Brosure - Eng

P r e v e n t i o n i s f o r L i f e h i v / a i d s : d i s pat c h e s f r o m t h e f i e l d prevention i s f o r life h i v / a i d s : d i s pat c h e s f r o m t h e f i e l d e Ditor /D esiGn /P Hoto C ontriBUtors : eDitor : PAtriCiA LeiDL oMAr GHArzeDDine , PAtriCiA LeiDL , GeorGe nGWA , trYGve oLfArnes , ArtHUr PLeWs , WiLLiAM A . rYAn C oPY - eDitinG : P roDUCtion AnD P rintinG : triAnA D ’ orAzio PHoeniX DesiGn AiD / p r ev en t i on i s fo r l i f e: h i v / a i d s d i s pat c h e s f r o m t h e f i e l d DenMArK WWW . PHoeniXDesiGnAiD . DK foreword: A WorLD WitHoUt AiDs 1. CritiCAL MAss: YoUtH AnD Hiv reachinG oUt: hiv and GanGs in Belize sharinG the secret: YoUth and hiv in the rUssian federation 2. ConDoMs: MeetinG DeMAnD AnD BUiLDinG sUPPLY introdUcinG the female condom in niGeria 3. WoMen AnD GirLs: ProteCtinG riGHts AnD reDUCinG risK BankinG on Women in tajikistan 4. LinKinG Hiv Prevention WitH seXUAL AnD reProDUCtive HeALtH ethiopia: hopes for an aids-free fUtUre 5. vULnerABLe GroUPs: eMPoWerinG At-risK PoPULAtions the riGht track: china’s railWaYs Back hiv prevention drive deliverinG prevention in cairo’s slUms endnotes chris de Bode / Unfpa / panos pictures Women and their infants, left and on cover, wait at a Unfpa-sponsored reproductive health care centre in nigeria. for eWorD : A WorLD WitHoUt Ai Ds p revention works. and this booklet will tell you how, by providing real-life examples of how communities can make a difference and save lives. since the hiv/aids epidemic erupted on the global health care scene in the early 1980s, researchers, health care workers, community leaders and activists, including those most at risk of acquiring hiv, have underscored the necessity of promoting the most cost-effective, rights-based, evidence-informed and rational intervention within the public health arsenal: prevention. in theory and in practise this means arming people with the information, counselling, services and commodities—such as male and female condoms—that will enable them to avoid acquiring HIV in the irst place. This is hardly a revolutionary concept, but it is one that has to be reafirmed over and over as each new generation moves into their sexually-active and reproductive years and as the virus continues to make inroads into vulnerable populations such as women, migrants, young people and children. prevention is for life, and is life-long. as such, it requires a sustained and committed response. it means that Un agencies, nongovernmental organizations (nGos), donors, national governments and communities of people living with hiv and aids must work together to apply what works and to adapt these success stories to diverse cultural and geographical settings. Prevention: A PUBLiC HeALtH MAinstAY although hiv can strike anyone, it is not an equal opportunity virus. Gender inequality, poverty, lack of education and inadequate access to comprehensive sexual and reproductive health services continue to fuel the epidemic. United Nations Member States have repeatedly reafirmed that “HIV prevention be the mainstay of national, regional and international responses to the pandemic”. comprehensive, rights-based and evidence-informed prevention, linked with access to effective sexual and reproductive health programmes and services, represent our best hope to halt the pandemic. nevertheless, despite a plethora of evidence that shows that behavioural change and comprehensive condom programming lowers transmission rates, prevention programmes tend to be under-funded, patchy or simply not available. in the hardest-hit, sub-saharan african countries the average male has access to only ten condoms—per year. Warrick page / Unfpa / panos pictures adolescent girls and boys attend an hiv and reproductive health class at school number one in dushanbe, tajikistan. 5 BUiLDinG on oUr Core strenGtHs as one of ten co-sponsors of the joint United nations programme on hiv/aids (Unaids), Unfpa (the United nations population fund) works to intensify and scale up hiv-prevention efforts by using rights-based and evidence-informed strategies in 154 countries worldwide. Unfpa also promotes prevention activities by seeking to redress gender inequalities that fuel the epidemic. With more than three decades of experience dealing with gender relations and sexuality in different socio-cultural settings, UNFPA is uniquely qualiied to strengthen the global response to hiv. Within Unaids, Unfpa focuses its efforts on comprehensive male and female condom programming and hiv prevention, particularly among women and young people. Unfpa reaches out to the most at-risk populations, including indigenous communities, young people, women, migrants, sex workers and their clients. It supports sexual and reproductive health care that is tailored to the speciic needs of vulnerable populations and those already living with hiv. Unfpa always seeks the participation of those it serves when it comes to shaping policies and programmes. linking hiv/aids with sexual and reproductive health remains the over-arching strategy of the Unfpa, and is key to bringing transmission rates down and reaching the goal of universal access to prevention, treatment, care and support. DisPAtCHes froM tHe fieLD this booklet will detail how and why prevention works. By applying the principles of prevention to diverse populations around the world, the global community can help slow, and possibly halt, what is proving to be one of the greatest health challenges of our time. prevention services cost money, but hiv infection costs far more—in lost lives, ruined families and gutted communities. hiv and aids is currently rolling back decades of human development and is threatening to derail anti-poverty initiatives around the world. one averted hiv infection represents hundreds of thousands of dollars saved and a more secure future for generations to come. Prevention WorKs: Let’s MAKe it for Life. . . . Warrick page / Unfpa / panos pictures A street vendor eyes an adolescent girl as she lits by in Dushanbe, Tajikistan. # 7 c r i t i ca l Y m a s s : Yo U t h a n d hiv outh is at the centre of the global aids epidemic; Unfpa actively involves them in programmes and policies that intimately affect them. and it works! Young people are a force for change when given opportunities to participate in programmes and in enabling environments that allow them to make informed choices about their lives and their future. in its 2007 aids update, Unaids reported that from 2000 to the present hiv prevalence among young pregnant women (ages 15-24) attending antenatal care clinics declined in 11 out of the 15 most affected countries. in addition, preliminary data shows favourable changes in risk behaviour among young people in a number of countries (cameroon, chad, haiti, kenya, malawi, rwanda, togo, tanzania, zambia and zimbabwe).1 researchers attribute the drop in numbers to behavioural change—e.g., delayed sexual debut, fewer partners and increased condom use, as well as improved surveillance methodology and reporting. despite this promising trend, young people in other regions continue to be vulnerable—particularly young women who continue to bear the brunt of new infections owing to biological susceptibility, marginalization, discrimination and gender-based violence. in order to be effective, prevention activities targeting all sectors of the population—and particularly young people— need to be consistent, long-term and include the direct input of the at-risk population. indeed, youth participation can take many forms. The UNFPA’s commitment to youth participation is relected in a wide range of initiatives—from peer education (Ypeer) to advocacy, access to reproductive health care, voluntary testing and counselling. Unfpa also encourages young people to participate in the preparation of national and Un plans and other development frameworks. these initiatives build on and utilize the skills, knowledge and enthusiasm of young people. Worldwide, Unfpa is training young people from all walks of life to raise awareness of the perils of unprotected sex, the impact of stigmatization and the importance of making responsible, informed choices about their sexuality and reproductive health. carolyn drake / Unfpa / panos pictures # Young women preparing for beauty treatments at an aesthetics and hairdressing salon in moscow, the russian federation. 9 r e A C H i n G o U t : H i v A n D G A n G s i n B e L i z e elize City, BELIZE—Raymond Gentle, 32, is the owner B the HIV prevention work is positive, not everybody welcomes the of a convenience store on Belize City’s infamous South YFF volunteers. Side. His narrow glance, gold-capped teeth, tattoos and baseball HiGH PrevALenCe, HiGH PovertY cap tilted sideways suggest he’s not your average “mom and pop” Belize, a Caribbean nation of 270,000 inhabitants wedged between business owner. Mexico and Guatemala, has one of the highest HIV prevalence When asked about his role as a gang leader, he responds: rates in the region. UNAIDS estimates that 2.5 per cent of “People say [I am]…the police say so.” But he does not it the Belizeans between 15 and 49 years of age are living with HIV. The image of a Central American marero, or gang member, widely Caribbean as a whole has the second highest HIV prevalence rate regarded as dangerous and unscrupulously violent. He is a father in the world—ranging between 1 to 1.2 per cent of the population, of two, and wants his kids to grow up with a chance at making with Haiti at the upper end of the scale.2 HIV prevalence is topped an honest living. only by sub-Saharan Africa. AssiGneD At BirtH GroWinG UP sCAreD Gang membership on the South Side of Belize City is practically “I was once hit in the head with a broken bottle,” recalls Douglas assigned at birth. There are no initiation rites for membership. If Hyde, an oficial with the Belizean Ministry of Youth and a you live on Craw Road, chances are you will be a member of the coordinator of the Youth for the Future prevention programme. Craw Road Gang. “Another time, someone pointed a gun to my head when I urged Mr. Gentle is a gang leader who openly admits that members them to turn their life around and go back to school.” Several of rob, steal and ight other gangs on the South Side; but, at the same the volunteers who were ex-gang members have been killed over time, he helps organize sports events for neighbourhood children the past number of years. as an alternative to “hanging out on the street and smoking The OPEC Fund for International Development and UNFPA weed”. He seems to understand that there is no excuse for illegal fund the “Prevention of HIV/AIDS Among Youth in Especially activities, and says he doesn’t want the next generation to “grow Dificult Circumstances” initiative. Working with gang members is up like that”. only a small part of this project’s many activities, which are spread A Better fUtUre over six Central American and Caribbean countries (Costa Rica, Mr. Gentle also volunteers for Youth for the Future, an NGO, Guatemala, Guyana, Honduras and St. Lucia, in addition to Belize). which forms part of a regional project to prevent HIV infection High-level political support for HIV prevention and mobilization among vulnerable young people. Even though his attitude towards of youth are just two of the project’s major achievements. “Someone pointed a gun to my head when I urged them to turn their life around and go back to school.” —Douglas Hyde, Youth for the Future coordinator carina Wint / Unfpa a young gang member shows off his tattoo in downtown Belize city. Gang violence in Belize is fuelled by the latin american drug trade. 11 A WiDe rAnGe of ACtors Activities in Belize involve a wide range of organizations, such as the 4H, the Cadet Corp (a type of correctional facility for males between the ages of 13 and 18), the United Belize Advocacy Movement and a community-based organization called the Cornerstone Foundation. The Belize chapter of the YWCA (Young Women’s Christian Organization), another participant, helps educate young women about HIV prevention and teaches them vocational skills to prepare them for adulthood. CUttinG to tHe CHAse: BArBer sHoPs Marleni Espinoza, 17, is among those who have beneitted. “I didn’t get good grades in school, so I decided to learn about working in a beauty parlour,” says Ms. Espinoza. She is taking part in a “barber shop” programme where participants learn how to protect themselves and their customers from HIV infection. The Slip ’n Slide barber shop in Belize City is among participating salons. Its owner, Anthony Lofter, explains that he often talks to customers about HIV prevention and hands out condoms to some of them. The programme also offers shop owners The OPEC Fund/UNFPA project has helped the Cornerstone free advertising as an incentive. Lofter says this has helped him Foundation print and distribute educational material for use in increase his customer base. local schools. It also distributes HIV-prevention pamphlets and Hiv AWAreness for ALL condoms to about 20 local hotels. San Ignacio seems far removed from Belize City’s violent South “About three or four years ago, it seemed that everyone here knew Side, even though it is barely a couple of hours drive away. The someone who was HIV positive. That is when we experienced small but bustling city located 10 kilometres (6.7 miles) from the an inlux of requests for education,” says Pamela VanDeusen, an Guatemalan border is an adventure tourism destination. It also international development consultant working for Cornerstone. serves as headquarters for the Cornerstone Foundation, which “Now we need to reach a deeper level and end discrimination and runs a variety of HIV-prevention programmes. stigma against those who are HIV positive.” carina Wint / Unfpa anthony lofter, above, owner of the slip ’n slide barber shop in Belize city, participates in an hiv-prevention programme. he frequently talks to his costumers about how to prevent getting infected. carina Wint / Unfpa Youth for the future is one of the programmes that receives funding from the opec fund for international development and Unfpa. left, a programme coordinator with a former gang member now actively involved in hiv prevention and violence reduction programmes. 13 s H A r i n G i n t H e t H e s e C r e t : r U s s i A n Y o U t H A n D H i v f e D e r A t i o n oscow, the RUSSIAN FEDERATION—Yulia lives on M Yulia only learned of her status following routine prenatal the outskirts of Moscow with her mother and six-year- screening. “When the doctors told me of the diagnosis I couldn’t old daughter. She is 25-years-old and sports dark blonde, shoulder- believe it. I became so depressed. I didn’t know what to do with length hair. She is of a generation that retains only dim memories my life or whether I would be dead in ive years.” of the waning days of the Soviet Union and is learning to adapt— Yulia’s case was a particularly tough one: not only was she positive in ways that her parents and grandparents are inding increasingly but she also was ill with one of the opportunistic infections that dificult—to the new Russia with its new opportunities, new rules can wind up claiming the lives of those living with HIV. She and doctors told me and new inequalities. But Yulia feels equal to the task. “I am young,” her husband were eventually divorced and then, worst of all, of the diagnosis I she says. “I can always earn money and take care of my mother. It authorities took her baby away for fear that the little girl could is hard for the older people—they have no options.” become infected. couldn’t believe it. one of tHe WorLD’s fAstest-GroWinG ePiDeMiCs I became so de- But Yulia is also at the vanguard of another trend—one that “When the at times leaves her so depressed that on some mornings she can Yulia’s story is not an unusual one. Names and circumstances barely roll out of bed. change but the verdict—HIV—is becoming increasingly common. pressed. I didn’t Yulia is HIV positive and only one of a growing legion of young Today, Russia is in the grips of the largest epidemic in Europe. know what to do with Russians infected with the virus—a cohort that is adding to an Initially concentrated among injecting drug users and sex workers, HIV epidemic that continues to skyrocket. She worries that for all newly-diagnosed HIV infection is now being detected among my life or whether of her youth, and for all of her energy, the amount of time she the individuals who report heterosexual contact as the source of I would be dead has to secure her daughter’s future and to ensure her mother’s care infection.3 is decidedly too short. Young people, in particular, have been the hardest hit with the Like many HIV-positive Russians she acquired the infection majority of new infections occurring in youth between the ages while still a teenager—18 to be exact. She had fallen in love, of 15 and 29. This can be attributed to factors such as injecting married young and only learned later that her husband was a drug use, which remains the main mode of HIV transmission former injecting drug user who may have been aware of his HIV- in the Russian Federation. Of the newly registered HIV cases positive status well before they met. “He was sick but didn’t say in 2006 where the mode of transmission was known, two thirds anything,” she says ruefully. “And I didn’t know any better. And (66 per cent) were due to injecting drug use and about one third then we had a baby.” (32 per cent) to unprotected heterosexual intercourse.4 The latter in ive years.” —HIV-positive activist Yulia Bulanova carolyn drake / Unfpa / panos pictures # a young man checks out a woman on a busy moscow street. 15 proportion, though, has been increasing steadily since the late health professionals, staff or psychologists with speciic training 1990s, especially in areas with comparatively mature epidemics. to deal with youth,” she says. Although there are now youth- Less than 1 per cent of newly registered HIV cases in 2006 were friendly clinics throughout Russia, they are not enough. She adds, 5 attributed to unsafe sex between men. Pavel Krotin, Chief Physician for UNFPA-supported Juventa, “Russia is an enormous country. We need more professional and experienced people. This is not an easy population to reach.” the main clinic of a network of 20 youth-friendly clinics that A MAjor DrAW for YoUtH operate throughout St. Petersburg, believes that politicians and To that end, Juventa offers comprehensive health services to schools are failing young people because of an inability to address Russian youth, including reproductive health care. In 2001 and the risk before young people become sexually active. 2002, UNFPA provided technical support to medical providers A siLent ePiDeMiC to build capacity and a new initiative to integrate HIV prevention, “We believe that the “We believe that the real numbers of those who are HIV positive including voluntary testing and counselling, into reproductive are actually ive to six times higher than oficial statistics,” he health services. By offering a conidential telephone hotline, real numbers of those asserts. One of the reasons, he says, why researchers believe that educational programmes and medical services, the Juventa clinic real numbers are higher than oficial estimates is a small number has become a model in youth-friendly services. of pilot studies undertaken in university student hostels that ACtUAL nUMBers fAr HiGHer showed that the prevalence rate among what would normally be Visits to the clinic, which opened in 1993, have increased from considered a low-risk population is “unexpectedly high”. nearly 77,000 in 1996 to more than 400,000 in 2007 with the main stiLL iMPervioUs clinic logging in 150,000 visits per year. Juventa’s peer counsellors The key, says Dr. Krotin, is to offer comprehensive sex education use their training and knowledge to help other youth avoid high- in school as well as services that combine reproductive health with risk behaviour and make informed, responsible choices. HIV-prevention programming. Unfortunately, young and older Sergey Smirnov, Director of the UNFPA-supported Community men are still largely impervious to reproductive health matters; of People Living with HIV/AIDS, a regional NGO, is among those however, “whether girls are willing to admit it or not, they are who believe that the actual number of young people infected with all concerned with reproductive health—they worry about getting HIV is far higher than oficial estimates. Stigma, discrimination pregnant and it is this group that we are most likely to reach.” and poor access to life-saving anti-retroviral therapy are also Lidia Bardakova, UNFPA Assistant Representative for Russia, having an impact: why get tested when what lies ahead is only concurs; but, she adds that despite the fact that authorities are trouble, rejection and heartbreak? Particularly acute is the situation supportive of youth-friendly clinics and programming, building for positive women, whose numbers are rising dramatically. professional capacity is a major stumbling block. “There is no Despite the fact that it operates from a tiny basement apartment system for the training and capacity-building of reproductive on a shoestring budget and includes a core staff of only four who are HIV positive are actually ive to six times higher than oficial statistics.” —Dr. Pavel Krotin, Chief Physician for UNFPA-supported Juventa carolyn drake / Unfpa / panos pictures hiv activist Yulia Bulanova, 25, at her home in moscow. her daughter, anastasia (nastia) Bulanova, is 6 and is hiv negative. they live in the novokosino area of moscow with Yulia’s mother, who takes care of nastia while Yulia is at work. having contracted hiv from her former husband, Yulia now is divorced but wants to remarry and have more children. 17 people, the Community of People Living with HIV/AIDS has just completed a situational analysis documenting the plight of Russia’s HIV-positive women—and the scenario is bleak. DePriveD of CoUnseLLinG AnD treAtMent Because most services are concentrated in Moscow and St. Petersburg, women living in Russia’s vast hinterland are deprived of counselling, services and access to uninterrupted anti-retroviral therapy. “Too often women, particularly young women, are told they should not conceive and that they should abstain from sex,” says Mr. Smirnov. For a young woman, such edicts can constitute a kind of death sentence. In fact, prevention and treatment is such that HIVpositive women can look forward to a safe sex life, motherhood and the opportunity to raise healthy offspring without fear of a premature death from AIDS. In Yulia’s case, it was the Community of People Living with HIV/AIDS that eventually provided her with the support and help she needed to confront and eventually accept her status. HIV status. “I’ve been refused manicures and even dentists won’t Now, she spends part of her time working with the organization see me,” she says. and informing other young people of their risks and what to do More oPen, Less jUDGeMentAL should they ind themselves in the position that she did. Still, she is optimistic. Though more vulnerable to HIV, the younger A reAson for HoPe generation is also more open, more aware and less judgemental. Yulia now has her little girl back, but her trust and her faith in “Young people are starting to act in a different way and they are the future have been badly battered even as she bravely informs not scared of this—or of me,” she says. “When I tell some young others of their risk. It is a tough road. The stigma that she and people that I have HIV their reaction is just the opposite of older others like her face is as seemingly boundless as her love for her people—they become interested and want to know more. They child and her hopes that her little one will grow up without fear are curious.” of HIV. Just recently, staff at a medical clinic Yulia visited to have her lu symptoms treated turned her away when they learned of her carolyn drake / Unfpa / panos pictures Galina sich and sergey smirnov, of the Unfpa-supported nGo community of people living with hiv/aids, pose for a picture in front of a poster of a woman and her daughter, who are both nGo beneiciaries. “I am hopeful for the future,” she adds. “I have to be. I want my daughter to grow up in a world where HIV will simply be considered an illness like any other.” carolyn drake / Unfpa / panos pictures # a video projection above a store on a moscow street. expensive shops and restaurants have appeared all over moscow signalling new prosperity, but also highlighting the growing impoverishment that is exacerbating the hiv epidemic—particularly among young people. 