Letter from United Nations Population
Fund (UNFPA)
I am writing with reference to your email communication
of 5 February requesting a response to the Call for Evidence of
10 December 2007.
As you know, on 21 January 2008, a joint response
of the Joint United Nations Programme on HIV/AIDS (UNAIDS) was
forwarded to Mr. Preston. UNFPA, The United Nations Population
Fund, as one of the 10 cosponsor agencies of UNAIDS was very much
involved in that response. The detailed response is attached for
your convenience.
However, given the importance of linkages between
sexual and reproductive health and HIV, we would like to take
this opportunity to provide some additional detail regarding the
recommendation `Support closer integration of HIV services
with other health programmes especially for sexual and reproductive
health, and to strengthen health systems more widely' as set
forth in the UNAIDS response under Issue 5 related to principal
blockages to achieving progress in the prevention of HIV.
It is well documented that the majority of HIV
infections are sexually transmitted or associated with pregnancy,
childbirth and breastfeeding. The presence of sexually transmitted
infections (STIs) can increase risk of HIV acquisition and transmission.
And importantly, sexual and reproductive ill-health and HIV share
root causes, including poverty, gender inequality and social marginalization
of the most vulnerable populations. Linking SRH and HIV services
will improve clinical care outcomes and community health with
the understanding that linkages are bi-directional, require multiple
models and should address policy, systems and service delivery.
Potential wide-reaching benefits of linking sexual and reproductive
health and HIV include:
1. Improved access to, and uptake of key
HIV and sexual and reproductive health services;
2. Better access of people living with HIV
to sexual and reproductive health services tailored to their needs;
3. Reduced HIV-related stigma and discrimination;
4. Improved coverage of under served and
marginalised populations with sexual and reproductive health services;
5. Greater support for dual protection against
unintended pregnancy and sexually transmitted infections (STIs),
including HIV;
6. Improved quality of care; and
7. Enhanced programme effectiveness and efficiency.
One of the most prominent examples of linkages
is the rapid and widespread adoption of prevention of mother-to-child
transmission (PMTCT) programs as an example of an integrated service
initiative that addresses a recognized need in a comprehensive
and well-accepted structure. Comprehensive PMTCT is defined as
a four-element intervention, including:
1. Primary prevention of HIV;
2. Prevention of unintended pregnancy;
3. Prevention of HIV transmission from an
infected mother to her child; and
4. Provision of care and support for HIV-infected
mothers and their infants, partners, and families.
Although political commitment to linkages has
been steadily gathering force, including with the 2005 World Summit
Outcome reaffirming the global commitment to achieving universal
access to reproductive health by 2015, including its role in achieving
the Millennium Development Goal (MDG) dealing with HIV, far too
many policies and programmes addressing either sexual and reproductive
health or HIV have failed to link these two global commitments.
In addition, further practical guidance on what and how to link
is needed to implement on a national scale including overcoming
issues such as:
1. Reproductive health commodities (HIV test
kits, STI drugs, female and male condoms, safer delivery kits,
PEP kits, contraceptives etc.) are still not readily available
and accessible;
2. Special efforts are required to reach
priority populations most under-served by current programmes,
including poor women, young people and marginalised populations;
3. Greater and more effective involvement
is needed of all potential beneficiaries, especially people living
with HIV, women and young people, in the design, governance and
delivery of sexual and reproductive health and HIV initiatives;
4. The sexual and reproductive health needs
and human rights of people living with HIV are still not adequately
promoted and supported;
5. Although over 100 countries globally implement
PMTCT programmes, most responses tend not to be comprehensive
(neglect primary prevention and sexual and reproductive health
of women living with HIV) and are often not well integrated into
maternal health and other core sexual and reproductive health
programmes; and
6. International debate on reproductive health
and rights is rarely over technical issues but is over cultural/political
issues. Efforts must be made to identify positive cultural values
that are present in all societies and contribute to human rights,
and empower people to change those practices that violate these
rights. Elimination of gender-based violence and child marriage
are examples of how linking SRH and HIV can occur not only at
service delivery but also at a policy level.
Finally, as we move further in strengthening
the linkages between sexual and reproductive health and HIV, it
is important to recognize that linked services cannot be delivered
by "one size fits all" programs and that linking HIV
and SRH goes beyond just combining services. Comprehensive linkages
require change at the policy and societal levels in order to address
issues such as child marriage, gender-based violence, and the
lack of male involvement in SRH issues.
3 March 2008
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