lead to disruption of drug supply to PLWHA - complicating treatment and leaving people without proper care. This has been noted in Guatemala and Jamaica - where lack of finance has led to ARV supply disruption.
6.2 IPPF urges the UK government to ensure there are reliable and constant funding streams to ensure a continuous supply of ARVs.
IPPF recommends that donors ensure there is a continuous supply of ARVs Issue: Prevention and treatment: achieving a balance
IPPF recommendations:
7 ACCOUNTING FOR THOSE WHO ARE HIV POSITIVE 7.1 Conventional prevention activities have usually focussed on the needs of HIV negative people, yet this ignores the SRH needs and rights of PLWHA. Positive prevention refers to a set of actions that help PLWHA protect their sexual health, avoid other STIs, delay HIV/AIDS disease progression, and avoid passing HIV infection to others.
7.2 IPPF urges the UK Government to ensure that all prevention and treatment activities include policy and programmatic reference to the SRH needs and rights of PLWHA, and recognise their crucial role in the epidemic.
IPPF recommends that all prevention and treatment activities need to account for those who are HIV positive
8 EVIDENCE BASED PREVENTION ACTIVITIES 8.1 Many prevention activities have focussed on broad messages that do not account for the specific needs of certain marginalized and vulnerable populations. These could, in different regional and national settings, be Men who have Sex with Men (MSM), Intravenous Drug Users (IDUs) and their partners, or sex workers and their partners. Inappropriate prevention programmes can mean those who most require services do not receive them. IPPF recognises the UK government is promoting the need to support vulnerable populations and rightfully raises the issues of affordability, stigma and discrimination - all barriers to effective action[6], yet prevention and treatment programmes also need to be designed to cater for the needs of marginalized and vulnerable populations.
8.2 Prevention and treatment programmes need an evidence based approach to designing policies and programmes - vulnerable populations have rights and specific needs that need to be addressed.
IPPF recommends that all prevention activities need to be evidence based when targeting vulnerable populations
9 REVISION OF ABC 9.1 ABC - Abstain, Be Faithul, Use a Condom - has been promoted by many agencies as a prevention strategy. However as a strategy it does not provide universal protection. Many young women and girls have no control over condom use or their age of sexual debut, making abstinence for some an impossiblility. Marriage is also not a protective factor for many - in some areas married women are more likely to become infected than their unmarried counterparts[7]. Consequently, as a strategy, ABC is not protecting many young women and girls.
9.2 IPPF urges the UK government to support efforts to find an alternative message to ABC.
IPPF recommends that ABC as a prevention strategy is revised
10 PREVENTION AND TREATMENT ARE LINKED 10.1 Prevention and treatment activities are mutually beneficial - for example - treatment of STIs acts to reduce vulnerability to HIV and therefore acts as a mode of HIV prevention. This is further recognition of the linkages between SRH and HIV/AIDS. The most efficient response would discuss prevention and treatment in terms of links (and thus see them as mutually supporting), instead of discussing them in terms of 'balance' (which would in some ways see prevention and treatment as mutually exclusive).
10.2 Recognition of this synergy would lead to a more efficient use of resources and greater levels of both prevention and treatment. This refers again to the beneficial linkages between SRH and HIV/AIDS
IPPF recommends that prevention and treatment are seen as linked and mutually supporting activities
November 2005
[1] The Glion Call to Action, The New York Call to Commitment and A Framework for Priority Linkages (UNAIDS/UNFPA/WHO/IPPF - available from www.ippf.org and see appendix 1) [2] An independently commissioned case study by the United Nations Population Fund (UNFPA) has been written on the project run by the Family Planning Association of Kenya (see Appendix 2 - hard copy submitted with letter and electronic copy submitted with this Memorandum). This highlights the pioneering work being done by our Member Association in Kenya in integrating SRH and HIV/AIDS services. [3] See 'A Framework for Priority Linkages' (IPPF/UNAIDS/UNFPA/WHO, November 2005) available from www.ippf.org - the document provides a framework for key policy and programme actions to strengthen the linkages between sexual and reproductive health and HIV/AIDS programmes. [4] DFID, 'Sexual and reproductive health and rights, a position paper' (July, 2004), p7 and UK Government 'Taking Action, The UK's strategy for tackling HIV and AIDS in the developing world', p43.
[5] DFID, 'Sexual and reproductive health and rights, a position paper' (July, 2004), p17 [6] UK Government 'Taking Action, The UK's strategy for tackling HIV and AIDS in the developing world', p48 [7] See Staneki, K. (2002) The AIDS pandemic in the 21st Century. Draft report. US Census Bureau, July 2002 - http://www.dec.org/pdf_docs/PNACP816.pdf
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