19 condoms: m e e t i n G d e m a n d a n d B U i l d i n G s U p p lY t oday, Unfpa continues to procure the largest number of condoms, supporting projects in every region to build demand for both male and female condoms. Unfpa encourages condom use through family planning clinics and mobilizes outreach workers to raise awareness in the workplace, barber shops, night clubs, hairstyling salons, in schools and within the military. it also uses mainstream media to spread the word through soap operas, ad campaigns, celebrity spokespersons and other channels. Within Unaids, Unfpa leads by securing a steady supply of male and female condoms. Working closely with national governments and a large network of partners, Unfpa collects data, forecasts needs, mobilizes and monitors donor support, procures supplies and builds capacity so that countries can increasingly manage their own logistical operations. Programming is informed by ongoing research that helps reine messages aimed at distinct audiences depending on geographical, cultural and social context. Unfpa also seeks to dispel myths and misperceptions surrounding condom use. through the female condom initiative (fci), Unfpa is scaling up efforts to distribute and market the device, which offers women protection that they can more easily initiate and control. carina Wint / Unfpa a Unfpa storage facility in port au prince, haiti. condoms and other reproductive health commodities are stored here. 21 i n t r o D U C i n G t H e f e M A L e C o n D o M i n O for more than 2,000 people living with HIV/AIDS. sun State, NIGERIA—Abiodun Titi, several months n i G e r i A pregnant, lashes her best stage smile as she explains how Living Hope Care is one of the many NGOs working with UNFPA to use a female condom at the headquarters of Living Hope to halt the spread of HIV by delivering condoms to groups who Care, an NGO that works with HIV-positive people in southern need them most. In Nigeria, NGOs such as Ms. Ibiyemi’s are often Nigeria. Ms. Titi is HIV positive but her husband is HIV negative. better-equipped to work with at-risk groups such as sex workers, The child they are having together—their second—was conceived youth and migrants than government institutions or hospitals. Because of the without exposing her husband to infection. How? It is thanks to In fact, these organizations are responsible for distributing some female condom, the female condoms she received at Living Hope Care, and whose 70 per cent of all the male condoms countrywide. They are also, use she is now demonstrating. naturally, the key to UNFPA’s efforts to ensure that the female “discordant” condom becomes available here as well. couples can It just seems possible that her smile might not be a staged one after all. Subsequent to Ms. Titi and her husband having Unlike the male condom, the female version is inserted into the intercourse, they harvested his semen from the female condom vagina rather than over the penis. The principle is basically the and injected it back into her body with the aid of a plastic syringe. same as the male version: it provides a barrier to the exchange of Because of the female condom, “discordant” couples such as Ms. bodily luids that can lead to HIV transmission. Titi and her husband can still conceive and practise safe sex—an feMALe-ControLLeD important beneit in a region where fertility is so highly prized. Today, there are two types of female condoms available in Nigeria. LivinG WitH HoPe: DoinG so WitH CAre and practise safe sex. The FC1 is made with polyurethane plastic and the newer FC2 6 is made of synthetic latex. Both are thin, soft, odourless and Nearly 4 per cent of the country’s population aged 15 to 49 is strong. Explains Stella Akinso, UNFPA Adviser in Osun State, Today, approximately 2.9 million Nigerians are living with HIV. still conceive infected with the virus. Living Hope Care is one of the many Nigeria: “In terms of safety, they are more durable—less likely to NGOs working to ight the epidemic. A remarkable Nigerian by burst or to break—and can be lubricated with water- or oil-based the name of Fakande Ibiyemi founded the organization in 1994. lubricants.” 7 A former nurse, she started the organization after a man was Their other great advantage is that they allow women to take brought into her hospital who had tried to hang himself after more control over their own sexual health—although research learning he had contracted HIV. Today, Ms. Ibiyemi’s organization shows that it still requires a degree of male consent. The female offers support, job training, free meals, micro-credit and treatment condom can be inserted some time before intercourse and chris de Bode / Unfpa / panos pictures a young woman holds her newborn at a Unfpa-sponsored reproductive health-care centre. 23 still function perfectly. Because it is the woman who wears the It appears to have been a success. Only 25,000 female condom, it helps counter the common and serious problem of condoms had been distributed in the entire country in 2003, men who refuse to wear condoms themselves. mainly through limited trials by some NGOs. By the end of Nevertheless, the female condom cannot be inserted secretly—a male partner will be aware of its presence, and could still insist 2006, however, the total had climbed to 375,000—15 times that of 2003. Eighty per cent of these were distributed by NGOs. upon its removal. The fact that it is the woman who puts it in, The government, UNFPA and other donor agencies are however, represents a serious advantage. Previously, women were making female condoms available to the Nigerian public entirely reliant on the willingness of men to wear condoms and through a variety of means, but the most intriguing is the thus protect both partners from HIV. scheme developed for distribution through NGOs. Andrew Ezekiel, a support group coordinator at Living Hope CostLY BUt effeCtive Care, is at least one man who inds it unlikely that his brethren Unfortunately, demand is constrained by cost. A female condom would go so far as to sabotage the usefulness of a female condom usually sells here for 20 naira—the equivalent of $0.15. UNFPA by insisting that a woman remove it before sex. “Men will submit. and the Nigerian government subsidize the female condom, They will not say no,” he laughs. placing it well below the actual manufacturing cost. LoW AWAreness, HiGH PotentiAL For the average Nigerian, however, it is still a signiicant In spite of these advantages, a 2005 UNFPA survey revealed that amount of money. A male condom, in comparison, costs just female condom awareness and the understanding of its proper one naira. In a country where the average annual income is only use are still very low. NGOs, who had successfully marketed $900, the difference can be prohibitive. the male condom, were hesitant to include the female version in “If the price of the female condom comes down,” says Mary their prevention arsenal, citing higher costs and the fact that they Babalola, another Living Hope Care support group coordinator, lacked the ability to explain to their clients how to use it. UNFPA “it will become as popular as the male condom.” responded with a widespread advocacy push, presenting the She has good reason to say so. The male condom, in absolute advantages of female condoms in seminars, community outreach terms, remains more popular at Living Hope Care than its more programs and advertising jingles on the radio. expensive cousin. Since the organization started selling the female UNFPA has also sponsored the training of 80 “master trainers”: condom, however, a new trend has become evident. Living Hope individuals instructed on the art of educating and counselling Care’s clients, many of them destitute, have spent more than twice clients on the use of the female condom. UNFPA has also as much buying female condoms than they have male ones. provided 200 community-based distributors, 50 male motivators Clearly, there is demand for the female condom in Nigeria. As and 700 other health-care and service providers with training on its cost declines, the desire for the device can only be expected to how to effectively use the device. rise—along with the independence of Nigeria’s women. chris de Bode / Unfpa / panos pictures a group of nigerian men discuss hiv and aids outside a Unfpa-sponsored clinic. chris de Bode / Unfpa / panos pictures female and male condoms alongside other reproductive health commodities. 25 Women W a n d G i r l s : p r ot e c t i n G r i G h t s a n d r e d U c i n G r i s k hen aids emerged in the 1980s, it mostly affected men. But today women account for approximately half of all people living with hiv worldwide.8 over the past two years, the number of hiv-positive women and girls has increased in every region of the world, with the proportion of females living with hiv also growing in all regions.9 in sub-saharan africa, about three quarters of young people (aged 15-24) living with 2 hiv are female.10 Most women with HIV/AIDS are in the prime of their productive and reproductive lives. Simply being identiied as HIV positive may result in discrimination, lack of access to life-saving information, gender-based violence, unemployment, abandonment or the loss of other human rights and other freedoms. addressing the gender inequities that leave women and girls vulnerable to hiv and the violation of their rights lies at the very core of Unfpa’s work. Women and girls face risks that men and generally boys do not—sexual violence, coercion and complications associated with pregnancy and childbirth. Unfpa highlights the special risks that women and girls face during the turmoil of humanitarian emergencies, and quickly responds with protective services and lifepreserving commodities. Unfpa also protects the health of women and children. Unfpa helped formulate a four-pronged policy framework to “prevent mother-to-child transmission” (PMTCT), which begins with preventing HIV infection in women in the irst place. UNFPA is working in partnership with the World Health Organization and other key partners to establish guidelines for care, treatment and support for hiv-positive women and their children. Warrick page / Unfpa / panos pictures two young women share a tender moment at Unfpa-sponsored Guli surkh (red flower), an nGo located in dusnabe, tajikistan. Guli surkh provides voluntary counselling and support for those living with hiv and aids. 27 B A n K i n G G o n W o M e n i n t A j i K i s t A n arm, TAJIKISTAN—It is late afternoon in a small village and water and I became very depressed with the situation.” With outside the town of Garm, and a group of women are the help of the Migrant Wives Project, Ms. Hakimova was able sitting cross-legged on the brightly-coloured, padded quilts to purchase a cow whose milk now feeds her children and whose ubiquitous in all Tajik households. Outside the jamoat—or dung now warms her stove. community centre—a chill wind is lattening the rough grasses MiCro-CreDit, MACro Benefits surrounding this tiny collection of one-story houses. Nozegul Kengaeva, 31, is another migrant wife. Four years ago her Garm is at the very gateway of the Alay Mountain range—an extension of the Pamir plateau that reaches through China, husband left for Russia and never came back. With ive children to feed and no income, Ms. Kengaeva was desperate. Afghanistan and into Tajikistan, a small and rugged country. It A year ago, she followed her father-in-law’s advice and joined the is a wild, dry and remote place rendered glitteringly alive by the Migrant Wives Project. The one goat she purchased with a micro- autumnal sunlight that glints off the nearby river and bounces off credit loan has proven to be dizzyingly proliic. Today, many goats the whirling leaves of surrounding aspen. now scamper around her small compound and her children are Inside the jamoat, a three-room building with broken windows that stare out jaggedly from the wattle and daub walls, ive women well-fed and clothed for the winter. “I am so happy,” she says. “I am independent and my children can go to school.” are eagerly leaning forward and talking all at once. The topic is There are many women just like Ms. Hakimova and Ms. micro-credit, HIV, human rights and how the UNFPA-supported Kengaeva: women who are beneitting from minute amounts pilot Migrant Wives Project has transformed their lives. of cash judiciously dispersed—with strings attached. Migrant Left BeHinD wives are expected to attend special classes. Through the Migrant Their brightly coloured salwar kameez—with their ruched bodices Wives Project, UNFPA and partners are seeking to provide HIV- and billowing skirts—are distinctive to Tajikistan and contrast with prevention services and to address issues of reproductive health, the dark green of the wall behind them. The youngest is 27 and the poverty, gender equity, human rights and gender-based violence oldest is 54, but they all have one thing in common: their husbands through the provision of micro-credit. have left to ind work in Russia. Some will never come back. “I am so happy. I am independent and my children can go to school.” —Nozegul Kengaeva, beneiciary of the UNFPA-supported Migrant Wives Project The thinking behind this innovative and far-reaching Guliston Hakimova is one such migrant wife. Married for programme is that women cannot be empowered unless they 12 years and the mother of four children, she found herself can feed themselves and their children, and they cannot become completely alone after her husband remarried in Russia. “Life was economically independent without loans—some of which are very dificult,” she says. “I could only feed the children potatoes as small as $50 but not exceeding $100. With $3,000 and plenty Warrick page / Unfpa / panos pictures migrant’s wife and mother of six, myshgairesso Gesova, aged 31, stands in her small grocery store built with the assistance of Unfpa. after leaving for moscow in search of work, her husband met another woman and married. in three years he has sent only one remittance and has never called. 29 of support from UNFPA, the people of Garm have boosted the Ministry of Health survey undertaken in two cities showed a high economy of an entire community and altered a mindset that was level of HIV infection among drug users, sex workers, prisoners once unsympathetic to the rights of women. and migrant populations.11 Migrants are vulnerable because they A roCK AnD A HArD PLACe: MiGrAtion to rUssiA are away from their families, often work in harsh conditions and In order to support their families, many Tajik men, and increasingly are more likely to engage in high-risk behaviour such as injecting some women, are now faced with an unforgiving imperative: leaving drug use and unprotected relations with sex workers. one’s family in order to provide for them. In some regions of the “You can’t encourage behavioural change—especially concerning country, entire communities are now devoid of young men. In the HIV—without addressing the root cause of migration, which is Garm region, fully 3,000 of an estimated population of 12,000 are poverty,” says Ms. Faromuzova. “These women are intelligent working in Russia or the oil-rich Gulf States. Most, if not all, are and committed to feeding and caring for their children. We give young men—a situation that is repeated throughout every region them the tools to empower themselves, they tell their friends and with the exception of the Tajik capital city of Dushanbe. children and they in turn tell their friends and children.” This Back at the jamoat the stories come thick and fast and all are “cascade effect” is now being felt throughout the Garm region heartbreaking in their similarity. There is 45-year-old Barno and is manifesting in some surprising ways. Norboeva, whose husband left for Russia eight years ago and A neW PArADiGM never came back. Today, he is married with young children and Kutbidin Kadirov is the oficer in charge of audits for the Garm never calls “unless I call him irst”. Like so many migrant wives, jamoat. A small wiry man, Mr. Kadirov sports a benign expression Ms. Norboeva was unable to support their ive children with only below his traditional Muslim cap tilted slightly askew atop his grey, the produce scratched out from her tiny garden. tightly-cropped hair. He says that not only the women, but also Twelve months later, she runs a small shop that sells sweets, Warrick page / Unfpa / panos pictures Oficer in charge of audits for the Garm jamoat, kutbidin kadirov maintains that the migrant Wives project has transformed his community by improving relationships between men and women, alleviating poverty and boosting the economy. the men, are becoming more aware of women’s rights. fabric and a host of other small necessities. Her children are now According to Mr. Kadirov, the changes have been both overt going to school and she is talking to her eldest daughter, who will and subtle. Prior to the Migrant Wives Project, most women didn’t soon be married, about family planning, reproductive health and know how to manage money, write a business plan or even apply how to protect herself against HIV. This last topic, says project for a passport. Men would not sit or speak with women who were director Katoyan Faromuzova, is particularly critical. not close kin. “But now I have spoken to more than 1,000 women tAjiKistAn, Hiv AnD MiGrAtion and they have taught me a great deal. I was very surprised.” Although still considered a low prevalence country, many experts Says Ms. Hakimova, “I married my eldest daughter off because believe that a combination of drug and human traficking, poverty, we had no money; but I want my second daughter to go to injecting drug use and migration means that Tajikistan is poised Dushanbe to study nursing. Before this project the thought that on the brink of a “generalized HIV epidemic”. A 2005-2006 Tajik my daughters could work wouldn’t even have occurred to me.” “If you help women, you help society as a whole,” adds Mr. Warrick page / Unfpa / panos pictures # a little girl peers shyly out of the door of her family’s house in Garm, tajikistan. Because of the Unfpa-sponsored migrant Wives project, she and others like her will be able to attend school. 31 l i n k i n G hiv prevention W i t h s e x U a l a n d r e p r o d U c t i v e h e a lt h l inking hiv and aids interventions with sexual and reproductive health services improves and strengthens health systems. Both types of services are hampered by the same health challenges—shortages of trained staff, essential supplies and equipment, adequate facilities and management skills. they also must overcome obstacles in dealing with sensitive or taboo subjects and require similar supplies and the same types of health provider skills. more comprehensive services not only would be more convenient but also, to individuals who have limited access to sexual and reproductive health care, would prove to be a lifesaver. the poor typically receive only piecemeal information and services—even though they may have urgent concerns regarding hiv and other reproductive health issues. many argue that offering a minimum package of services under one roof is the best way to meet their pressing needs and protect their right to health. in sub-saharan africa, where the aids epidemic is widespread, 63 per cent of women have an unmet need for effective contraception, and consequently undergo a high proportion of unintended pregnancies. many of these women do not know their hiv status, have limited access to information and services and thus risk passing the virus on to their children. Under these circumstances, access to even a minimal, integrated package of care—including family planning, management of sexually transmitted infections, hiv prevention and maternal health—can enable women to protect themselves from both unintended pregnancies and hiv, and also prevent transmission to their children. integrating hiv/aids services into sexual and reproductive health and rights is one of the many interventions called for in various international agreements. carolyn drake / Unfpa / panos pictures # victoria Yurova, 21 (foreground, 38 weeks pregnant) and anna larina, 29 (background, due that day) at a Unfpa-supported maternity hospital for women with high risk pregnancies in sochi, the russian federation. the maternity ward also counsels, treats and supports pregnant women and mothers living with hiv. 33 e t H i o P i A : A H o P e s f o r A n A i D s - f r e e f U t U r e ddis Ababa, ETHIOPIA—Elsabet (not her real name) According to 2007 Federal Ministry of Health estimates, over looks considerably older than her 26 years. Slim, of medium 800,000 Ethiopians are living with HIV and AIDS (60 per cent height and sallow, she is heavily pregnant with her fourth child. of which are women). HIV prevalence is highest among 15 to She worried about her current pregnancy, because the previous 24-year-olds, with women and girls more affected than males. one was complicated. She was always sick. But her husband, a Prevalence appears to have levelled off in urban areas but trafic police oficer, and her in-laws had insisted that she get continues to rise in the countryside, where 85 per cent of the pregnant again—especially because her previous three children population lives. HIV transmission occurs primarily through were all girls. So, ive months ago, she gave in to her partner’s heterosexual sex, mother-to-child and unsafe medical procedures, wish—or rather, his order. including unsafe blood transfusion. An inCreAsinGLY CoMMon PreDiCAMent “It wasn’t just the usual morning sickness that I 13 Mother-to-child-transmission (MTCT) caused 90 per cent of had experienced with the previous pregnan- But from the beginning, she had premonitions that this one would infections among children living with HIV and AIDS. Main risk not go well. “It wasn’t just the usual morning sickness that I had factors include poor obstetric practices, the amount of virus experienced with the previous pregnancies. I had high fever for circulating in the mother’s blood and whether the mother is days without end. I felt weak all the time and lost my appetite nursing her infant—HIV can be secreted in breast milk. Recent and a lot of weight.” A visiting elder brother was so alarmed by UNAIDS estimates suggest that between 30,000 and 220,000 her health that he took her to the nearest health centre in Bole, a children under the age of 14 are living with HIV in Ethiopia.14 satellite community of Addis Ababa. There, as part of treatment, HiGH risK, LoW CoverAGe health-care workers counselled and encouraged her to have an Of the 2 million women who, like Elsabet, become pregnant each HIV test. The result shocked her: She had just become the newest year, up to 75,000 will test positive and give birth to 14,000 infected member of the legions of Ethiopians infected by HIV. babies. Experts estimate that generally, without interventions, —A young mother living with HIV/ Elsabet’s predicament is growing increasingly common. With between 20 to 45 per cent of babies born to HIV-positive mothers AIDS in Addis Ababa, Ethiopia a national adult HIV prevalence of 1.4 per cent, the country will become infected. About half of these develop AIDS and die has one of the largest populations of HIV-infected persons within two years.15 All children born to HIV-infected mothers— in Africa. Even though Ethiopia is in a state of generalized whether themselves infected or not—run a high risk of being 12 orphaned because both parents are likely to be HIV positive and epidemic, with an estimated 5,000 people infected every week, the seriousness of the pandemic is often masked by the country’s cies. I had high fever for days without end. I felt weak all the time and lost my appetite and a lot of weight.” may die as a result. huge population, currently estimated at 77 million inhabitants. petterik Wiggers / Unfpa / panos pictures # Manalegne Tegegie, 31, with her baby boy Bethel Wondimu, age 2. Both have beneitted from UNFPA-supported PMTCT services. 35 But things are looking up for Elsabet and her family, as well as to full services. Up to 90 per cent of all births in rural Ethiopia the four other HIV-positive pregnant women waiting to meet with take place at home. Of the one in ten who give birth in a health a counsellor on this rain-soaked afternoon: their chattiness says a facility, most attend for the irst time during labour. Identifying lot about the hope they place in the government programme. the HIV status of women in labour and offering counselling and Prevention of MotHer to CHiLD trAnsMission prophylaxis is now routine. At the inception of the programme, there were few facilities The rollout of the PMTCT programme has come with a host of outside the capital or private health clincs and hospitals offering problems, not least of which is the very participation of pregnant prevention-of-mother-to-child-transmission (PMTCT) services. women and their partners at various stages. Not all women who Today, there are 396 sites available nationwide—at health posts, avail themselves of counselling services want to be tested; those health centres and district, regional and referral hospitals. who are tested do not always return for their results. “Pregnant women are Theoretically, a full range of PMTCT services should be Sister Yetemwork attributes these obstacles to continued denial implemented at these sites. However, the surge in service demand and social stigma. “Pregnant women are reluctant to be identiied as makes the offered services grossly inadequate. According to HIV infected for fear of stigmatization in the community and the Ethiopia’s Federal HIV/AIDS Prevention and Control Ofice fear of their partners’ reaction if their status is known,” she says. (FHAPCO) spokesperson Sister Yetemwork, more and more MAnY CHALLenGes, too feW resoUrCes pregnant women and their partners in urban and rural communities Although the PMTCT programme is beginning to make inroads in the community and the are showing up for counselling and testing. Nevertheless, because into existing maternal and child health programmes, the national health system is poorly resourced: health centres and clinics are fear of their partners’ some communities require that testing occur before marriage, it is putting “tremendous” pressure on existing facilities, which often struggling to provide conventional services, let alone new ones. reaction if their status are not adequately equipped. Human resources are strained. Low morale and poor motivation inCreAsinG DeMAnD is known.” for frontline health-care providers often result in high turnover Greater efforts to reach women, men, community leaders and among trained staff. Some aspects of the health system remain —Sister Yetemwork, spokesperson with traditional birth attendants have also increased demand. This is very weak. For example, most women in Ethiopia deliver at home Control Ofice of Ethiopia because knowledge of HIV status is essential in order to consider rather than in public health facilities. all available treatment options, and to make informed decisions related to partner infection, pregnancy and childbearing. reluctant to be identiied as HIV infected for fear of stigmatization the Federal HIV/AIDS Prevention and Furthermore, widespread poverty hampers access to health facilities and makes it dificult for HIV-positive mothers to maintain In most sites, women who are offered voluntary counselling good nutrition. Many nursing mothers resort to mixed feeding—a and testing (VCT) must decide whether to take an HIV test or combination of breast milk and infant formula. Debritu (not her not. HIV testing is offered as a routine component of standard real name), Elsabet’s friend at the Bole PMTCT Centre, says, “we maternal health care. If the client opts out, she still retains the right are many in the house and we have no money”. petterik Wiggers / Unfpa / panos pictures Belaynesh kassa, 25, and baby boy natinael eshetu, age one year and six months. ms. kassa is living with hiv. 37 vUlneraBle p G r o U p s : e m p o W e r i n G at - r i s k p o p U l at i o n s rotecting the health and human rights of vulnerable and most at-risk populations is both an end in itself and an essential element of hiv prevention. from a human rights perspective, Unfpa is committed to assisting those who are most disenfranchised. on a practical level, prevention activities aimed at key affected and at-risk groups can curtail the spread of the disease into the general population, especially in countries where hiv prevalence is low and concentrated among certain sub-groups. In such settings, speciic interventions to reach those at highest risk should be combined with broader efforts. Unfpa supports a variety of programmes aimed at vulnerable or at-risk groups, such as women and young people affected or displaced by humanitarian crises, the armed forces and out-of-school youth. in 2005, Unfpa was given lead responsibility within its partnership with Unaids to bring hiv services for those engaged in sex work. poverty and the marginalization associated with it contributes to vulnerability. poverty may, for instance, force girls or women to trade sexual favours for food to feed their families, or prevent individuals from buying condoms. it can keep adolescents out of school, depriving them of an opportunity to learn about how the virus is transmitted, and putting them at greater risk of drug abuse and risky sexual encounters. it can exacerbate family tensions that lead to domestic violence. addressing the underlying causes of vulnerability to infection, including poverty and gender inequality, is critical to eventually ending the epidemic. carina Wint / Unfpa the headmistress of a school in ouanaminthe, haiti watches her students play in the yard. the Unfpa-supported school is one of a number of sites where young adults receive information about hiv prevention from members of the haitian olympic committee. 39 t H e r i G H t r A i L W A Y s B t r A C K : B A C K C H i n A ’ s H i v P r e v e n t i o n D r i v e eijing, CHINA—Jiang Xiao Ying is a cheery woman. She face. In the station’s clinic, health personnel provide counselling. moves among train passengers with ease and unlappable People who want to know their HIV status are referred to testing good nature. Ms. Jiang is a conductor on the train that runs facilities. from Beijing to Panzhihua near the border with Myanmar. It And the need is great. Despite a huge, rapidly-growing population is a journey that takes exactly 44 hours and 7 seconds. Garbed of educated, middle class workers, many Chinese are lagging in green with a conductor’s hat worn proudly atop her shiny behind when it comes to HIV awareness. Migrant workers are black hair, Ms. Jiang is among the 2.2 million who staff China’s particularly vulnerable. Many come from poorer and more remote intricate and far-lung railway system. She provides directions, rural communities where information is scarce. Away from their takes tickets and sometimes calms the occasional irritated, but families and too often alone among strangers, with little support always cramped, passenger. and few opportunities aside from low-paying manual labour, too fLoAtinG PoPULAtion vULnerABLe many ind themselves engaging in high-risk behaviour including But Ms. Jiang also does far more. She is at the vanguard of an paid sex and drug and alcohol abuse. innovative new initiative that seeks to bring life-saving information MovinG tArGets for Hiv to China’s huge “loating” population of migrant workers along “No, I don’t know anything about HIV,” says one labour migrant. with everyday travellers. In addition to other duties, she also “I see it in newspapers and on TV, but I don’t understand.” informs travellers about HIV, how to prevent it and instructs Train travel offers a unique opportunity to educate this large passengers what to do if he, or she, or a loved one, has acquired loating population about HIV. Since 2003, Chinese railway the virus. workers have been spreading the word. “Ladies and gentlemen “We have been trained,” says Ms. Jiang, smiling. “We also have been asked to make particular efforts to reach out to passengers and to give out information about HIV prevention.” “No, I don’t know anything about HIV. I see it in newspapers and on TV, but I don’t understand.” —A migrant worker outside the Beijing West train station welcome aboard, I’d like to tell you about HIV/AIDS,” sings Ms. Jiang into a loudspeaker. “On average passengers will spend two hours in the station and Some 70,000 people pass through the Beijing West Station each 20 hours on the train,” notes Han Shu Rong, Deputy Director day. Electronic boards lash messages about HIV and in the waiting General in the Ministry of Railways’ Department of Labour and rooms large screens televise instructive videos. Station workers Health. “There is a lot of time to conduct activities on AIDS often distribute brochures. During busy travel periods, such as the prevention. It’s easy for people to accept it.” annual spring holiday when up to 300,000 passengers a day use On the journey from Beijing to Panzhihua, near the border with the station, workers staff tables to give out information face to Myanmar, two half-hour prevention messages are broadcast over William a. ryan / Unfpa Many of China’s railway passengers are rural migrants. Owing to a dificult combination of mobility, poverty and isolation, migrants are more likely to engage in high-risk behaviour that makes them more vulnerable to hiv infection. 41 the train’s video screens, one in the morning and one in the evening. Staff also hand out lyers, and they have been trained to answer questions about HIV. In addition to handing out lealets and making public service announcements, conductors also distribute playing cards emblazoned with HIV prevention messages. MessAGinG for YoUnG Men “The main target group is men between 25 and 40,” Ms. Han states. “Rural people are shy talking about sexual issues. We conducted research on the effectiveness of different approaches to shape messages for migrants. In a limited time, we try to get across information about the three HIV transmission routes and prevention. Our research indicates that passengers learn a lot.” Besides educating the passengers, the Ministry of Railways undertakes HIV awareness efforts aimed at protecting the 2.2 million Chinese railway workers and their families. Education is also under way in nine major transit hubs, as part of a pilot effort started by the Ministry with support from UNFPA. Oficials hope they eventually will be able to expand the programme to many more of the country’s 5,700 train stations. sPeCiAL CoLLABorAtion Condom promotion, once a sensitive topic in China, is an explicit part of the railway campaign. Information materials stress the effectiveness of condoms in preventing HIV infection. Condom work systematically with the railway system.” vending machines have been installed in station toilets, but Ms. To Siri Tellier, former UNFPA Representative in China, Han acknowledges that they are often out of order, adding, “We the railway campaign is indicative of a high level of oficial are trying to procure better machines.” commitment to ighting the epidemic. “I think it’s quite clear and Ms. Han appreciates the support given by United Nations widely recognized,” says Ms. Tellier, “that the Chinese government agencies involved in HIV prevention, particularly the help in has really taken much stronger steps to prevent HIV in the last learning about other countries’ experiences. “Our collaboration three years.” Qilai shen / panos pictures aids patient Yu da Guan sitting on his sickbed at home in dongguan village. a recent convert to christianity, he died two weeks after this picture was taken. with UNFPA is special,” she says. “They were the irst agency to mark henley / panos pictures Women call to prospective customers, left, from a hair-dressing salon/massage parlour located in a china-myanmar border town. a Unfpa, chinese Government hiv awareness intiative is targeting hard-to-reach and vulnerable populations such as migrant workers. 43 D e L i v e r i n G C P r e v e n t i o n i n C A i r o ’ s s L U M s airo, EGYPT—Although garbage is everywhere, the acrid community are adamant about knowing their status.” Around 16 odour begins to subside a few minutes after arrival, as one’s per cent of the Egyptian population is infected with hepatitis C, nose becomes accustomed to the stench. In Al Zarayeb, part of which now makes it a national priority. the Manshiyat Nasser slum in Cairo, trash is a cherished source of MoBiLe CLiniCs first of tHeir KinD income—one that is hauled into houses, carefully sifted through Halawethom Gerges has just stepped out of the vehicle with a and then re-sold. smile on her face. “My ingers often get pierced by syringes while “... in just a short period Every morning, the community’s men transport piles of handling the trash,” says the 27-year-old. “My husband learned garbage, including medical waste, into their houses, where women about this clinic from an educational session in church, so he of time, we were able and girls sort them in a rudimentary form of recycling. Plastic and came to the van to get tested. He then asked me to do the same. I to overcome the glass are manually separated, then cut, washed, melted and sold am glad we are both safe.” to manufacturers who transform them into all kinds of consumer The mobile clinic at Al Zarayeb is one of nine vehicles irst sent products, including bottles and chairs. Vegetables, fruits and food out in March 2005 to serve high-risk groups in various Egyptian remains are fed to the goats, pigs and chickens that thrive on the governates. UNFPA paid for the vehicles—$70,000 each—and detritus from wealthier homes. also provides technical advice, trains the clinic teams and pays HAzArDoUs WAste additional overhead expenses, such as testing kits and other Al Zarayeb is also where the UNFPA-supported mobile voluntary supplies. The mobile testing units are the irst of their kind in the counselling and testing (VCT) clinic is parked today. A steady low entire Arab region. of visitors is passing through the van’s doors. In addition to being GAininG trUst AnD GUArAnteeinG PrivACY worried about drug-addiction and HIV, clients are concerned “We are extremely happy with the results of these mobile VCT about one particular occupational hazard. clinics,” says Faysal Abdul Gadir, UNFPA Representative in Cairo. While sorting through the garbage, ingers get pricked—often “We are also happy that, in just a short period of time, we were by discarded syringes and other sharp objects—exposing people able to overcome the stigma that haunts vulnerable groups by to hepatitis and other dangers, including HIV. That is why Dr. gaining their trust and guaranteeing their privacy.” Mohammed Ali, the attending physician of the VCT clinic, “Initially, injecting drug users and most-at-risk populations is always so busy when his van is parked outside the dump. would send others to the clinics to check them out before going “Hepatitis B and C live outside of the body for up to 10 days,” themselves,” says Dr. Ihab Abdelrahman, of the National AIDS says Dr. Ali during a break between clients, “so people of this Programme at the Egyptian Ministry of Health, who monitors the stigma that haunts vulnerable groups ...” —Faysal Abdul Gadir, UNFPA Representative in Cairo teun voeten / Unfpa / panos pictures a Unfpa-sponsored mobile voluntary counselling and testing (vct) clinic opens its doors to slum dwellers in al zarayeb, cairo. 45 nine clinics. “They wanted to make sure that their identities would be kept conidential.” Now, he adds, each of the clinics receives an average of 16-20 clients between the hours of 9:30 a.m. and 3:00 p.m. every day. The VCT mobile clinics move from one neighbourhood to another on a weekly basis, and base their schedules on a “risk map” that identiies the possible locations of vulnerable groups, according to Dr. Abdelrahman. Would-be clients are informed of future stops through community outreach and awareness campaigns. A hotline also provides scheduling information. voLUntArY CoUnseLLinG AnD testinG The van parked at Al Zarayeb this week is composed of three parts: the driver’s cab, completely separated from the rest of the vehicle; a counselling compartment in the middle; and a blood testing lab in the back. In addition to the driver, a physician, a counsellor, a nurse and a health instructor are also in attendance. Before entering the vehicle, clients are ushered into a waiting area at the nearby community centre, where the health instructor provides information and prevention messages through an audiovisual presentation. Clients then enter the vehicle, where they get a blood test and “People conide in me because I do not ask them about undergo two counselling sessions. Before the blood test, outreach their names or ages, nor do I keep any records,” says workers ask clients about their habits and other related information. counsellor Mustapha Mohammed Riyad from behind his After about a 10-15 minute wait, clients are notiied of the results small desk inside the VCT mobile clinic. “I try to change their and go through post-testing counselling. behaviours, but I don’t care about their identities.” “Those who test negative receive long post-testing counselling to It is now past 3:00 o’clock, and people are still gathering remind them not to be complacent, and to instruct them on how to around the mobile clinic to get tested. Dr. Ali, the attending remain disease-free,” says Dr. Abdelrahman. “Those who are found physician, tries to turn them away by assuring them that he’ll to be positive, on the other hand, go through a very brief session; be back in the morning. “They all want to make sure they they are often in shock and don’t want to listen to anything.” are ine.” teun voeten / Unfpa / panos pictures a family gazes down at the street in one of cairo’s slum neighbourhoods. teun voeten / Unfpa / panos pictures a little girl grins at the camera in the slum of al zarayeb, cairo. 47 enDnotes 1 Unaids and Who. 2007. AIDS Epidemic Update. Geneva, switzerland. joint United nations programme on hiv/aids (Unaids) and World health organization (Who). p. 14. 2 Unaids and Who. 2007. AIDS Epidemic Update. Geneva, switzerland. joint United nations programme on hiv/aids (Unaids) and World health organization (Who). p. 29. 3 ladnaya, nn. 2007. The National HIV and AIDS Epidemic and HIV Surveillance in the Russian Federation. presentation to “Mapping the AIDS Pandemic” meeting. 30 June 2007. Moscow. 4 ladnaya, nn. 2007. The National HIV and AIDS Epidemic and HIV Surveillance in the Russian Federation. presentation to “Mapping the AIDS Pandemic” meeting. 30 June 2007. Moscow. 5 eurohiv. HIV/AIDS Surveillance in Europe. Mid-year report 2007. saint-maurice: institut de veille sanitaire. 2007. no. 76. 6 Unaids. 2006. Report on the Global AIDS Epidemic. Geneva, switzerland. p. 421. 7 Unaids. 2006. Report on the Global AIDS Epidemic. Geneva, switzerland. p. 421. 8 Unaids and Who. 2007. AIDS Epidemic Update. Geneva, switzerland. joint United nations programme on hiv/aids (Unaids) and World health organization (Who). p. 1. 9 chan, dr. margaret, Who director General. 2007. message for World aids day. 30 november, 2007. http://www.who.int/ mediacentre/news/statements/2007/s18/en/index.html 10 Unaids. 2006. Report on the Global AIDS Epidemic. Geneva, switzerland. p. 8. 11 ministry of health tajikistan. 2007. situation on hiv epidemic in the republic of tajikistan, according to the results of sentinel survey for 2006 presentation to national conference. 21-22 may 2007. dushanbe. available in russian at http://www.caftar. com/clientzone/aids teun voeten / Unfpa / panos pictures A little boy contemplates “wall art” in Al Zarayeb, Cairo. 48 12 Who. 2007. Health Action in Crisis. Ethiopia. september 2007. Geneva, switzerland. ww.who.int/entity/hac/crises/eth/ background/ethiopia_sept07.pdf 13 federal ministry of health ethiopia. 2007. www.moh.gov.et 14 Unaids. 2006. Report on the Global AIDS Epidemic. Geneva, switzerland. annex 2. p. 507. 15 Who. hiv/aids program. 2006. Taking Stock: HIV in Children. April 2006. Geneva, switzerland. p. 2. Unfpa, the United nations population fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. Unfpa supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of hiv/aids, and every girl and woman is treated with dignity and respect. Unfpa — because everyone counts. for additional information please contact: United nations Population fund 220 east 42nd street new York, new York 10017 UsA www.unfpa.org # isBn 978-0-89714-879-5 

Children and AIDS Third Stocktaking Report, 2008 Children and AIDS: Third Stocktaking Report, 2008 Cover photo: © UNICEF/HQ06-2216/Giacomo Pirozzi; back cover photo: © UNICEF/HQ06-2212/Giacomo Pirozzi. The paintings on the covers of this report are by children at the Maputo Day Hospital, Mozambique, a facility providing medicine and psychosocial support, including counselling and antiretroviral therapy, to children living with HIV. UNAIDS, the Joint United Nations Programme on HIV/AIDS, brings together the efforts and resources of 10 UN system organizations to the global AIDS response. Co-sponsors include UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, ILO, UNESCO, WHO and the World Bank. Based in Geneva, the UNAIDS secretariat works on the ground in more than 75 countries worldwide. Figures 1 and 2 on pages 4 and 5 of this report have been corrected; the figures remain uncorrected in the summary version that was issued in advance of this report. For additional updates subsequent to the issue of this report, please visit the UNICEF website and www.unicef.org/publications. CONTENTS Page 2 Introduction Page 4 1. Prevention of mother-to-child transmission of HIV Page 10 2. Providing paediatric treatment and care Page 16 3. Preventing infection among adolescents and young people Page 21 4. Protection and care for children affected by AIDS Page 26 Conclusions Page 29 References Page 32 Annex: Notes on the data Page 33 Goal 1. Preventing mother-to-child transmission of HIV in low- and middle-income countries Page 36 Goal 2. Providing paediatric treatment in low- and middle-income countries Page 39 Goal 3. Preventing infection among adolescents and young people Page 42 Goal 4. Protecting and supporting children affected by HIV and AIDS UNITE FOR CHILDREN UNITE AGAINST AIDS 1 INTRODUCTION This Stocktaking Report, the third since the Unite for Children, Unite against AIDS initiative was launched in 2005, examines data on progress, emerging evidence, and current knowledge and practice for children as they relate to four programme areas known as the ‘Four Ps’: preventing mother-to-child transmission of HIV, providing paediatric HIV care and treatment, preventing infection among adolescents and young people, and protecting and supporting children affected by HIV and AIDS.1 The phrase ‘know your epidemic and response’ has become extremely important in the fight against HIV and AIDS, given the different levels of epidemic and diverse patterns in a range of geographical, cultural and social settings and the many ways in which the epidemic has an impact on various population groups. The phrase ‘know your epidemic and response’ has become extremely important in the fight against HIV and AIDS. But to better serve children, knowing your epidemic and response must be paired with ‘know your children’. Knowing your epidemic is about analysing the local situation – who is infected and what factors are driving the risks and behaviours – and understanding and acting on that analysis. Knowing your response is about knowing the details of the current response, the actions taking place, the coverage being achieved, the quality of the intervention, the policies that are in place or still needed, and the populations being targeted. Consensus in the scientific community and in civil society is that interventions based on such understanding and tailored to the local situation are needed and, importantly, can work. But to better serve children, knowing your epidemic and response must be paired with ‘know your children’ – determining which children are vulnerable to HIV and AIDS, which children are affected by the epidemic and what impact it has on them; how to reach children affected by AIDS, how to prevent them from getting infected with HIV and how to treat them; how to care for their mothers and how to support them when their mothers or fathers have died; and how to help all children grow safely and develop into adulthood. To address these issues and further improve children’s prospects of survival and for their futures, countries are drawing on experiences and evidence to do things differently than they have in the past. In Botswana, Rwanda and Thailand, for example, access to CD4 cell-count testing has been expanded, increasing the numbers of pregnant women living with HIV receiving antiretroviral treatment for their own health. Keeping mothers healthy and alive significantly contributes to the health and well-being of their children, whether they are infected or not. In South Africa, many infants born to HIV-positive mothers are now tested for HIV at six weeks of age, using dried blood spots for polymerase chain reaction (PCR) testing for HIV DNA, and many of those who test positive receive antiretroviral treatment. A recent study found increased survival rates among infants who were provided with antiretroviral therapy as soon as they were diagnosed with HIV.2 Without 2 UNITE FOR CHILDREN UNITE AGAINST AIDS adolescents, can be sustained during periods of upheaval. In 2006, 1.8 million people living with HIV were also affected by conflict, disaster or displacement – about 1 in 20 people living with HIV worldwide. Of this number, an estimated 930,000 were women and 150,000 were children under the age of 15.4 © UNICEF/HQ06-1878/Robert Few Responses have been refined in situations of short-term emergency, humanitarian crisis and protracted conflict in countries with varying levels of epidemic. During recent emergencies in China and Kenya, for example, immediate assistance for people living with HIV was focused on maintaining access to antiretroviral therapy. In the Democratic Republic of the Congo, Somalia and the Sudan, programmes for youth have addressed life skills, HIV and AIDS, and essential services. In Uganda, services for the prevention of mother-to-child transmission and paediatric treatment and care have been dramatically scaled up in the north, a region affected by more than 20 years of conflict. intervention, at least a third of children born with HIV will die from an HIV-related cause by their first birthday, and half will die before their second birthday.3 In the South Asian countries of Afghanistan, Bhutan, Maldives and Sri Lanka – where the risk of HIV infection in the general population is low – national strategic plans on HIV and AIDS have been adjusted to focus on prevention for adolescents who are most at risk. Governments are increasingly investing in social protection in the form of safety nets for families and communities. In Brazil, the number of families affected by HIV and AIDS receiving social welfare assistance has increased. Cash transfers have shown promise in helping vulnerable children in Bangladesh, Cambodia, El Salvador, Kenya and several other countries. Focused responses work. More pregnant women than ever have access to and use services to prevent transmission of HIV to their babies. More children than ever are receiving treatment. HIV prevalence in young people is declining in a number of high-prevalence countries, and greater knowledge of vulnerability in children affected by AIDS is resulting in a better understanding of how to protect and care for all vulnerable children. Furthermore, assistance for people living with HIV, including children and All the signs of progress made to date are not signals to rest, however, but an invitation to acknowledge the stark facts they underscore: •฀ Pregnant women are not receiving sufficient counselling and related services for primary prevention of HIV, prevention of unintended pregnancies and safer infant feeding. Most pregnant women diagnosed with HIV do not have access to essential care and treatment that includes antiretroviral therapy: for their own health, to further reduce the likelihood of HIV transmission and to prevent orphaning. •฀ A critical cohort of the youngest children, those under one year old, are not being identified in time to benefit from life-saving antiretroviral therapy. They are dying of AIDSrelated illnesses without ever being diagnosed. •฀ Significant numbers of young people continue to be infected with HIV each year, and girls in sub-Saharan Africa, in particular, remain vulnerable. Young people living with HIV are not receiving good-quality counselling and services to help them live with a chronic disease and successfully make the transition to adulthood. •฀ Social systems of protection and care in most countries are not adequate to meet the needs of all children made vulnerable by the AIDS epidemic or other causes. To improve the quality of assistance for children and families, and to reach the unreached, much more remains to be done. The funds available for assisting children have increased but are not yet sufficient; often activities are not adequately tracked and results are not duly assessed. Critical links to overall child survival goals have yet to be forged in many countries. Governments, donors, development partners and communities all have an important role in addressing these issues. UNITE FOR CHILDREN UNITE AGAINST AIDS 3 PROGRESS AND ACHIEVEMENTS 1. PREVENTION OF MOTHERTO-CHILD TRANSMISSION OF HIV Strengthened maternal, newborn and child health services will enable women to access the array of services to prevent mother-to-child transmission of HIV and promote Coverage of services to prevent mother-to-child transmission of HIV (PMTCT) is expanding in low- and middle-income countries. Still, in 2007, only 33 per cent of pregnant women living with HIV in these countries received antiretroviral regimens, including antiretroviral therapy to prevent transmission of the virus to their infants, compared to only 10 per cent in 2004.5 Far too few pregnant women are aware of their HIV status. In 2007, only 18 per cent of pregnant women in low- and middleincome countries where data were available received an HIV test.6 The rates of HIV testing among pregnant women are highest in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS) and in Latin America, regions with low-level or concentrated epidemics in most countries. The proportion of facilities providing antenatal care that includes HIV testing and counselling is also highest in these two regions, highlighting that overall access and uptake are strongly related to the expansion and integration of services. In Eastern and Southern Africa – the region with the highest number of pregnant women living with HIV – only 38 per cent of antenatal facilities provided HIV testing and counselling in 2007. Consequently, only 28 per cent of the estimated number of pregnant women in this region received an HIV test (Figure 1). maternal and child survival as part of a continuum of care. Figure 1. Percentage of pregnant women tested for HIV and level of facility coverage, by region, 2007 100% >95 80% % of pregnant women who received an HIV test 80 % of facilities providing antenatal care that also provide HIV testing and counselling 60% 53 52 46 40% 38 28 20% 19 12 0% CEE/CIS Latin Eastern and America and Southern the Caribbean Africa 18 14 10 8 7 East Asia and the Pacific West and Central Africa South Asia 1 Middle East Total low- and and middle-income North Africa countries Source: UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008 (UNICEF, UNAIDS, WHO), pp. 34–42. Regions were recalculated according to UNICEF classification of regions. Data from 2004–2007 show a doubling or near doubling in uptake of HIV testing during antenatal care in all three country groupings: seven ‘hyper-endemic’ countries in which adult HIV prevalence rates are more than 15 per cent (Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe); countries with adult HIV prevalence of 1 per cent to 15 per cent; and countries with adult HIV prevalence of 4 UNITE FOR CHILDREN UNITE AGAINST AIDS Figure 2. Percentage of pregnant women tested for HIV, by prevalence level in adult population, 2004–2007 80% 75 70% 60% 60 50% % of pregnant women receiving HIV testing and counselling (2004) % of pregnant women receiving HIV testing and counselling (2005) % of pregnant women receiving HIV testing and counselling (2006) % of pregnant women receiving HIV testing and counselling (2007) Average % of facilities providing antenatal care that includes HIV testing and counselling (2007) 47 51 40% 30% 33 37 20% 28 31 7 0% Adult HIV prevalence >15% Adult HIV prevalence 1%–15% In comparison, antiretroviral coverage below 10 per cent in Ethiopia and Nigeria in 2007 may reflect these countries’ below-average levels of antenatal care: 28 per cent in Ethiopia and 58 per cent in Nigeria (see the statistical table on pages 33–35 ). 22 15 15 10% up from 15 per cent in 2004. In the same years, coverage in Mozambique rose from 3 per cent to 46 per cent and in Zambia from 18 per cent to 47 per cent. The increase is related to antenatal care coverage rates of 85 per cent or more in all these countries.7 7 11 12 Adult HIV prevalence <1% Source: UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008 (UNICEF, UNAIDS, WHO), pp. 34–42. less than 1 per cent. The largest increase in testing was seen in the hyper-endemic countries, all of them in Southern Africa. In these countries, the proportion of pregnant women who received an HIV test and counselling during antenatal care visits and at the time of delivery increased from 33 per cent in 2004 to 60 per cent in 2007 (Figure 2 ). In part, this is because an average of 75 per cent of facilities in the hyper-endemic countries were providing antenatal care and HIV testing and counselling at the end of 2007, compared to an average of 46 per cent in all low- and middle-income countries. Overall, provision of antiretrovirals for PMTCT has improved in sub-Saharan Africa, reaching 43 per cent of pregnant women living with HIV in Eastern and Southern Africa in 2007, up from 31 per cent in 2006, and 11 per cent in West and Central Africa, up from 7 per cent. Uptake increased in East Asia and the Pacific from 24 per cent in 2006 to 38 per cent in 2007 and in South Asia from 10 per cent to 13 per cent. There was no change in CEE/CIS and in Latin America and the Caribbean between 2006 and 2007 (Figure 3 ). Many countries are now phasing in combination antiretroviral regimens for PMTCT that are more effective than one drug alone. In 2007, in 60 low- and middle-income countries with disaggregated data on antiretroviral regimens for PMTCT, 49 per cent of HIV-infected women who received antiretroviral drugs received single-dose nevirapine, 26 per cent a combination of two antiretrovirals and 8 per cent a three-drug combination.8 In general, coverage of antiretrovirals for PMTCT depends on a multitude of factors, including uptake of HIV testing, early reporting of women for antenatal care, attendance at delivery by skilled personnel, and health-system infrastructure, including laboratory and human resource capacity. Strong political commitment and leadership, enabling policies and the adoption of innovations in service delivery – namely, the introduction of provider-initiated testing and counselling, combined with rapid testing with same-day results, within antenatal and delivery care settings – have contributed to increasing access and uptake of HIV testing in the context of PMTCT. Figure 3. Percentage of HIV-infected pregnant women who received antiretrovirals for PMTCT, 2004–2007 100% 90% 80% 70% 60% 50% 43 38 33 36 36 31 30% 19 20% 19 20 11 0% 71 71 61 40% 10% Throughout sub-Saharan Africa, there is wide variation in the percentages of pregnant women living with HIV who receive antiretroviral regimens for PMTCT. In South Africa, coverage reached 57 per cent of the estimated 220,000 pregnant women living with HIV in 2007, 72 2004 2005 2006 2007 7 24 11 5 3 2 4 Eastern and Southern Africa West and Central Africa East Asia and the Pacific 33 26 10 South Asia 23 13 10 Latin America and the Caribbean CEE/CIS 15 Total low- and middle-income countries Note: The lines on the bars show the uncertainty bounds for the estimates. Data were insufficient to calculate an average for the Middle East and North Africa region. Source: UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008 (UNICEF, UNAIDS, WHO), pp. 19, 43. Regions were recalculated according to UNICEF classification of regions. UNITE FOR CHILDREN UNITE AGAINST AIDS 5 The seven hyper-endemic countries are also benefiting from important funding opportunities, including considerable financial support from the US President’s Emergency Plan for AIDS (PEPFAR), in addition to financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria and other sources.9 Four of them are PEPFAR focus countries. Overall improvements, however, belie important areas where work must be expanded to reach the international target of 80 per cent of pregnant women accessing interventions to prevent motherto-child transmission of HIV. New guidance from the World Health Organization (WHO), UNICEF and partners calls upon the international community to renew its commitment to global PMTCT scale-up and make it a priority. MAIN ISSUES HIV testing and counselling as integral components of maternal care HIV testing and counselling provided as part of the routine package of screening tests during pregnancy and delivery represent the main gateway to HIV prevention, care and treatment for most women of reproductive age. But too often, HIV testing has been either unavailable or not recommended to women during antenatal and delivery care. This lack of access to testing services leaves many women unaware of their HIV status. Many national programmes have now shifted to the ‘opt-out’ approach in which HIV testing is recommended and women can specifically decline to be tested. WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommend that HIV testing and counselling be recommended by health-care providers as part of the normal standard of care for all pregnant women in antenatal, delivery and post-partum care settings in generalized epidemics.10 Botswana, in 2004, introduced providerinitiated HIV testing and counselling with the option to opt out as part of routine antenatal and delivery care. This policy, 6 UNITE FOR CHILDREN UNITE AGAINST AIDS combined with the use of rapid testing with same-day results and the involvement of lay counsellors, resulted in an increase in the proportion of pregnant women tested from 27 per cent in 2002 to around 80 per cent in 2007.11 Botswana focused its initial efforts on expanding PMTCT services to all public health facilities providing maternal and child health services. The involvement of male partners in PMTCT has been found to increase service uptake and might help reduce some of the stigma surrounding women’s use of such services. In Rwanda, remarkable efforts have been made to engage male partners of pregnant women in PMTCT interventions, particularly HIV testing. In 2007, nearly two thirds of male partners of pregnant women tested for HIV during antenatal and delivery care visits agreed to be tested themselves.12 In countries with concentrated epidemics, provider-initiated HIV testing and counselling should be recommended for women identified as being at high risk of HIV exposure. Efforts should be made at both the policy and service-delivery levels to facilitate access by women who are most at risk – particularly most-at-risk pregnant women – to HIV prevention, care, support and treatment services as well as to antenatal, delivery and post-partum care. A continuum of care for women living with HIV The ultimate goal of PMTCT is to reduce maternal and child mortality by delivering a comprehensive package that includes primary prevention of HIV infection among women of reproductive age, prevention of unintended pregnancies among women living with HIV, counselling and support on infant feeding, as well as antiretroviral therapy for mothers, cotrimoxazole prophylaxis for mothers and infants, and early infant diagnosis and initiation of antiretroviral treatment. PMTCT services should link operationally to maternal and child survival interventions – immunization; nutrition support, including the management of severe wasting and other forms of acute malnutrition; and prevention and treatment of pneumonia, diarrhoeal diseases and malaria – as well as sexual and reproductive health care to improve maternal health and treat HIV-infected mothers. The linkages to child survival interventions are of the utmost importance because pneumonia, diarrhoeal diseases and malaria, often exacerbated by undernutrition, are major causes of death among HIV-infected infants and children. Adopting such a comprehensive approach calls for a strategic shift in perspective from only averting HIV infection in children to improving maternal and child survival. In most resource-limited settings, the majority of women identified as HIV-positive have access to care and treatment, including antiretroviral therapy, only through referral to antiretroviral treatment clinics. But many of the needed services can and should be delivered within maternal, neonatal and child health-care settings. Clinical and immunological assessment of women’s eligibility for antiretroviral therapy, for example, can be delivered by trained health personnel as a component of routine antenatal care for pregnant women living with HIV. HIV-positive pregnant women at an advanced stage of disease are at higher risk of transmitting HIV to their infants and are more likely to die themselves compared to women at an early stage.13 Initiation of antiretroviral therapy for these women not only addresses their health needs; it also significantly reduces the risk of HIV transmission to their infants and can promote the survival of their children, regardless of the child’s HIV status. The results of a recent study in Uganda show that among uninfected children under age 10, there was an 81 per cent reduction in mortality and a 93 per cent reduction in orphanhood if their HIV-infected parents were receiving antiretroviral therapy and cotrimoxazole prophylaxis, compared with children whose parents received no intervention.14 Women who become infected with HIV during pregnancy and lactation are more likely to pass on the virus to their infants than women who were infected before they became pregnant.15 Primary prevention services should therefore give special attention to pregnant women who are not infected – and to keeping them uninfected throughout pregnancy, childbirth and breastfeeding. Many national programmes offer a primary prevention package for all women during antenatal care visits that includes health information and education, HIV counselling, family planning based on country policies, and couples testing and counselling on safer sex practices such as condom use. Retesting for pregnant women who previously tested negative, as is the policy in Brazil and Ukraine, should be considered based on available resources, especially in generalized epidemic settings. There is emerging evidence that administering antiretrovirals to mothers throughout the breastfeeding period and extended antiretroviral prophylaxis to infants born to HIV-positive women can significantly reduce post-natal transmission.16 In Mozambique, for example, provision of antiretroviral therapy to HIV-positive women up to six months after delivery resulted in very low rates of motherto-child transmission: less than 2 per cent in infants at six months of age.17 More information is needed, however, on the implications of such an approach for mothers’ and children’s health, as well as for their future treatment options, before it is recommended or scaled up. Data from 32 countries of sub-Saharan Africa reveal that up to 61 per cent of people living with HIV who received antiretroviral therapy in this region in 2007 were female. However, access to antiretroviral therapy through PMTCT programmes for pregnant women living with HIV remains poor for various reasons, including limited access to CD4 cell count testing. In low- and middle-income countries where these data were available, only 12 per cent of pregnant women identified as HIV-positive during antenatal care visits were assessed to determine whether they were eligible to receive antiretroviral therapy for their own health.18 Scaling up antiretroviral therapy for women, especially pregnant women, in the context of PMTCT requires investment in facility improvement, laboratory equipment and human capacity-building within maternal, newborn and child health services. Timely initiation of antiretroviral therapy requires Improving access to antiretroviral treatment for pregnant women living with HIV With trained health-care providers and expanded laboratory infrastructure and capacity, immunological assessment can be added to routine antenatal and delivery care for HIVpositive pregnant women. In Malawi, CD4 cell count testing was expanded to all 28 districts and five referral hospitals in 2008 after a study found that CD4 cell counts are a more reliable way to assess women’s eligibility for antiretroviral treatment than observing clinical signs and symptoms. Only 2 per cent of 724 pregnant women assessed clinically at eight antenatal clinics were found to be eligible for antiretroviral treatment for their own health, while 54 per cent of this same group of women assessed by CD4 cell counts were found to be eligible.19 Rwanda introduced more efficacious antiretroviral regimens for PMTCT, including antiretroviral therapy for eligible women, in 2005. At most facilities offering PMTCT services, pregnant women identified as HIV-positive are increasingly being assessed through CD4 cell count testing and receive appropriate treatment as needed. The installation of CD4 cell count testing equipment at sites around the country facilitates timely access to this test.20 UNITE FOR CHILDREN UNITE AGAINST AIDS 7 Figure 4. Percentage of sexually active women aged 15–49 who used a condom at last sexual activity, by women’s HIV status, 2003–2006 50% 46 HIV-negative HIV-positive 40% 32 30% 21 20% 16 15 16 10 10% 0% 21 18 14 15 9 11 8 13 9 6 Swaziland Lesotho Cameroon Côte d'Ivoire United Republic of Tanzania Burkina Faso Ghana Zimbabwe 8 5 Kenya 12 8 5 Malawi 4 Guinea 13 10 3 2 1 Senegal Rwanda Ethiopia 4 <1 Niger Source: Selected Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 2003–2006. clinical and immunological assessment of all HIV-infected pregnant women. PMTCT services are increasingly being implemented as the main entry point to a continuum of interventions intended to reach pregnant women, mothers and their children. Even in resource-limited settings affected by conflict, PMTCT services can be efficiently provided. More than 20,000 mothers in the Kitgum and Pader districts of northern Uganda – a region affected by conflict for more than 20 years – have been reached with PMTCT services as part of a programme introduced in 2002. Coverage in these districts increased from 25 per cent in 2002 to 63 per cent in 2007, and 33 per cent of HIV-positive mothers received antiretrovirals for PMTCT. 21 Primary prevention must become an even greater priority Studies have suggested that increasing women’s access to a package of primary prevention and family planning is the most cost-effective way to prevent HIV infection in infants,22 and many national programmes are providing all women attending antenatal care with such a package. Some data indicate that health education and HIV counselling provided in the context of PMTCT could lead to the adoption of safer sex practices, such as condom use. Analysis of Multiple Indicator Cluster Surveys (MICS) and Demographic 8 UNITE FOR CHILDREN UNITE AGAINST AIDS and Health Survey (DHS) data from 15 countries in 2003–2006 show that women who are HIV-positive were more likely to use a condom during the last sexual intercourse than women who are HIV-negative (Figure 4 ). The experience of programmes to prevent HIV infection in young people has shown that accurate information, good education and skills-building programmes can lead to significant risk reduction in this group.23 PMTCT programmes should build on this experience to develop appropriate strategies that take into consideration the special needs of young people – and adolescent girls and young women in particular – related to pregnancy, the post-partum period and HIV infection. PMTCT services, as well, must be adolescentsensitive in order to reach this age group. Maternal and child health services, including PMTCT services, can be linked with male circumcision, including neonatal male circumcision and circumcision of HIV-negative male partners. These services can be delivered using a familycentred approach as part of an integrated programme of HIV prevention for mothers (both HIV-negative and HIVpositive) and, more broadly, for women of childbearing age, including adolescent girls. Implementation will need to be contextualized to the country situation and take into account the fact that investing in neonatal male circumcision will not result in tangible impacts for many years. Sustained support for preventing mixed feeding Supporting HIV-positive mothers to make appropriate infant feeding decisions can improve early child survival. Around one third of overall HIV mother-to-child transmission takes place in breastfed children up to two years of age.24 Yet there are important health risks for the infant who is not breastfed. WHO and UNICEF recommend exclusive breastfeeding for infants of mothers with HIV for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe. Recent studies among women who received nevirapine found that the risk of transmission during the first four months of the infant’s life is halved when the mother breastfeeds exclusively and avoids mixed feeding.25 Modelling studies based on data from sub-Saharan Africa suggest that exclusive breastfeeding for six months, with promotion and support, would save nearly one in four HIV-exposed children, more than twice the number that would be saved with replacement feeding.26 Although breastfeeding is the norm in subSaharan Africa, exclusive breastfeeding is not necessarily so. An analysis of DHS surveys conducted during 2003–2006 in 12 countries in this region shows that only 31 per cent of HIV-positive women exclusively breastfeed their infants up to six months of age; among HIV-negative women, this figure is 38 per cent.27 PMTCT programmes should provide counselling and support on infant feeding to HIV-positive mothers during the period after birth in order to inform infant feeding choices that must be made at critical moments in infancy: around the time of early infant diagnosis of HIV at six weeks of age, and during weaning at around six months of age. A rapid assessment in 2007 of HIV and infant feeding in Kenya, Malawi and Zambia found that the three countries have taken steps to revise infant feeding policies and strategies, and there is increased awareness of the need to address this issue within HIV programmes.28 More definitive evidence on the safety and efficacy of infant feeding interventions within the context of PMTCT is anticipated in 2009. PMTCT services can strengthen health systems To be successful, PMTCT interventions require functioning health systems that provide quality care for maternal, neonatal and child health (MNCH), as well as sexual and reproductive health care. Rapid expansion of PMTCT services, especially antiretroviral regimens, requires antenatal, delivery and postnatal care services to be strengthened. Most countries that have made significant progress in scaling up PMTCT services have performing health systems with high coverage rates of antenatal care and skilled attendance at delivery. In Ukraine, for example, the full integration of PMTCT interventions into MNCH programmes, free antenatal and delivery services, and high coverage of antenatal care and skilled birth attendance have been central to the success of scaling up PMTCT. In 2000, the Ministry of Health enacted a national policy of universal HIV testing with an opt-out option for all pregnant women upon registration at antenatal clinics and at the time of delivery. Overall, the rate of motherto-child transmission has been reduced to 7 per cent in 2006, from 25 per cent in 2000, according to the Ministry.29 More than 40,000 primary health-care centres in Brazil offer PMTCT services including HIV testing and counselling. In 2007, 62 per cent of pregnant women were tested for HIV during pregnancy. The centres, however, are concentrated in urban settings and do not reach the north, where transmission rates are almost double the national average.30 In many countries, the provision of PMTCT services is constrained by human resource shortages, poor work conditions and limited laboratory capacity. However, implementation of PMTCT presents an opportunity to improve quality and increase uptake of antenatal, delivery and post-natal services. A recent survey conducted in Rwanda, for example, shows that pregnant women identified as HIV-positive through PMTCT services are more likely to deliver in health facilities than pregnant women with unknown HIV serostatus.31 Assessing the impact of PMTCT services requires clear, standardized approaches that take into account both HIV prevalence and the levels of child morbidity and mortality in the country. Data on the coverage of PMTCT services and of paediatric HIV care, support and treatment interventions are collected annually through an inter-agency collaborative process facilitated by UNICEF and WHO in partnership with national governments. Ongoing data collection is essential in tracking progress towards the scale-up of services, but as yet there is little information on the extent to which current interventions avert HIV infections in infants or improve child survival. A number of evaluations and studies have been completed with varying success to monitor the effectiveness of PMTCT programmes, but support is still needed for ongoing work to identify ways of evaluating the impact of national programmes so that successful interventions can be widely replicated in low- and middleincome countries. UNITE FOR CHILDREN UNITE AGAINST AIDS 9 PROGRESS AND ACHIEVEMENTS 2. PROVIDING PAEDIATRIC TREATMENT AND CARE The number of children under age 15 in low- and middleincome countries who receive antiretroviral treatment rose dramatically, to almost 200,000 in 2007, up from around 127,000 in 2006 and 75,000 in 2005. The increase is occurring in every region of the world, with the most significant gains in sub-Saharan Africa (Figure 5 ). It is nonetheless evident that those children currently on treatment still represent only a small proportion of those who need it. The most recent global estimates from WHO and UNAIDS report 2 million children under 15 years old with HIV infection and 370,000 new infections in 2007.32 Coverage will need to be greatly expanded if the Unite for Children, Unite against AIDS goal of providing antiretroviral treatment, cotrimoxazole or both to 80 per cent of children in need by 2010 is to be met. New evidence highlights early HIV diagnosis and antiretroviral treatment as particularly critical for infants with HIV. It indicates that a significant number of lives can be saved by initiating antiretroviral treatment for HIV-positive infants immediately after diagnosis within the first 12 weeks of life. The Children with HIV Early Antiretroviral Therapy (CHER) study from South Africa demonstrates a 76 per cent reduction in mortality when treatment was initiated within this time period.33 Other studies have shown limited immune recovery and increased mortality even among children on antiretroviral treatment if it is initiated at more advanced stages of disease.34 Clinical guidelines issued by WHO now recommend immediate initiation of antiretroviral therapy for all infants under one year of age diagnosed as infected with HIV rather than waiting until children show signs of infection.35 Despite the encouraging increase in the number of children on antiretroviral treatment, the youngest cohort of children exposed to the virus – those under age one – are not getting diagnosed and are missing out on treatment. As a result, large numbers of very young children are dying every year © UNICEF/HQ05-1873/Donna DeCesare because of AIDS. 10 UNITE FOR CHILDREN UNITE AGAINST AIDS Figure 5. Number of children under 15 receiving antiretroviral therapy in low- and middle-income countries, 2005–2007 51,000 Eastern and Southern Africa 85,000 132,000 4,000 11,000 West and Central Africa 26,000 11,000 17,000 17,000 Latin America and the Caribbean 2005 6,000 9,700 12,000 East Asia and the Pacific 2006 2007 1,500 3,000 9,000 South Asia 1,000 1,500 1,900 CEE/CIS <100 <200 <500 Middle East and North Africa 75,000 Total low- and middleincome countries 127,000 0 50,000 100,000 150,000 198,000 200,000 Note: Regional totals do not add up to the total for low- and middle-income countries because of rounding. The seven ‘hyper-endemic’ countries are all in the Eastern and Southern Africa region. Source: UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008 (UNICEF, UNAIDS, WHO), pp. 34–42. Regions were recalculated according to UNICEF classification of regions. Numerous partners – including the Baylor International Pediatric AIDS Initiative, the Clinton Foundation HIV/AIDS Initiative, Columbia University’s International Center for AIDS Care and Treatment Programs, the Elizabeth Glaser Pediatric AIDS Foundation, PEPFAR, UNICEF and WHO – have identified early HIV diagnosis as a priority activity in child health programming and have contributed towards its implementation. The US Centers for Disease Control and Prevention (CDC), for example, are helping to build national and regional laboratory capacities to facilitate HIV-related diagnosis in infants and to monitor disease progression and treatment response (see box). © UNICEF/HQ05-2063/Donna DeCesare Integrated laboratory training In resource-limited countries with high burdens of infectious disease, laboratory services and skilled staff are critically needed to provide diagnostic testing that is accessible, appropriate and of high quality. In response to this need, PEPFAR has recently allocated funding, through the Global AIDS Program at the US Centers for Disease Control and Prevention, for the establishment of an African Centre for Integrated Laboratory Training. Located in Johannesburg, the Centre offers hands-on training to laboratory staff in the region. After needs assessments in 10 resource-limited African countries, PCR testing for HIV DNA in infants was identified as a priority issue and was the focus of an initial course offered in September 2008. UNITE FOR CHILDREN UNITE AGAINST AIDS 11 MAIN ISSUES viral therapy, an illustration of the critical gap in data covering children’s access to HIV and AIDS services. Early infant diagnosis and early access to care and treatment Several countries have revised child health cards to include HIV-related information, making tracking of exposed children easier and increasing the likelihood that infants known to be exposed to HIV are referred for virological testing, then early treatment if needed. Many countries have high levels of immunization coverage, and the age at which infants receive their first dose of diphtheria, pertussis, tetanus immunization (DPT1) – at or around six weeks old – is an ideal time for early virological testing for HIV. Children under one year old are among those most vulnerable to HIV and AIDS and traditionally among the least served. Evidence demonstrates that early initiation of antiretroviral treatment in infants with HIV can save lives. Yet very few children under age one are currently receiving such treatment. Recent studies find that the median age at which children with HIV begin antiretroviral treatment is between five and nine years old.36 This has serious repercussions: One third of HIV-infected children without access to antiretroviral treatment die by the age of one year, and half by age two.37 In addition, late commencement of treatment may mean that the child’s immune system is already severely compromised when the treatment is started. One important study in the United States showed that infants and children started on antiretroviral treatment when they were already severely immunodeficient never regained normal levels of immune functioning even after five years on treatment.38 Another study, in sub-Saharan Africa, showed that such infants and children are significantly more likely to die than those initiated on treatment at an earlier stage.39 Most infants with HIV are not treated because health workers are not aware that the child was exposed to HIV; this may be due to a lack of information about the child’s HIV status or because systems were not in place to transmit that information to the health worker. Even when information about the child’s status is available, the child may not be referred for early infant HIV testing, or PCR-based HIV diagnosis may not be locally available. In 2007, only 8 per cent of children born to HIV-positive women were tested before they were two months old.40 There are no clear data on how many of these children tested positive or actually began antiretro- 12 UNITE FOR CHILDREN UNITE AGAINST AIDS Zambia began documenting HIV status on child health cards in 2006. Following the inclusion of this information, the number of HIV-exposed children benefiting from a virological test increased from 1,931 in 2006 to 7,664 in 2007 and 6,000 in the first six months of 2008 alone, according to government data.41 These cards have also helped HIV-exposed children receive other critical interventions such as cotrimoxazole preventive therapy and nutritional support. For countries to be able to provide these services, however, health-care workers need to know if a child is exposed to HIV. Another modality for scaling up diagnosis of HIV in young children takes advantage of child health days, organized in many countries to deliver health and nutrition services on a large scale. During child health days in Lesotho in 2007, more than 4,400 children were tested for HIV (including with PCR through dried blood spot specimen collection) and screened for tuberculosis and malnutrition. Nearly 100 per cent of participants (adults and children) were tested. Overall HIV prevalence among children was 3 per cent, and children who tested positive were immediately referred to appropriate care at the nearest antiretroviral treatment clinic.42 As a model for provider-initiated HIV testing, the Lesotho experience is important to highlight and discuss because of its high participation rate and apparent effectiveness – and also because such experiences raise crucial questions about achieving a balance between ensuring access to care and treatment for the infant and the implicit testing of mothers when children are tested. Several countries are rapidly building national capacity for infant diagnosis of HIV so that children do not have to wait as long to know if they are infected and require treatment. In 2007, 30 low- and middle-income countries used dried blood spot filter paper to collect specimens for PCR testing for HIV DNA in infants, up from 17 countries in 2005.43 Many of these countries – Botswana, Kenya, Malawi, Mozambique, Rwanda, South Africa, Swaziland and Zambia – are in sub-Saharan Africa, the region with the largest number of exposed infants. Through the implementation of testing networks using dried blood spot filter paper, these countries have made virological testing possible even in remote rural areas. The Clinton Foundation HIV/AIDS Initiative has placed a special emphasis on scaling up early infant diagnosis through dried blood spot PCR testing in heavily affected areas (see box ). UNITAID, through its support to both PMTCT and paediatric HIV care and treatment, is providing reagents and other commodities for PCR testing for HIV DNA to a number of countries. The Clinton Foundation HIV/ AIDS Initiative’s contributions to scaling up early infant diagnosis The Clinton Foundation HIV/AIDS Initiative supports the expansion of early infant diagnosis in 29 countries through the donation of commodities with UNITAID funding, as well as by providing technical assistance to strengthen governments’ capacity to run tests, establish sample transport networks and train health-care workers to ensure that children who test positive are referred immediately for antiretroviral treatment. The initiative has helped make DNA PCR reagents more affordable and has facilitated procurement and distribution. In 2007, the number of sites providing early infant diagnosis in programme countries grew from approximately 200 to more than 1,400, and 200,000 DNA PCR tests were conducted.44 Many children with HIV, however, are identified only when they become very sick. A 2006 study of referral patterns for HIV care and treatment for children under age 15 in Malawi found that only 1 per cent of referred children came from PMTCT services. The vast majority, 80 per cent, came from children’s wards or nutritional rehabilitation units. To address this issue, the Ministry of Health has begun to routinely test sick children of unknown HIV-exposure status; 35 per cent of those tested have had positive test results, and of those, a large number were started on antiretroviral therapy.45 For many children with HIV, serious illness can be delayed or prevented through the use of the common antibiotic cotrimoxazole against opportunistic infections and malaria. Cotrimoxazole should be started as early as possible in infants who have been exposed to HIV or are infected. Yet, despite its efficacy and crucial role in saving children’s lives, it is estimated that in 2007 cotrimoxazole prophylaxis was started in only 4 per cent of infants under two months of age born to HIV-positive women.46 Child health cards with HIV-specific information can prompt health workers to initiate this critical intervention in a timely manner. UNICEF and WHO, with UNITAID support and in collaboration with the Clinton Foundation in several countries and the US Government in others, are providing donations of cotrimoxazole for use as prophylaxis in HIVexposed and infected populations in countries of sub-Saharan Africa and South Asia. Early infant diagnosis and early access to care and treatment, including cotrimoxazole and antiretrovirals, must be part of a broader approach to HIV care and treatment, including routine monitoring and adherence support. They must also be fully integrated into the broad spectrum of child survival and based on a comprehensive package of care – including optimal infant feeding, growth monitoring, immunization and other essential child survival interventions – as well as good-quality HIV-specific care that offers drugs (both antiretrovirals and cotrimoxazole), routine monitoring and adherence support. The push to place greater numbers of HIV-infected infants on treatment means an increased need for the development of more and cheaper antiretroviral treatments suitable for the youngest populations. UNICEF, WHO and partners in the Unite for Children, Unite against AIDS initiative continue to talk with manufacturers and advocate for this increased availability. Improved treatment coverage for children will also require better estimates of HIV infection and treatment needs. UNICEF, WHO and partners met in New York in July 2008 with the UNAIDS Reference Group on Estimates, Modelling and Projections to review epidemiological assumptions for estimating the numbers of children needing treatment. Estimated antiretroviral needs for children are being recalculated based on revised assumptions and estimates of mother-to-child transmission rates, the availability and use of new PMTCT regimens, and new WHO recommendations on eligibility for antiretroviral therapy in infants. The recalculated estimates, which will be available in 2009, will facilitate the setting of national and subnational targets for the youngest patients in the epidemic and should ultimately increase their access to life-saving treatment. Quality improvement initiatives Countries are using a number of simple quality-improvement tools with children that have been utilized successfully with adults, including visual prompts and reminders to clinicians UNITE FOR CHILDREN UNITE AGAINST AIDS 13 to provide routinely needed services and better documentation. Initial work is taking place in Botswana, Guyana and Uganda to apply quality improvement principles to health-care delivery to children as part of broader child survival measures. the management of antiretroviral treatment for people living with HIV. In an effort led by the Ministry of Health through its National Programme for AIDS and Sexually Transmitted Infections, drugs were pre-positioned, staff were deployed in different areas around the country to support rapid access and service delivery, and an advisory was issued in the major daily newspapers, complemented by radio announcements in local languages and in English. At the same time, provincial and district AIDS coordinators were equipped to coordinate the intervention and liaise with civil society organizations engaged in humanitarian activities. Improving the quality of care in Uganda In 2007, UNICEF teamed up with the Ministry of Health, the CDC and HIVQUAL International to support the application of quality improvement methods to basic child survival and HIV care in Uganda. One facility in the northern part of the country, the Lacor Hospital, noted that no children under age five were documented as routinely having their growth monitored – an essential intervention – and subsequently implemented a number of simple measures over the first six months of 2008. These included introducing growth monitoring charts, encouraging patients to bring their children in for monitoring when they came for prescription refills, and improving documentation. During this period, the proportion of children whose growth was monitored increased to more than 70 per cent. Other quality improvements have included the provision of additional scales for growth monitoring and making growth charts readily available as part of patient records. Systems have been redesigned to collect CD4 test specimens on site, patients are escorted to the laboratory to ensure that lab tests are performed on schedule, and results of CD4 and tuberculosis tests are followed up.47 Following the devastating earthquake affecting China’s Sichuan province in 2008, public information and announcements were disseminated as part of a communication strategy, including the locations where treatment, care and support services could be obtained. A newsletter linked local nongovernmental organizations with people living with HIV in earthquake areas. New relationships to assist in the care and treatment of women and children living with HIV continued into the recovery phase, with support from UNICEF and civilsociety partners. Young people living with HIV The many children and young people now living with HIV face particular challenges: accepting their HIV status and disclosing it to family, peers and others; maintaining adherence to treatment and overall medical care; and coping with feelings of isolation and stress.48 Adolescents face the additional challenge of addressing their emerging sexuality, including having to disclose their HIV status to sexual partners and avoid high-risk behaviours. In a qualitative study sponsored by WHO and UNICEF examining psychosocial issues facing adolescents and young people living with HIV, 41 per cent of respondent organizations working with young people with HIV identified adherence as a principal concern.49 A separate study comparing adolescents (aged 11–19) and adults who initiated antiretroviral therapy In situations of conflict and emergency, it is essential to maintain the delivery of HIV services and access to life-saving interventions for children and their families affected by HIV and AIDS. During the unrest following the 2007 elections in Kenya, for example, an immediate concern related to 14 UNITE FOR CHILDREN UNITE AGAINST AIDS © UNICEF/HQ06-1364/Giacomo Pirozzi Programming for children in conflict or emergency settings Towards a comprehensive action agenda for young people living with HIV In a study of 732 perinatally HIV-infected adolescents aged 15–19 in four districts of Uganda, 52 per cent of the respondents reported that they were currently in a relationship, 33 per cent had already had sex, and 40 per cent of those not sexually active reported a desire to have sex. Among those who reported having sex, only 37 per cent had used a method to prevent HIV infection. Of the sexually active female adolescents, 41 per cent had been pregnant at least once and 73 per cent of them chose to continue their pregnancies. The study found that disclosing serostatus to friends was a major fear for 51 per cent of those surveyed; about 38 per cent of respondents who were in a relationship had disclosed their HIV status to partners. Some expressed anxiety about whether they would have meaningful sexual relationships, be loved despite their status or be able to have children. The study identified several priority areas for programmatic action, including: •฀ Strengthening prevention for sexually active HIV-positive adolescents, including increased information and skills to help them negotiate disclosure and utilize protection correctly and consistently. •฀ Making pregnancy safer for adolescents with HIV, including through access to a full range of antenatal care that provides PMTCT services. •฀ Training service providers and counsellors on methods to discuss sexuality with adolescents, including those with HIV, in an engaging and respectful way, and encouraging parents to discuss these issues with adolescents. •฀ Supporting adolescents and young people with a full range of adolescent-friendly services as they transition from paediatric to adult clinics. •฀ Strengthening adolescent support groups, which can be very effective in skills building and for obtaining critical information about safer sexual activity. •฀ Improving the life skills of adolescents with HIV, including how to make informed and responsible choices. The study was carried out by Frontiers in Reproductive Health of the Population Council and TASO with support from the United States Agency for International Development (USAID) and the Ford Foundation.51 between 1999 and 2006 for virological outcome and levels of adherence found that adolescents were less likely to achieve 100 per cent adherence at 6 months (29 per cent vs. 49 per cent) or 12 months (15 per cent vs. 34 per cent).50 Issues associated with dating and sexual relationships, including disclosure of HIV status to partners, are also of concern for young people living with HIV (see box). Programmes in several countries are now addressing the special challenges these young people face. In Mali, for example, children and adolescents being treated at the Gabriel Touré Hospital in Bamako learn of their HIV status over the course of several group sessions with their parents or guardians. The methods of disclosure are age-appropriate and accompanied by psychosocial support for the child as needed. In Uganda, The AIDS Support Organization (TASO) runs peer support groups for adolescents on treatment. Through group discussion, recreational activities, music, dance, drama and writing, participants share information, support one another in their experiences – of stigma, peer pressure and disclosure of HIV status, among others – and learn to advocate for their needs. In Botswana, the Botswana-Baylor Children’s Clinical Centre of Excellence is developing interventions to provide psychosocial support to adolescents living with HIV. The response to young people living with HIV also presents an important opportunity for collaboration across two ‘Ps’: paediatric treatment and care, and preventing infection among adolescents and young people (see Chapter 3 ). UNITE FOR CHILDREN UNITE AGAINST AIDS 15 PROGRESS AND ACHIEVEMENTS 3. PREVENTING INFECTION AMONG ADOLESCENTS AND YOUNG PEOPLE Across the globe, a renewed emphasis on prevention presents an important opportunity to ensure that adolescents and young HIV prevalence among young people aged 15–24 is declining in many countries, in some of them significantly. HIV prevalence among young women aged 15–24 who are attending antenatal clinics has declined since 2000–2001 in 14 of the 17 countries with sufficient data to determine trends. In seven of these countries, prevalence in this group declined by at least 25 per cent, the global target set for 2010 at the UN General Assembly Special Session on HIV/AIDS (UNGASS) in 2001.52 Several countries with high HIV prevalence have experienced declines in risky behaviours, including the initiation of sex before age 15, sex without condoms and sex with multiple partners. Yet a significant number of young people continue to be infected with HIV; in the 15-and-older age group, 45 per cent of all new cases in 2007 were found among those 15–24 years old.53 Table 1. Young people aged 15–24 living with HIV, 2007 Region Sub-Saharan Africa Female Male Total 2,550,000 860,000 3,400,000 300,000 390,000 690,000 South Asia Latin America and the Caribbean 160,000 240,000 400,000 people benefit from prevention East Asia and the Pacific 210,000 360,000 580,000 CEE/CIS 120,000 220,000 340,000 efforts that take local realities into Middle East and North Africa 55,000 43,000 98,000 3,400,000 2,100,000 5,500,000 consideration. There is strong consensus that combination prevention – integrating behavioural, structural and biomedical approaches – works. Total Note: Some numbers do not add up to totals because of rounding. Source: UNAIDS/WHO, unpublished estimates, 2008. On average, about 30 per cent of males and 19 per cent of females aged 15–24 in developing countries have comprehensive and correct knowledge about HIV and how to avoid transmission.54 These knowledge levels are far below the UNGASS Declaration of Commitment’s goal of comprehensive HIV knowledge of 95 per cent among young people by 2010. MAIN ISSUES Vulnerability of girls and young women There is strong consensus based on evidence that girls and young women remain disproportionately vulnerable to HIV infection in sub-Saharan Africa, particularly in the hyperendemic countries, where prevalence is greater than 15 per cent (Figure 6 ). In Southern Africa, adolescent women are 2 to 4.5 times more likely to be infected than males of the same age.55 Addressing the vulnerability of girls is a priority focus of key development partners, including the Global Fund, as well as the UNAIDS secretariat and co-sponsors. An in-depth analysis of DHS data from five countries – Cameroon, Swaziland, Uganda, the United Republic of 16 UNITE FOR CHILDREN UNITE AGAINST AIDS Tanzania and Zimbabwe – found a significant association between a young woman’s HIV status and the number and age of her partners. Young women aged 15–24 were more likely to be infected with HIV when they had multiple partners (Figure 7 ) and when their partners were older (Figure 8 ). Odds ratio Figure 8. Risk of HIV infection among young women aged 15–24, by age difference with last sexual partner, 2003–2006 Countries with adult HIV prevalence above 15% Botswana 10.3 3.4 Zimbabwe 7.7 2.9 8.5 Mozambique 2.9 Malawi Females Males 5.5 1.1 4.3 3.9 1.3 3.9 Gabon 1.3 United Republic 0.9 of Tanzania 0.5 0% 5% 10% 15% 20% 25% Source: Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, Annex 1. Odds ratio Figure 7. Risk of HIV infection among young women aged 15–24, by the number of partners in her lifetime, 2003–2006 3.5 One partner (baseline) Two partners 3.0 Three or more partners 2.5 2.0 2.2 2.1 1.5 1.6 1.5 1.0 1.0 1.0 0.5 0.0 Cameroon Swaziland 1.0 1.0 1.6 1.9 Swaziland 1.0 1.1 1.5 2.4 United Republic of Tanzania 2.3 2.7 1.0 Zimbabwe Note: The odds ratio compares the magnitude of the association of HIV infection between the comparison group and the baseline group. In this chart, the comparison groups are women whose partners are 2–4 years older, women whose partners are 5–9 years older and women whose partners are 10+ years older; the baseline group is women whose partners are 0–1 year older. An odds ratio of 1.0 indicates the HIV infection rate is equal in the two groups; an odds ratio of greater than 1.0 indicates the HIV infection rate is higher in the comparison group than in the baseline group, and an odds ratio of less than 1.0 means the HIV infection rate is lower in the comparison group than in the baseline group. For example, in Swaziland, women whose partners are 2–4 years older are equally likely to be infected with HIV as women whose partners are 0–1 year older; women whose partners are 5–9 years older are 1.6 times more likely to be infected as women whose partners are 0–1 year older. Source: Preliminary analysis of DHS and MICS data (2003–2006) by UNICEF and Macro International, 2008. 8.4 2.4 1.2 1.0 0.8 1.4 1.7 6.5 In the Caribbean, girls and women comprise 50 per cent of people aged 15 and older living with HIV, and in some countries HIV prevalence rates among young women aged 15–24 are two to three times higher than for men of the same age group.56 In this region, HIV is spread primarily through heterosexual transmission, with commercial sex and sexual exploitation having a significant role in many countries. 11.3 3.6 Namibia Countries with adult HIV prevalence between 5% and 15% 12.7 4.0 Zambia Uganda 14.9 5.9 South Africa Cameroon 15.3 5.1 Lesotho Central African Republic 22.6 5.8 Partner is 0–1 year older (baseline) Partner is 2–4 years older Partner is 5–9 years older Partner is 10+ years older Cameroon Figure 6. HIV prevalence among young people aged 15–24, 2007 Swaziland 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 3.0 2.8 2.9 3.3 2.9 2.1 1.0 Uganda 1.0 1.0 United Republic of Zimbabwe Tanzania Note: The odds ratio compares the magnitude of the association of HIV infection between the comparison group and the baseline group. In this chart, the comparison groups are women with two partners and women with three or more partners; the baseline group is women with one partner. An odds ratio of 1.0 indicates the HIV infection rate is equal in the two groups; an odds ratio of greater than 1.0 indicates the HIV infection rate is higher in the comparison group than in the baseline group, and an odds ratio of less than 1.0 means the HIV infection rate is lower in the comparison group than in the baseline group. For example, in Swaziland, women with two partners are 1.6 times more likely to be infected with HIV compared to women with one partner; women with three or more partners are 2.2 times more likely to be infected compared with women with one partner. Source: Preliminary analysis of DHS and MICS data (2003–2006) by UNICEF and Macro International, 2008. Urgent attention is needed to increase understanding of this vulnerability and to reduce it, taking into account the greater HIV risks to girls of multiple concurrent partnerships, intergenerational sex, transactional sex, and violence against women and girls. At a June 2008 technical meeting on young women’s vulnerability to HIV infection in Southern Africa, sponsored by UNAIDS and the Reproductive Health and HIV Research Unit of the University of the Witswatersrand, Graça Machel, the international advocate for women’s and children’s rights, spoke of what she called the lack of empowerment and choice in the region, and called for reflection on and transformation of the cultural practices and attitudes that place girls at risk. The meeting stressed the need for communities to advocate zero tolerance for gender-based violence and recommended prioritizing secondary-school education for girls and economic empowerment of young women.57 Countries are responding to the evidence about girls and HIV. Zimbabwe, for example, has developed a national behaviour change communication strategy with a strong focus on gender issues. A key issue highlighted in the strategy is that sexual relations between young women and men who are five or more years older is the major factor in the spread of HIV to the younger generation. The strategy recognizes that sexually active young people need support in avoiding multiple partnerships and in using condoms, and that young people who are not sexually active need support in delaying sexual initiation. 58 UNITE FOR CHILDREN UNITE AGAINST AIDS 17 The ‘Woman to Woman Initiative on HIV’, launched in 2007 in Somalia, supported women’s non-governmental organizations to reach some 31,000 women – including female heads of households, women who were internally displaced because of the emergency and adolescent girls – with correct information and risk-reduction measures. Results suggest that participants gained new knowledge, mastered certain life skills and are now more likely to provide care and support for people living with HIV.59 HIV risk among adolescents and young people in low-prevalence and concentrated epidemics HIV risk among adolescents and young people in countries where prevalence is low and the epidemic is concentrated in specific populations is now well documented. In Central and Eastern Europe, seven countries have collected disaggregated data on risk behaviour among the most-at-risk boys and girls (see box). Further, legislative reviews are promoting discussion of most-at-risk adolescents and young people and related ethical issues. In Egypt, a behavioural surveillance study focusing on children and adolescents living or working on the street in two cities is providing baseline evidence for targeted intervention programmes. Many of these children aged 15–17 in Alexandria (61 per cent) and Greater Cairo (52 per cent) are engaged in at least two risky behaviours. Harassment and ill-treatment by the police, as well as physical and sexual abuse, are among the problems experienced by the children. A combination of responses is therefore required to address root causes and change behaviours; these include initiatives with relevant ministries and the police to increase protection and access to services.60 Prevention in national HIV and AIDS strategic plans National HIV and AIDS strategic plans need to have a strong focus on prevention, taking into account assessments of young 18 UNITE FOR CHILDREN UNITE AGAINST AIDS Adolescents and risk in Central and Eastern Europe A seven-country project in Central and Eastern Europe, conducted in partnership with the London School of Hygiene & Tropical Medicine and UNICEF, looked at adolescent risk behaviour in the region – including injecting drug use, unprotected sex between males, and sex in exchange for gifts and money – and awareness and use of services. Preliminary survey results being shared with governments show that in Bosnia and Herzegovina, injecting drug users aged 18–24 – most of whom had initiated drug use prior to age 18 – were likely to engage in multiple risk behaviours.61 These results, along with the high levels of hepatitis C virus and low levels of HIV and syphilis in the target population, suggest an opportunity for rapid scale-up of harm-reduction services. In Ukraine, survey data corroborated earlier findings in a study of children and young people living or working on the street that they had all been subject during their lives to some form of serious trauma, such as violence, abuse and sexual or labour exploitation.62 In Serbia, indicators on most-at-risk adolescents have been included in studies by the Global Fund to Fight AIDS, Tuberculosis and Malaria to establish national baseline data, and the information will be updated every two years as part of the Global Fund’s monitoring system. people’s risk and vulnerability. In Malaysia, a five-year National Strategic Plan on HIV/AIDS (2006–2010) covers issues from young people’s vulnerability to the delivery of health-care services and antiretroviral treatment and provides funding for programmes with marginalized and most-at-risk populations; the plan was developed and drafted with the involvement of civil society. In South Asia, four countries with low levels of epidemic – Afghanistan, Bhutan, Maldives and Sri Lanka – finalized or approved national strategic plans in 2007 that readjusted efforts to focus on prevention for people most at risk, especially adolescents engaging in high-risk behaviour. UNAIDS, the United Nations Population Fund (UNFPA), UNICEF and WHO have been promoting a focus on HIV prevention among young people in national plans in a number of countries in Eastern and Southern Africa, including Botswana, Lesotho, Namibia and Swaziland, and encouraging young people’s participation in such plans. Malawi has developed a national acceleration plan for prevention for young people that takes advantage of better evidence and improved coordination. In Namibia, a prevention subcommittee prioritizing young people has been established under the national coordination structure, and the subnational response includes a focus on most-at-risk adolescents. Young people are a component of the national HIV strategic plans of 22 countries in West and Central Africa, a region with generalized and potentially mixed epidemics. But there is a need for specific plans that focus on risk, vulnerability and disparities among young people both in school and out of school. Such plans have been elaborated in Cameroon, the Democratic Republic of the Congo and Nigeria. In Cambodia, the second National Strategic Plan for HIV (2008–2010) prepared by the Ministry of Education, Youth and Sport aims to increase coverage and quality of HIV education for children and youth who are especially vulnerable and at higher risk; a National Strategic Plan on Women, the Girl Child and HIV and AIDS (2008–2012) includes a focus on family values and social cohesion. Adolescent participation in local programming The lack of data is a major constraint on responding appropriately to young people’s need for information on how to prevent HIV. Strategic information on the epidemic and the social factors driving it should inform and support programme and policy decision-making to achieve national goals. National strategic plans also should take into consideration such salient factors as poverty, gender inequalities and human rights violations associated with the epidemic. In Brazil, young people participate in implementing the Health and Prevention in Schools Programme, and many of the delegates to the national congress on health and prevention in schools in 2008 were young people. A young person now represents youth at the decision-making council for civil society in the National AIDS Programme. In 2007, young people living with HIV launched Escuta só! (Listen up!), a magazine and website that seeks to break through HIV-related stigma and prejudice. In regions with low prevalence and concentrated epidemics, such as CEE/CIS, there is growing recognition that national HIV strategic plans need to include a focus on targeted interventions for most-at-risk adolescents and young people. In Ukraine, such adolescents are now recognized as needing special attention in the newly approved National HIV/AIDS Concept and Programme 2009–2013, and advocacy is ongoing to ensure the full integration of a focus on adolescents and young people at risk. Processes to integrate a similar focus in strategic review and drafting of plans are also under way in Albania, Moldova and Romania. The expanded UN Inter-Agency Task Team on HIV and Young People, particularly through its working group on young people most at risk, emphasizes the need for strategic information, disaggregated by age and sex, and evidence-informed programmes tailored to local realities and developed with the participation of such young people.63 The involvement of adolescents and young people in the planning, design, implementation, monitoring and evaluation of interventions that affect them is crucial, and significantly more work is needed to ensure their meaningful participation in local programming, with attention to engaging those most at risk. But there are some important examples of what is possible. In Mali, adolescents were actively involved in the design and implementation of the country’s first situation analysis of young people and HIV and AIDS. Trained in simple qualitative research techniques and the rights-based approach, they developed tools and questionnaires based on their own priorities and helped undertake field research that led to some of the key findings. In Uganda, the Straight Talk Foundation, a non-governmental organization focusing on health communication, has made participation of adolescents and young people a cornerstone of its work. Young people are part of all aspects of its programmes and work on the 3,400 radio shows annually that include interviews by and for young people. The education sector In generalized epidemic settings where children are in school, the education sector is a crucial avenue for reaching adolescents with the gender-sensitive information and skills that are a necessary part of preventing the spread of HIV. There is strong evidence that school-based sex education can be effective in changing the knowledge, attitudes and practices that lead to risky behaviour. HIV components within life skills-based education are now a part of many education sector responses to the epidemic, and these responses are increasingly being tailored to specific national and local needs, based on evidence. Evaluations are under way to assess the efficacy of such interventions in Lesotho, Namibia and Zambia, and frameworks of life skillsbased education that specifically address HIV prevention and the factors driving the epidemic are being developed in Botswana and the United Republic of Tanzania. UNITE FOR CHILDREN UNITE AGAINST AIDS 19 The HIV Alert School model The HIV Alert School model has been adopted in Ghana as a national strategy for school-based HIV prevention. The model was developed in five regions of the country, where 40 per cent of schools are certified as ‘HIV Alert’. Teachers in these schools are trained in behaviour change education for children. Parent-teacher associations and school management committees discuss HIV and AIDS as part of their regular meetings. An annual assessment and award process helps ensure that an HIV Alert School strives to maintain its status while motivating non-participating schools to seek certification. As of early December 2007, 131,572 teachers – 95 per cent of those in primary and junior secondary grades – had received training on the programme.64 An important breakthrough in 2008 was the signing by Ministers of Education and Health from Latin American and Caribbean countries of a historic declaration pledging support to multisectoral strategies to provide comprehensive sex education as part of school curricula, as well as activities to promote sexual health. The declaration was signed at the conclusion of the First Meeting of Ministers of Education and Health to Prevent HIV in Latin America and the Caribbean. Most countries in this region offer sex education at all levels of schooling, although there are significant differences in legislation, the scope and appropriateness of what is taught and the effectiveness of curricula.65 The education sector has a significant role in making sure that schools are safe places for children and adolescents, and policies need to be in place to ensure that students who are living with HIV can exercise their right to education in an enabling and supportive environment. Notably, Jamaica’s National Policy for HIV/ AIDS Management in Schools has the goal of promoting effective prevention and care within the educational setting. 20 UNITE FOR CHILDREN UNITE AGAINST AIDS The education sector’s response needs to be part of a comprehensive approach to prevention that covers HIV prevention, treatment, care and support, and addresses the societal and cultural factors driving HIV infection at the individual and community levels and in the wider environment. Male circumcision Male circumcision, with full attention to safety, needs to be introduced as an additional strategy in a comprehensive package of prevention measures that includes condom use, reduction in number and concurrency of partners, and delaying the onset of sexual activity. In Swaziland, strategies are emerging on how best to reach adolescents through their schools and communities with accurate and relevant information about male circumcision. Activities include awareness raising among parents, making male circumcision available during school holidays, training staff to be ‘youth-friendly’ and reducing the cost of the procedure. Male circumcision can provide an important entry point for promoting safer sex practices, improving sexual and reproductive health and contributing to positive gender attitudes and behaviours.66 A September 2008 consultation on male circumcision in the Eastern and Southern Africa region, organized by the UN InterAgency Working Group on Prevention with the participation of youth organizations, recommended young people’s involvement in the review and development of policies and strategies, in national mobilization efforts to increase demand for male circumcision and in the development of information materials. The consultation also recommended that male circumcision become part of countries’ adolescent sexual and reproductive health strategies, thus having the potential to ‘re-energize’ adolescent-friendly health services, among several other recommendations. Following the consultation, young people participated in the preparation of a questionand-answer document on male circumcision for use with other young people.67 HIV prevention in situations of emergency Northern Sudan provides an example of how vulnerable populations in emergency situations are being reached. As part of a mass communication campaign for behaviour change in communities and camps for internally displaced people, young peer educators and community workers were mobilized to lead activities and share information on HIV transmission and prevention. The campaign was launched in 2007 by UNICEF in cooperation with the National AIDS Programme and the Federal Ministry of Information. PROGRESS AND ACHIEVEMENTS 4. PROTECTION AND CARE FOR CHILDREN AFFECTED BY AIDS Worldwide in 2007, there were an estimated 15 million children who had lost one or both parents to AIDS, including nearly 12 million children in sub-Saharan Africa.68 Many millions more were orphaned due to other causes. An analysis of recent household survey data in 47 countries shows that orphanhood from all causes exceeds 5 per cent in many countries and is over 20 per cent in Lesotho, Rwanda, Swaziland and Zimbabwe (Figure 9 ). Orphaning rates are lowest in countries of CEE/CIS. AIDS is not the only cause of orphanhood. As of 2007, an estimated 47.5 million children in sub-Saharan Africa had lost one or both parents to any cause. For example, in Burundi and Rwanda, where the levels of orphanhood from all causes were 19 per cent and 21 per cent, respectively, orphanhood is more likely to result from armed conflict than from the epidemic.69 There is growing evidence in support of programming that is AIDS-driven – but not AIDS- Figure 9. Percentage of children under 18 who have lost one or both parents, in countries with HIV prevalence greater than 1 per cent, 2003–2007 Zimbabwe vulnerable children, including those Swaziland affected by AIDS. 28 Lesotho exclusive – and that will assist all 24 23 21 Rwanda 19 Burundi 15 Uganda 12 Malawi 12 Mozambique Ethiopia 11 Guinea-Bissau 11 Haiti 11 11 Sierra Leone 10 10 Cameroon Togo 10 United Republic of Tanzania 9 Côte d’Ivoire 9 Congo 8 8 Chad Ghana 7 7 Benin Senegal 6 Guyana 6 Trinidad and Tobago Belize 5 Jamaica 5 5 5 Thailand Ukraine 0% 5% 10% 15% 20% 25% 30% Source: UNICEF, Progress Report for Children Affected by HIV and AIDS, draft dated June 2008. UNITE FOR CHILDREN UNITE AGAINST AIDS 21 Considerable variability exists in orphan-related vulnerability, making programme targeting problematic. There is, however, growing consensus among most practitioners and policymakers that responses should be AIDS-sensitive – but not AIDS-exclusive – and that a focus should be on strengthening social protection systems. The AIDS epidemic has highlighted the vulnerabilities facing many children; in the most affected regions, addressing those vulnerabilities also reaches those children more directly affected by AIDS. National-level responses for orphans and other vulnerable children have been increasing since the 1990s, and nearly 50 countries globally are developing some type of AIDS-sensitive response. It is estimated that 32 countries have developed or finalized national plans of action (NPAs) with benefits for orphans and vulnerable children.70 Countries of Eastern and Southern Africa have generally made the most progress in developing and implementing national responses, while programming for orphans and vulnerable children is relatively new in West and Central Africa. In the East Asia and Pacific region, Cambodia, Malaysia, Papua New Guinea and Viet Nam are in the process of drafting national plans. In South Asia, India was the first country to establish a national response to children affected by HIV and AIDS.71 But the process of developing NPAs has generally been slow, and implementation at scale is lacking. The often limited capacity of governments and implementing partners and lengthy periods for plan development (three to seven years or more) are major challenges identified by a working group of the Inter-Agency Task Team on Children and HIV and AIDS in a paper documenting evidence and lessons learned from the development and implementation of national plans.72 Insufficient resources for implementing NPAs are reflected in the levels of social assistance provided to vulnerable households. In 18 countries where 22 UNITE FOR CHILDREN UNITE AGAINST AIDS household surveys were conducted between 2005 and 2007, the proportion of orphans and vulnerable children whose households received basic external support ranged between 1 per cent in Sierra Leone and 41 per cent in Swaziland, with a median value of 12 per cent (Table 2 ). Such support included education assistance, medical care, clothing, financial support and psychosocial services. The Unite for Children, Unite against AIDS goal is to reach 80 per cent of children most in need with services by 2010. Table 2. Percentage of orphans and vulnerable children whose household received basic external support, 2005–2007 Country Percentage Survey Swaziland 41 DHS (2006) Zimbabwe 31 DHS (2005–2006) Thailand 21 MICS (2005–2006) Malawi 19 MICS (2006) Namibia 17 DHS (2006–2007) Zambia 16 DHS (2007) Jamaica 15 MICS (2005) Guyana 13 MICS (2006–2007) Rwanda 13 DHS (2005) Uganda 11 DHS (2006) Cameroon 9 MICS (2006) Côte d’Ivoire 9 AIS (2005) Democratic Republic of the Congo 9 DHS (2007) Guinea-Bissau 8 MICS (2006) Central African Republic 7 MICS (2006) Togo 6 MICS (2006) Haiti 5 DHS (2005) Sierra Leone 1 MICS (2006) Source: Multiple Indicator Cluster Surveys (MICS), Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS), 2005–2007. MAIN ISSUES Effective programming reinforces support systems Assistance to orphans and vulnerable children continues to be carried out primarily by families, faith-based groups and other small organizations, and successful programming reinforces the capacity of these support systems. Governments have an important role in coordinating these efforts. In Zimbabwe, in March 2007, the Government began distributing funding pooled from all major donors to a broad network of 26 civil society organizations, which then managed more than 150 other partners and implementing agencies to provide services to orphans and other vulnerable children. As of March 2008, the programme had reached 165,980 children, surpassing its first-year target, according to a report issued by the Government with UNICEF. 73 Several donors – including the Global Fund to Fight AIDS, Tuberculosis and Malaria, Irish Aid, PEPFAR and the UK Department for International Development – have increased resources for HIV and AIDS, which signifies opportunities for better support to vulnerable children and families. But donors’ different approaches to aid delivery, with some funding civil society more directly and others supporting sectorwide approaches and government systems, must be coordinated nationally to ensure complementarities of interventions.74 The Paris Declaration, endorsed in 2005, outlines ways in which international aid should be delivered.75 Not all vulnerable children are orphans The overall situation of children’s vulnerability is complex and needs to be analysed within specific country and local contexts. An analysis of household surveys in 36 countries found, for example, that in many countries children who are orphaned are worse off than other children in relation to certain indicators of child development – nutritional status, school attendance, sexual debut – but in other countries they are equally well or better off.76 Some of this inconsistency can be explained by the situational context. For example, in countries with moderate levels of wasting, there were quite large differentials between orphans and nonorphans, but if there was a high level of wasting in a country, all children were affected. Similarly, in countries with high levels of overall school attendance nearly the same percentages of both orphans and non-orphans attended school, but in countries with lower levels of school attendance many countries showed large disparities between orphans and non-orphans. The same study assessed an expanded set of 37 potential indicators of vulnerability for nine countries. It found that the indicators most consistently revealing of vulnerability were asset ownership, household wealth status and education level of adults in the household. A similar result is highlighted by a 2008 study in Eastern and Southern Africa involving DHS data from 11 countries, which found that orphan vulnerability “was frequently and substantially outweighed by other factors,” such as whether the child lives in an urban or rural location, or whether the household is rich or poor. As such, “a single-minded focus on orphan–non-orphan disparities within each region runs the risk of losing sight of the bigger disparities within the country, and the related policy implications.”77 The shift towards inclusive programming to help all vulnerable children, including those directly affected by AIDS, is having an impact. The growing call for a broader, more inclusive definition of vulnerability is reflected in many countries’ national plans of action in Eastern and Southern Africa. In Zimbabwe, for example, a new programme of support to the National Plan of Action for Orphans and Other Vulnerable Children accepts a wide definition of vulnerability beyond orphanhood and vulnerability due to AIDS.78 This shift also addresses problems observed across a variety of countries and programmes where there is perceived inequality in favour of orphans (sometimes called the ‘lucky orphan syndrome’) or where children singled out as orphans become the object of social stigma. Social protection can have a positive effect on households and children Social protection has been defined as “public and private initiatives that provide income or consumption transfers to the poor, protect the vulnerable against livelihood risks, and enhance the social status and rights of the marginalised; with the objective of reducing the economic and social vulnerability of poor, vulnerable and marginalised groups.”79 Measures for social protection include social transfers, social welfare services and social policies. UNICEF and other agencies are examining how ‘childsensitive’ social protection measures can be designed with children’s development, well-being and protection in mind, and how they can address the higher risk of exclusion for children in marginalized communities and for children who are additionally excluded due to gender, disability, HIV and AIDS, and other factors. Specific ‘AIDS-sensitive’ social protection interventions for children include cash transfers, social work, early childhood development and alternative care. Cash transfers are increasingly promoted as a cost-effective approach to assist poor and vulnerable households. Cash allows families affected by illness to access the support they need, when they need it, and regular transfers can help keep children in school who would otherwise have to work to assist the UNITE FOR CHILDREN UNITE AGAINST AIDS 23 family. Linking transfers with social welfare services can increase their reach and effectiveness. The Livingstone Accord (March 2006) committed 13 countries in Eastern and Southern Africa, under the auspices of the African Union, to develop national social protection strategies and integrate them into development plans and budgets. A follow-up meeting, the First Conference of Ministers in Charge of Social Development, took place in October 2008 in Namibia, where social policy and social protection featured prominently in the agenda. institutionalization and scale-up of child-sensitive social protection has been leadership at a high governmental level.80 Cross-referral between faith-based and community groups and government social services is seldom undertaken, yet it is one clear way to expand the coverage and capacity of both sectors. The Church Alliance for Orphans (CAFO), for example, with a membership of 380 local congregations and faith- and community-based organizations in Namibia, plays a key advocacy role with the Government, particularly with the Ministry of Gender Equality and Child Welfare. The Ministry leads a permanent task force on orphans and vulnerable children; a subcommittee on care and support is chaired by CAFO’s Executive Director.81 Schools play an important role Social welfare sectors are most often responsible for coordinating services for vulnerable children and families, including the management and delivery of cash transfers. But welfare ministries often lack the capacity and resources to effectively coordinate and oversee the full range of family support and child protection services that fall within their mandate. The growing momentum towards consolidating a social protection agenda and reaching out to all vulnerable children, including those affected by AIDS, represents a key opportunity to address the capacity and organizational weaknesses of social welfare sectors. Some countries have already taken steps to improve welfare sector capacity. The need to reduce fragmentation and duplication in the social welfare system in Brazil, for example, led to institutional changes and the creation of the Ministry of Social Development. In Chile, the establishment of a comprehensive social protection system, Chile Solidario, has led to strengthened investments in social work capacity and reorganization of the delivery of social programmes and services to facilitate access by poor families. In South Africa, a social security agency has been created to administer the national cash transfer programme, which will help free up the social welfare ministries to address their core mandate of child protection, alternative care and social welfare service coordination. A common element to the successful 24 UNITE FOR CHILDREN UNITE AGAINST AIDS Schools continue to be vital places where children affected by AIDS – and all children – can find protection and support, and schools often serve as entry points for children in need to receive health services and meals. The right to education is crucial, as access to schooling helps children affected by HIV and AIDS cope with their situation and regain a sense of normalcy and stability in their lives. The protective nature of schooling is, however, dependent on safeguarding rights within education and providing safe and inclusive learning environments that minimize the distance from homes and have access to safe water and sanitation. Gender can frequently be associated with vulnerability, and vulnerable girls, in particular, need protection. School fees represent an obstacle to education for many families, and the abolition of school fees has led to increased school enrolment among vulnerable children, especially girls, in several countries.82 Ministries of education throughout Eastern and Southern Africa are working with external partners and nongovernmental organizations to better coordinate school-based interventions. Examples include Circles of Support, Schools as Centres of Care and Support, and Learning Plus. The Media in Education Trust Africa, the Open Society Institute, the United Nations Educational, Scientific and Cultural Organization (UNESCO), UNICEF and the World Bank are among the organizations and agencies that support such initiatives. It is also crucial to maintain and reinforce life-skills learning for reducing vulnerabilities and risks and increasing coping abilities and psychosocial well-being. Cooperation among teachers, local leaders and community members can help identify particularly vulnerable children for more intensified and targeted support. In Lesotho, the Ministry of Education and Training has developed a specific plan to provide educational opportunities and assistance for orphans and other children considered to be vulnerable. Other ministries, including the Ministry of Health and Social Welfare and the Ministry of Justice and Human Rights and Correctional Services, have also developed policies that incorporate the needs of orphans and vulnerable children. The participation of HIV-infected parents in antiretroviral regimens can have important benefits for their children’s education. Household data from Kenya indicate that the number of hours children are in school each week increases by 20 per cent within six months of initiation of antiretroviral treatment for an adult household member. Similarly, children living in such households experience sharp improvements in their nutritional status as measured by quantitative assessments once an adult household member begins treatment.83 Figure 10. OVC Policy and Planning Effort Index: Total scores in countries of Eastern and Southern Africa, 2004–2007 69 South Africa The OVC [orphans and vulnerable children] Policy and Planning Effort Index (OPPEI) Survey measures eight components of an effective national response. The 2007 survey found that national situation analyses, consultative processes, coordinating mechanisms and national action plans had improved over 2004, while the least progress had occurred in the areas of monitoring and evaluation, legislative review, policy and resources.84 Out of a possible score of 100 per cent, OPPEI scores in Eastern and Southern Africa in 2007 ranged from 51 per cent in Botswana to 81 per cent in South Africa (Figure 10 ). In this region, Zambia made the most progress, scoring 79 per cent in 2007. OPPEI scores in the West and Central Africa region ranged from 35 per cent in the Democratic Republic of the Congo to 87 per cent in Mali. That monitoring and evaluating the situation of orphans and vulnerable children is one of the weakest areas of national responses for these children was also found by the 2004 OPPEI. Challenges include fragmented efforts and limited coordination among governments, implementers and partners. 81 29 Zambia But the evidence base for effective programming in the area of protection and care for children affected by AIDS is improving. A UNICEF assessment of key indicators of the status of orphans and vulnerable children in 2008 shows the availability of more data in more areas compared to the previous assessment in 2006.85 The increased availability of data is a result of improvements in the design of such surveys as the DHS, MICS and AIDS Indicator Surveys (AIS) that make them more sensitive to relevant indicators. 79 65 Uganda Namibia 63 Zimbabwe Swaziland Rwanda 66 77 73 76 76 72 73 79 59 Burundi 65 United Republic of Tanzania 55 Mozambique 41 Lesotho 38 Nonetheless, more work is needed to ensure that enough data exist to effectively inform programming in this area. Data for the indicators for food security, psychological health, connection with an adult caregiver and children outside of family care have not generally been collected. In addition, the regions of CEE/CIS, Latin America and the Caribbean, the Middle East and North Africa, and South Asia have very limited or no data for most of the indicators. 65 65 65 49 Malawi 62 Angola 58 57 56 Ethiopia Kenya 2004 2007 55 Botswana 0% The challenges of mounting a national response 51 20% 40% 60% 80% 100% Note: Angola, Kenya and Botswana were not included in the 2004 OPPEI Survey. Source: UNICEF, ‘Report on Progress in the National Response to Orphans and Other Vulnerable Children in Sub-Saharan Africa: The OVC Policy and Planning Effort Index (OPPEI) Survey’, 2007. The Monitoring and Evaluation Working Group of the Inter-Agency Task Team on Children and HIV and AIDS has put together a guidance document for developing and operationalizing a monitoring and evaluation system for the national response for orphans and vulnerable children.86 Additional efforts are needed, however, to successfully plan, monitor and evaluate multisectoral responses at national and subnational levels. UNITE FOR CHILDREN UNITE AGAINST AIDS 25 CONCLUSIONS It is hoped that current and future efforts in response to the HIV and AIDS epidemic will be supplemented by endeavours to ‘know your children’ – and that in knowing children and young people better and how AIDS affects them, and by understanding the implication of evidence and best practices for their care, the second and third generations of children affected by AIDS will not lead to a fourth. The Third Stocktaking Report calls for several focused, concrete, achievable actions that can bear fruit in the next one to three years, and that can significantly improve prospects for children and women and help nations towards their goals. These initiatives involve changes in thinking, as well as concrete action. •฀ Scale up programmes that provide early diagnosis of infants exposed to HIV and treatment of children who are infected. Early initiation of treatment can significantly reduce AIDS-related mortality in infants and young children, underscoring the urgent need to expand access to virological testing for infants and start them promptly on treatment. Scaling up in most countries will require the strengthening of laboratory capacity, provision of equipment and ensuring a reliable supply of reagents, the training of service providers and the establishment of networks that effectively link diagnosis with care. National policies will need to be revised to include guidelines for early diagnosis and treatment targets. Infants diagnosed with HIV will require new fixed-dose combination medicines appropriate to the youngest populations. There is a need to develop and use innovative mechanisms such as mobile phones to reach families in a timely manner when test results are positive. Time is of particular importance for the youngest children, in whom rapid disease progression leads to early death. •฀ Expand access to antiretroviral drugs for pregnant women in need of treatment. Pregnant women infected with HIV need access to the best regimens possible for their own health, for the survival of their children and to prevent transmission of the virus to their infants. Treatment can be effectively provided through a decentralized health systems approach, and ministries of health must provide the necessary policy guidance that takes into consideration the implications for maternal, newborn and child health services, including the effective use of resources. Antiretroviral treatment for women’s own health requires repositioning PMTCT as a vital component of both maternal and child survival. Programme assessment should therefore consider not just service uptake but impact in terms of mothers’ and children’s lives saved. •฀ Integrate HIV and AIDS services with primary health-care programmes. HIV prevention, diagnosis, care and treatment should be integrated within existing health infrastructure for antiretroviral treatment sites and maternal, neonatal and child health (MNCH) care services. PMTCT should be available in all antenatal care and MNCH services. Integration allows for reaching more children and women with interventions. It also reduces stigma attached to AIDSonly facilities. Infants exposed to HIV can be identified and referred for testing, cotrimoxazole treatment can be initiated for children in need, and adherence to treatment can be supported during routine well-child visits, scheduled 26 UNITE FOR CHILDREN UNITE AGAINST AIDS immunization visits and in other settings. Health policies at national and subnational levels may need to be reviewed to improve linkages between HIV and AIDS and child survival interventions, family planning based on national policies, and services to prevent and treat sexually transmitted infections and tuberculosis, as well as to improve programme management and coordination. •฀ Make prevention programmes more relevant to the needs of adolescents and young people. Prevention approaches must respond to evidence and understanding of the epidemic in different contexts and be tailored to the specific needs of adolescents and young people. Prevention policies and programmes targeted for adolescents and young people engaging in highrisk behaviours are a critical priority where such behaviours as injecting drug use, men having sex with men, intergenerational sex and sex work are driving HIV transmission. A supportive policy environment will facilitate the work of the education sector in adapting and updating life skills-based programmes in schools, especially where their content covers potentially sensitive issues. National strategic plans with a focus on HIV prevention should include clear targets and mechanisms © UNICEF/HQ07-1754/Christine Nesbitt •฀ Accelerate efforts to support optimal and safe infant and young child feeding practices. The quality of counselling provided by health-care providers and lay counsellors as it relates to infant feeding and HIV in many countries will need to be improved in line with new evidence on infant feeding and AIDSrelated mortality and in light of the global food crisis. Counsellors will need to be retrained to be able to provide clear guidance on infant feeding options, including exclusive breastfeeding and appropriate weaning foods. Programmes should engage communities in promoting safe feeding practices and supporting mothers’ choices, and policies should facilitate the exercise of appropriate infant feeding options depending on individual circumstances. UNITE FOR CHILDREN UNITE AGAINST AIDS 27 •฀ Combine prevention strategies for a more effective response. A broad range of prevention strategies is available and best used in combination to ensure that the specific needs of adolescents and young people at risk are met. To be effective, HIV prevention programmes must combine information, life skills and behavioural change activities with actions to address the social issues that make adolescents and young people vulnerable to HIV and lead them to engage in risky behaviours. Although male circumcision has been shown to contribute to reducing HIV risk among men, it should be seen as an additional strategy rather than as a substitute for current prevention measures such as condom use, reduction in number of partners and delay of sexual activity. •฀ Understand and address the greater vulnerability of girls. Along with working to change individual behaviour, national governments and partners must openly address the social and cultural factors driving the particular vulnerability of girls, such as concurrent partnerships, intergenerational sex, transactional sex, and violence against women and girls. Being in school reduces the risk of HIV infection among girls, so efforts to keep girls in school until secondary-school graduation must be intensified. •฀ Prioritize the collection and disaggregation of high-quality data. Quantitative and qualitative data are essential to identify the populations most at risk, understand trends and evaluate prevention programmes. Data that are disaggregated by such factors as age, sex, marital status, wealth quintile and geographical location (urban or rural) can be informative for better programming. Improved 28 UNITE FOR CHILDREN UNITE AGAINST AIDS © UNICEF/HQ07-1364/Giacomo Pirozzi for monitoring progress. Evaluation is needed, as well, to assess the impact of HIV prevention efforts through the mass media, sports and celebrity involvement. knowledge about the under-5 and 15–18 age groups and the most at risk among them can inform the development of strong national strategies that are crucial to effective and continued prevention, care and treatment. •฀ Invest in the social sector to improve protection of the most vulnerable children. The global response to the AIDS epidemic can drive efforts for better support and protection not just for children affected by HIV and AIDS but for all of the most vulnerable children. Efforts and investment should be directed towards increasing access to basic services, ensuring appropriate alternative care, and providing social support and protection from abuse and neglect. Social cash transfers in particular can act as a protective mechanism for recipient households in the context of rising food prices. Partnerships with civil society can help support the capacity of families and communities to care for vulnerable children and minimize the need for care in institutional settings. Know your children Finally, this Third Stocktaking Report acknowledges the efforts by all those working in response to the HIV and AIDS epidemic to ‘know your epidemic’ and respond accordingly. It is hoped that these efforts will be supplemented by endeavours to ‘know your children’ – and that in knowing children and young people better and how AIDS affects them, and by understanding the implications of evidence and best practices for their care, the second and third generations of children affected by AIDS will not lead to a fourth. REFERENCES Health Organization, Towards Universal Access: Scaling up priority HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 21. 9 US President’s Emergency Plan for AIDS Relief, The Power of Partnerships: The U.S. President’s Emergency Plan for AIDS Relief – 2008 Annual Report to Congress, PEPFAR, Washington, D.C., p. 41; and Global Fund to Fight AIDS, Tuberculosis and Malaria, ‘Global Fund ARV Fact Sheet’, Global Fund, Geneva, 1 December 2007, <www.theglobalfund.org/en/ files/publications/factsheets/aids/ARV_Factsheet_2007.pdf>, accessed 18 September 2008. 10 World Health Organization and Joint United Nations Programme on HIV/ AIDS, Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities, WHO, Geneva, 2007, pp. 20, 23. 11 National data provided by UNICEF Botswana, September 2008. 12 Treatment and Research AIDS Center (Centre de Traitment et de Recherche sur le SIDA), Rapport Annuel du TRAC 2007, TRAC, Kigali, March 2008, p. ii. 13 World Health Organization, Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Towards Universal access – Recommendations for a public health approach, 2006 version, WHO, Geneva, 2006, p. 14. 1 2 3 Some of the data and evidence in this report were recently published in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008, issued by UNICEF, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization in June 2008, and the 2008 Report on the Global AIDS Epidemic, issued by UNAIDS in July 2008. Additional evidence is based on UNICEF analysis of household survey data and reporting by UNICEF regional and country offices in 2008. Violari, Avy, et al., ‘Children with HIV Early Antiretroviral Therapy (CHER) Study’, presentation at the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 22–25 July 2007. Newell, Marie-Louise, et al., ‘Mortality of Infected and Uninfected Infants Born to HIV-infected Mothers in Africa: A pooled analysis’, The Lancet, vol. 364, no. 9441, 2–8 October 2004, pp. 1236– 1243. 4 Lowicki-Zucca, M., et al., ‘Estimates of HIV Burden in Emergencies’, Sexually Transmitted Infections, no. 84, supplement 1, 2008, pp. i42–i48. 5 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World Health Organization, Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 19. 6 Ibid., p. 15. 7 UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, pp. 18, 40. 8 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World 14 Mermin, Jonathan, et al., ‘Mortality in HIV-Infected Ugandan Adults Receiving Antiretroviral Treatment and Survival of their HIV-uninfected Children: A prospective cohort study’, The Lancet, vol. 371, no. 9614, 1–7 March 2008, pp. 752–759. 15 Nielsen-Saines, Karin, et al., ‘Primary HIV-1 Infection during Pregnancy: High rate of HIV-1 MTCT in a cohort of patients in southern Brazil’, Retrovirology, vol. 5, supplement 1 (transcript of oral presentation), 9 April 2008; and Dunn, D. T., et al., ‘Risk of Human Immunodeficiency Virus Type 1 Transmission through Breastfeeding’, The Lancet, vol. 340, no. 8819, 5 September 1992, pp. 585–588. 16 Jackson, J. Brooks, ‘Intrapartum and Neonatal Single-Dose Nevirapine Compared with Zidovudine for Prevention of Mother-to-Child Transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial’, The Lancet, vol. 362, no. 9387, 13 September 2003, pp. 859–868. 17 Palombi, L., et al., ‘Treatment Acceleration and the Experience of the DREAM Program in Prevention of Mother-to-Child Transmission of HIV’, AIDS, vol. 21, supplement 4, July 2007, pp. 565–571. 18 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World Health Organization, Towards Universal Access: Scaling up priority HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 23. 19 Kamoto, L., et al., ‘Increasing Access to Anti-Retroviral Therapy for Eligible Pregnant Women through Strategic Use of CD4 Testing’, Abstract submitted for the 2008 HIV/AIDS Implementers’ Meeting, Kampala, Uganda, 3–7 June 2008, collected as no. 1812, p. 151. 20 National data provided by UNICEF Rwanda, September 2008. 21 Ciantia, Filippo, ‘Treating, Preventing and Caring: Three approaches to addressing HIV and AIDS’, AVSI Foundation, presentation at United Nations, 11 June 2008. 22 Sweat, Michael D., et al., ‘Cost-effectiveness of Nevirapine to Prevent Mother-to-Child HIV Transmission in Eight African Countries’, AIDS, vol. 18, no. 12, 20 August 2004, pp. 1661–1671. 23 Kirby, Douglas, et al., Sex and HIV Education Programs for Youth: Their impact and important characteristics, Family Health International, Research Triangle Park (USA), 2006. 24 Mbori-Ngacha, D., et al., ‘Morbidity and Mortality in Breastfed and Formula-fed Infants of HIV-1-infected Women: A randomized clinical trial’, JAMA, vol. 286, no. 19, 21 November 2001, pp. 2413–2420. UNITE FOR CHILDREN UNITE AGAINST AIDS 29 25 Kuhn, Louise, et al., ‘High Uptake of Exclusive Breastfeeding and Reduced Early Post-natal HIV Transmission’, PLoS ONE, vol. 2, no. 12, December 2007, pp. 1365–1371. 26 David, Sandra, et al., ‘Promotion of WHO Feeding Recommendations: A model evaluating the effects on HIV-free survival in African Children’, Journal of Human Lactation, vol. 24, no. 2, May 2008, pp. 140–149; Coovadia, Hoosen M., et al., ‘Motherto-Child Transmission of HIV-1 Infection during Exclusive Breastfeeding in the First 6 Months of Life: An intervention cohort study’, The Lancet, vol. 369, no. 9567, 31 March 2007, pp. 1107–1116. 27 Bradley, S. E. K., V. Mishra and M. Kothari, ‘Evaluation of Sub-Saharan African Women’s Breastfeeding Practices by HIV Status: New information from demographic and health surveys’, poster presentation, XVII International AIDS Conference, Mexico City, 2008. 28 United Nations Children’s Fund, World Health Organization and Medical Research Council, ‘Rapid Assessment of HIV and Infant Feeding in Kenya, Malawi and Zambia’, UNICEF Eastern and Southern Africa Regional Office, Nairobi, 2007, p. v. 29 National data provided by UNICEF Ukraine, October 2008. 30 National data provided by UNICEF Brazil, August 2008. 31 Nyankesha, Elévanie, ‘Scaling up PMTCT Programmes: Phasing more efficacious ARV regimens for PMTCT in resource limited settings – Lessons learned from Rwanda’, TRAC Plus/Center for Infectious Disease Control, Presentation at the XVII International AIDS Conference, Mexico City, 3–8 August 2008. 32 Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p. 33. 33 Violari, Avy, et al., ‘Children with HIV Early Antiretroviral Therapy (CHER) Study’, presentation at the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Sydney, 22–25 July 2007. 34 Patel, K., et al., ‘Long-Term Effects of Highly Active Antiretroviral Therapy on CD4+ Cell Evolution Among Children and Adolescents Infected with HIV: 5 years and counting’, Clinical Infectious Diseases, vol. 46, no. 11, 1 June 2008, pp. 1751–1760. 35 World Health Organization, ‘Report of the WHO Technical Reference Group’, Paediatric HIV/ ART Care Guideline Group Meeting, WHO Headquarters, Geneva, 10–11 April 2008, p. 4. 36 See, for example: Janssens, Bart, et al., ‘Effectiveness of Highly Active Antiretroviral Therapy in HIV-positive Children: Evaluation at 12 months in a routine program in Cambodia’, Pediatrics, vol. 120, no. 5, pp. e1134–e1140; and Reddi, Anand, et al., ‘Preliminary Outcomes of a Paediatric Highly Active Antiretroviral Therapy Cohort from KwaZulu-Natal, South Africa’, BMC Pediatrics, vol. 7, no. 13, 17 March 2007. 30 UNITE FOR CHILDREN UNITE AGAINST AIDS 37 Newell, M. et al., ‘Mortality of Infected and Uninfected Infants Born to HIV-Infected Mothers in Africa: A pooled analysis’, The Lancet, vol. 364, no. 9441, 2 October 2004, pp. 1236–1243. 38 Patel, K., et al., ‘Recovery of Immune Status with HAART is Dependent on CD4% at Time HAART is Initiated’, Clinical Infectious Diseases, 2008 (in press). 39 Arrivé, Elise, et al., ‘Response to Anti-Retroviral Therapy (ART) in Children in Sub-Saharan Africa: A pooled analysis of clinical databases – The KIDS-ART-LINC Collaboration’, poster abstract presented at the 14th Conference on Retroviruses and Opportunistic Infections, Los Angeles, 25–28 February 2007. 40 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World Health Organization, Towards Universal Access: Scaling up priority HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 24. 41 National data provided by UNICEF Zambia, August 2008. 42 Preliminary and summary reports on Child Health Days in Lesotho provided by UNICEF Eastern and Southern Africa Regional Office, February 2008 (internal documents). 43 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World Health Organization, Towards Universal Access: Scaling up priority HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 25. 44 Clinton Foundation HIV/AIDS Initiative data provided to UNICEF, August 2008. 45 HIV Unit, Department of Clinical Services, Ministry of Health; National TB Control Programme; Lighthouse Trust, Lilongwe; and Centers for Disease Control and Prevention, Malawi, ‘Report of a Country-wide Survey of HIV/AIDS Services in Malawi for the Year 2006’, HIV Unit, Department of Clinical Services, Ministry of Health, Lilongwe, July 2007, p. 20. 46 United Nations Children’s Fund, Joint United Nations Programme on HIV/AIDS and the World Health Organization, Towards Universal Access: Scaling up priority HIV services for women and children in the health sector – Progress Report 2008, UNICEF, New York, 2008, p. 26. 47 HIVQUAL International data provided to UNICEF, September 2008. 48 World Health Organization and United Nations Children’s Fund, More Positive Living: Strengthening the health sector response to young people living with HIV, WHO, Geneva, 2008. 49 Greifinger, Rena, and Bruce Dick, ‘Qualitative Review of Psychosocial Interventions for Young People Living with HIV’ (draft), Abstract presented at the XVII International AIDS Conference, Mexico City, 3–8 August 2008. 50 Nachega, Jean, et al., ‘Virologic Outcomes and ART Adherence in Adolescents Compared with Adults in Southern Africa’, Poster Abstract 821, 15th Conference on Retroviruses and Opportunistic Infections, Boston, 3–6 February 2008, <www.retroconference.org/2008/ Abstracts/32415.htm>, accessed 21 October 2008. 51 Birungi, Harriet, et al., ‘Sexual and Reproductive Health Needs of Adolescents Perinatally Infected with HIV in Uganda’, Frontiers in Reproductive Health, Population Council, Washington, D.C., July 2008. 52 Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p. 35. The seven countries are Botswana and Kenya (with declines occurring in both urban and rural areas), and Benin, Burkina Faso, Côte d’Ivoire, Malawi and Zimbabwe (with declines significant in urban areas only). 53 Ibid., pp. 33, 36. 54 UNICEF global databases, 2008. 55 Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p. 107. 56 United Nations Joint Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, pp. 229, 230, 232. 57 Joint United Nations Programme on HIV/AIDS and Reproductive Health & HIV Research Unit, University of the Witwatersrand, ‘Stopping the HIV Epidemic: Women, girls and HIV in Southern Africa – What must be done!’ (draft), Report for the Technical Meeting on Young Women in HIV Hyper-Endemic Countries of Sub-Saharan Africa, Muldersdrift, 18–19 June 2008, pp. 7–8. 58 National AIDS Council, Zimbabwe National Behaviour Change Strategy for Prevention of Sexual Transmission of HIV 2006–2010, National AIDS Council, Harare, 2005, p. 8. 59 UNICEF Somalia, ‘Annual Report 2007’ (internal document). 60 UNICEF Egypt, ‘Behavioral Survey among Street Children in Greater Cairo and Alexandria: Executive Summary’ (internal document). 61 Analysis based on data in United Nations Children’s Fund, Report on Results: Biological and behavioural survey among injecting drug users – Bosnia and Herzegovina, 2007, UNICEF, 2007, p. 45. 62 UNICEF and AIDS Foundation East-West, ‘Children and Young People Living or Working on the Streets: The missing face of the HIV epidemic in Ukraine’, UNICEF and AFEW, Kiev, 2006, p. 102; and UNICEF Ukraine, ‘A Review of the Evidence on HIV/AIDS and Most-at-Risk Adolescents and Young People in Ukraine’ (internal working document), April 2008. 63 Inter-Agency Task Team on HIV and Young People, ‘HIV Interventions for Young People in the Health Sector’ and ‘HIV Interventions for Most-at-Risk Young People’, Guidance Briefs, forthcoming in 2008. 70 Gulaid, Laurie A., for the Inter-Agency Task Team Working Group on National Plans of Action, ‘National Responses for Children Affected by AIDS: Review of progress and lessons learned’ (final draft), 8 May 2008, p. 10. 71 Ibid., pp. 11, 14–16. 72 Ibid., p. 10. 73 Ministry of Public Service, Labour and Welfare of Zimbabwe, National AIDS Council and United Nations Children’s Fund, A Partnership Making a Difference: Zimbabwe’s programme of support to the National Plan of Action for Orphans and Other Vulnerable Children, Harare, April 2008, pp. 13, 29. 74 Taylor, Nigel, ‘The Role of International Donors in Supporting Community Responses in Countries Severely Affected by HIV and AIDS’ (version 3, draft 1), Inter-Agency Task Team on Children and HIV/AIDS Working Group on Strengthening the Community Response, 12 May 2008, p. 8. 75 Paris Declaration on Aid Effectiveness, endorsed 2 March 2005, outcome document of the High Level Forum on Joint Progress Toward Enhanced Effectiveness, available at <www.oecd.org/document/18/0,3343,en_2649_ 3236398_35401554_1_1_1_1,00.html>, accessed 21 October 2008. 76 United Nations Children’s Fund and Futures Institute, ‘Identifying Measures of Vulnerability for Children Less than 18 Years Old’ (draft), 12 August 2008, p. 5. 77 Campbell, Penelope, et al., ‘A Situation Analysis of Orphans in 11 Eastern and Southern African Countries’ (prelimimary draft), January 2008. 78 Ministry of Public Service, Labour and Welfare of Zimbabwe, National AIDS Council and United Nations Children’s Fund, A Partnership Making a Difference: Zimbabwe’s programme of support to the National Plan of Action for Orphans and Other Vulnerable Children, Harare, April 2008, p. 7. 79 Devereux, Stephen, and Rachel Sabates-Wheeler, ‘Transformative Social Protection’, IDS Working Paper 232, Institute of Development Studies, Brighton, 2004, p. 9. 80 Inter-Agency Task Team on Children and HIV and AIDS Working Group on Social Protection, ‘Expanding Social Protection for Vulnerable Children and Families: Learning from an institutional perspective’ (working paper), March 2008, p. 11. 64 UNICEF Ghana, ‘2007 Annual Report’ (internal document). 81 Church Alliance for Orphans, CAFO Annual Report: October 2007–June 2008, CAFO, Katutura, Namibia, p. 17. 65 Galárraga, Omar, et al., Educación sexual para la prevención del VIH en Latinoamérica y el Caribe: diagnóstico regional, Instituto Nacional de Salud Pública, Mexico, July 2008. 82 Plank, David, ‘School Fees and Education for All: Is abolition the answer?’ (working paper), EQUIP2 (Academy for Educational Development) and United States Agency for International Development, Washington, D.C., 2007. 66 Schmid, George P., and Bruce Dick, ‘Adolescent Boys: Who cares?’ Bulletin of the World Health Organization, September 2008, vol. 86, no. 9, p. 659. 83 Thirumurthy H., J. F. Zivin and M. Goldstein, ‘AIDS Treatment and Intrahousehold Resource Allocations: Children’s nutrition and school in Kenya’, Working Paper No. 105, Center for Global Development, Washington, D.C., 2007. 67 UNICEF Eastern and Southern Africa Regional Office, ‘Summary Report: Regional MC Consultation with Youth Organizations in ESARO, Johannesburg, 3–5 September 2008’ (internal document). 84 United Nations Children’s Fund, ‘Report on Progress in the National Response to Orphans and Other Vulnerable Children in Sub-Saharan Africa: The OVC Policy and Planning Effort Index (OPPEI) Survey, 2007’, UNICEF, New York, 2007, p. iii. 68 Joint United Nations Programme on HIV/AIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p. 218. 69 United Nations Children’s Fund and Futures Institute, ‘Identifying Measures of Vulnerability for Children Less than 18 Years Old’ (draft), 12 August 2008, p. 8. 85 United Nations Children’s Fund, ‘Progress Report for Children Affected by HIV/AIDS’ (draft), UNICEF, New York, June 2008. 86 Monitoring and Evaluation Working Group of the Inter-Agency Task Team on Children and HIV and AIDS, ‘Guidance Document for the Development and Operationalization of a Monitoring and Evaluation System for the National Response for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS’, September 2008 (draft). UNITE FOR CHILDREN UNITE AGAINST AIDS 31 ANNEX NOTES ON THE DATA The PMTCT and Paediatric HIV Care and Treatment Report Card collects data for a 12-month period, January–December. For 2007, however, a few countries did not report on the entire 12-month period, so UNICEF, WHO and UNAIDS used these countries’ available partial data to project coverage for the entire year, January–December 2007. Details about the specific countries are available in Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. This report uses the actual service coverage numbers as reported by most countries for the 12-month period of January– December 2007. ESTIMATES ON HIV CARE AND TREATMENT NEEDS OF PREGNANT WOMEN AND CHILDREN DATA SOURCES AND COMPILATION The data and analyses presented in this Third Stocktaking Report are derived from information in UNICEF’s global databases and compiled from various sources, including nationally representative data collected from household surveys, e.g., Demographic and Health Surveys, Multiple Indicator Cluster Surveys and Reproductive Health Surveys; national programme service statistics collected annually by UNICEF and WHO through a standard PMTCT and paediatric HIV care and treatment questionnaire, on behalf of the Inter-Agency Task Team on Prevention of HIV Infection in Pregnant Women, Mothers and their Children; country estimates of HIV care and treatment needs modelled by UNAIDS and WHO; and the United Nations Population Division country estimates of the number of annual births. Detailed information about the household surveys is available at <www.measuredhs.com> and <www.childinfo.org>, and technical descriptions of the epidemiological methodology used to estimate HIV care and treatment needs are available at <www.unaids.org>. These data allow for a comprehensive assessment of progress being made towards the international goals of universal access to HIV prevention, care, treatment and support for children and women. 32 UNITE FOR CHILDREN UNITE AGAINST AIDS In August 2008, UNAIDS and WHO released new global estimates for 2007 of the numbers of people living with HIV, new infections and AIDS deaths. UNAIDS in 2007 refined the HIV and AIDS estimation methodology to reflect more reliable data available from population-based surveys and expanded national sentinel surveillance systems in a number of countries. As a result, UNAIDS has retrospectively generated new estimates for the past years based on the refined methodology. To achieve consistency and establish a comparative measurement of progress, trend analyses must be recalculated using only the newly generated estimates. Similarly, global estimates of the number of women needing PMTCT services have been refined, and the coverage rates reported for 2004, 2005 and 2006 have thus been recalculated using the newly generated estimates. Estimates on the HIV care and treatment needs of children under 15 years old were not available at the time of publication. As a result, only the actual numbers of children reported to be receiving specific HIV-related interventions are presented in this report. Overall, new estimates by UNAIDS and WHO of PMTCT coverage, the number of children living with HIV and the number of children orphaned by AIDS for 2007 are lower than estimates published in previous reports; the differences between these newly generated estimates and previously published estimates are not related to trends over time, and therefore the new and previous estimates are not comparable. Nor are other revised estimates comparable to estimates published in previous years. For example, it is incorrect to conclude that the estimated number of children living with HIV has decreased from 2.3 million in 2006 to 2.0 million in 2007 given that these estimates are not derived from trends over time but from more refined epidemiological modelling procedures. Trends over time may be assessed, however, using UNAIDS methodological revisions applied retrospectively to earlier HIV prevalence data. More details on the HIV estimates methodology can be found at <www.unaids.org>. GOAL 1. Preventing mother-to-child transmission of HIV in low- and middle-income countries Afghanistan Albania Algeria Angola Antigua and Barbuda Argentina Armenia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Democratic People's Republic of Korea Democratic Republic of the Congo Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Estimated adult HIV prevalence rate (%) (15–49 years), 2007 – – 0.1 2.1 – 0.5 0.1 0.2 3.0 – – 1.2 0.2 2.1 1.2 0.1 0.2 <0.1 23.9 0.6 – – 1.6 2.0 0.8 5.1 – 6.3 3.5 0.3 0.1 0.6 <0.1 3.5 – 0.4 3.9 <0.1 0.1 – – 3.1 – 1.1 0.3 – 0.8 3.4 1.3 2.1 0.1 5.9 0.9 0.1 1.9 – 0.8 1.6 1.8 2.5 2.2 0.7 0.3 0.2 Antenatal care coverage (%), 2000–2007* 16 97 89 80 100 99 93 77 98 – 51 100 99 94 84 88 79 99 97 97 – – 85 92 69 82 98 69 39 – 90 94 75 86 – 92 85 – 100 – 85 92 100 99 84 70 86 86 70 28 – 94 98 94 92 100 84 82 78 81 85 92 74 93 Annual number of births, 2007 (thousands) 1,314 52 704 810 0 693 37 134 6 13 3,998 3 91 7 365 12 263 34 47 3,706 8 68 654 399 382 649 15 158 492 250 17,374 876 28 133 0 80 687 41 118 317 3,118 24 0 231 283 1,840 158 20 191 3,201 18 34 60 48 703 2 449 377 84 13 270 200 27,119 4,386 Estimated number of HIV-infected pregnant women, 2007 Estimate – – <500 18,000 – 1,700 <100 <100 – – <500 – <100 <200 4,500 – <200 – 11,000 8,600 – – 8,300 7,800 1,600 34,000 – 11,000 18,000 <500 6,800 2,500 <100 4,400 – <200 28,000 – <100 – 38,000 820 – 1,600 <500 <200 650 710 2,500 66,000 <100 2,300 510 <100 14,000 – 5,300 6,200 1,500 <500 5,100 650 64,000 3,300 Low estimate – – <200 13,000 – 1,200 <100 <100 – – <200 – <100 <100 3,900 – <200 – 10,000 5,600 – – 6,800 5,100 1,200 22,000 – 9,800 10,000 <500 4,300 1,600 <100 3,400 – <100 21,000 – <100 – 33,000 610 – 1,200 <500 <200 <500 530 1,600 58,000 <100 1,600 <500 <100 12,000 – 3,200 5,000 1,000 <200 4,200 <500 37,000 2,100 High estimate – – 660 22,000 – 2,400 <100 <200 – – <500 – <200 <500 5,300 – <500 – 12,000 13,000 – – 10,000 10,000 2,000 42,000 – 12,000 22,000 500 11,000 3,700 <100 5,400 – <500 34,000 – <200 – 46,000 1,000 – 2,200 800 <500 1,100 950 4,000 74,000 <100 3,500 800 <100 16,000 – 8,100 8,600 2,100 <500 6,100 1,200 92,000 5,300 Reported number of HIV-infected pregnant women who received ARVs for PMTCT, 2007# 0 – 19 1,645 – 2,193 6 6 77 b – 5a – 127 55 1,830 – 34 0 12,419 6,188 – 1 1,480 1,102 505 7,516 b 51 3,714 b 254 a 117 593 c 144 0 240 – 21 a 3,240 b 2 41 – 3,435 52 a 1 795 268 5 130 103 a 168 b 4,888 7 494 133 b 22 2,896 7 373 679 b 349 144 a 1,107 220 8,816 89 UNITE FOR CHILDREN Estimated percentage of HIVinfected pregnant women who received ARVs for PMTCT, 2007** Estimate – – – 9 – – – – – – – – – – 40 – – – >95 – – – 18 14 – 22 – 34 1 – – – – 5 – – 12 – – – 9 6 – – – – – 14 7 7 – 21 – – 21 – – 11 24 – 22 – – – Low estimate – – 3 7 – 93 19 4 – – 1 – 90 24 35 – 13 – >95 49 – – 15 11 25 18 – 30 1 23 6 4 0 4 – 9 9 – 37 – 8 5 – 36 34 2 12 11 4 6 82 14 17 41 18 – 5 8 17 29 18 19 10 2 High estimate – – 12 13 – >95 45 17 – – 4 – >95 64 47 – 24 – >95 >95 – – 22 22 41 34 – 38 2 45 14 9 0 7 – 25 16 – >95 – 10 9 – 65 >95 4 32 20 11 8 >95 32 58 >95 24 – 12 14 34 >95 26 79 24 4 UNITE AGAINST AIDS 33 GOAL 1. Preventing mother-to-child transmission of HIV in low- and middle-income countries Iran (Islamic Republic of) Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Moldova, Republic of Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Qatar Republic of Korea Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Solomon Islands Somalia 34 UNITE FOR CHILDREN Estimated adult HIV prevalence rate (%) (15–49 years), 2007 0.2 – 1.6 – 0.1 – – – 0.1 0.2 0.1 23.2 1.7 – 0.1 11.9 0.5 – 1.5 – 0.8 1.7 0.3 – 0.4 0.1 – 0.1 12.5 0.7 15.3 – 0.5 0.2 0.8 3.1 – – – 0.1 – 1.0 1.5 0.6 0.5 – – <0.1 0.1 1.1 2.8 – – – – – – 1.0 0.1 – 1.7 0.2 – 0.5 Antenatal care coverage (%), 2000–2007* – 84 91 99 100 88 – – 97 27 96 90 85 – 80 92 79 81 70 – 64 – – – 98 99 97 68 85 76 95 – 44 90 46 58 – 99 100 61 – – – 94 91 88 – – 94 – 94 100 99 95 – 97 – 87 98 – 81 – – 26 UNITE AGAINST AIDS Annual number of births, 2007 (thousands) 1,441 935 55 154 297 1,479 0 51 115 157 74 59 189 145 722 573 555 7 595 0 102 19 2,088 3 43 49 8 641 855 891 53 0 796 140 701 5,959 0 145 58 4,446 0 70 190 153 584 2,295 14 448 211 1,515 435 1 3 2 5 5 618 439 127 3 268 37 15 377 Estimated number of HIV-infected pregnant women, 2007 Estimate 1,300 – <500 – <200 76,000 – – <100 <200 <100 12,000 3,100 – <500 73,000 1,300 <100 8,600 – <500 <200 3,100 – <100 <100 – <500 97,000 4,500 9,400 – 1,500 <200 3,300 190,000 – – – 2,300 – <500 1,900 <500 1,300 <200 – – <500 7,300 11,000 – – – – – – 4,400 <100 – 4,400 – – 940 Low estimate 940 – <500 – <100 66,000 – – <100 <100 <100 11,000 2,400 – <500 64,000 770 <100 6,800 – <500 <100 2,000 – <100 <100 – <500 81,000 2,900 7,600 – 990 <100 2,100 130,000 – – – 1,500 – <500 1,800 <500 890 <200 – – <200 4,500 9,100 – – – – – – 3,000 <100 – 3,100 – – 510 High estimate 1,800 – 640 – <500 86,000 – – <200 <500 <100 14,000 3,900 – 760 82,000 2,000 <100 11,000 – 770 <500 4,900 – <200 <100 – 550 120,000 7,100 11,000 – 2,300 <500 5,000 240,000 – – – 3,700 – 510 2,100 830 1,800 <500 – – <500 11,000 13,000 – – – – – – 6,300 <200 – 6,200 – – 1,700 Reported number of HIV-infected pregnant women who received ARVs for PMTCT, 2007# 22 – 292 b 2 126 52,858 b – – 3 24 – 3,966 224 – 25 23,158 183 – 1,018 – 45 19 146 a – 73 0 1 42 44,975 1,280 b 6,022 a – 36 43 1,006 b 12,278 – – – 5 – 71 b 84 141 b 502 1 – – 68 6,419 6,485 b – 11 – – 22 – 264 2a – 919 – – 11 Estimated percentage of HIVinfected pregnant women who received ARVs for PMTCT, 2007** Estimate – – – – – 69 – – – – – 32 7 – – 32 – – – – – – – – – – – – 46 – 64 – – – – 7 – – – – – – 4 – – – – – – – 60 – – – – – – – – – 21 – – – Low estimate 1 – 45 – 30 61 – – 2 9 – 29 6 – 3 28 9 – 10 – 6 6 3 – 51 0 – 8 39 18 53 – 2 15 20 5 – – – <1 – 14 3 17 28 <1 – – 22 59 51 – – – – – – 4 2 – 15 – – <1 High estimate 2 – >95 – >95 80 – – 8 36 – 36 9 – 9 36 24 – 15 – 20 23 7 – >95 0 – 18 56 43 80 – 4 44 47 10 – – – <1 – 29 5 57 56 <1 – – 42 >95 71 – – – – – – 9 5 – 29 – – 2 GOAL 1. Preventing mother-to-child transmission of HIV in low- and middle-income countries South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe SUMMARY INDICATORS Sub-Saharan Africa Eastern and Southern Africa West and Central Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS Low- and middle-income countries Developing countries World DEFINITIONS OF THE INDICATORS Estimated adult HIV prevalence rate: Percentage of adults (15–49 years old) living with HIV as of 2007. Antenatal care coverage: Percentage of women (15–49 years old) attended at least once during pregnancy by skilled health personnel (doctors, nurses or midwives). Annual number of births: Estimated number of live births in 2007. Estimated number of HIV-infected pregnant women: Estimated number of pregnant women living with HIV as of 2007. Reported number of HIV-infected pregnant women who received ARVs for PMTCT: Number of women testing HIV-positive during visits to antenatal clinics who were provided with antiretroviral therapy (ARVs) to prevent mother-to-child transmission. Estimated percentage of HIV-infected pregnant women who received ARVs for PMTCT: Calculated by dividing the reported number of HIV-infected pregnant women who received ARVs for PMTCT by the estimated unrounded number of HIV-infected pregnant women in 2007. The point estimates and ranges are given for countries with a generalized epidemic, whereas only ranges are given for countries with a low or concentrated epidemic. Ranges in coverage estimates are based on plausibility (uncertainty) bounds in the denominator, i.e., low and high estimated number of HIV-infected pregnant women. Estimated adult HIV prevalence rate (%) (15–49 years), 2007 18.1 – 1.4 2.4 26.1 – 0.3 1.4 <0.1 – 3.3 – 1.5 0.1 – <0.1 – 5.4 1.6 – 6.2 0.6 0.1 – – 0.5 – 15.2 15.3 5.0 7.8 2.6 0.3 0.3 0.2 0.6 0.8 – 0.9 † † † † † † † † Antenatal care coverage (%), 2000–2007* 92 99 60 90 85 84 77 98 94 61 84 – 96 92 81 99 – 94 99 – 78 – 99 – 94 91 41 93 94 Annual number of births, 2007 (thousands) 1,092 292 1,230 9 33 535 186 932 22 48 245 3 20 173 1,381 109 0 1,445 419 71 1,600 51 623 7 597 1,653 860 473 373 † 72 † 72 † 71 † 72 † 68 † 89 † 94 † 90 † – 77 † 30,323 † 14,268 † 16,056 † 9,726 † 37,986 † 29,773 † 11,381 † 5,560 † – 122,266 † 0.8 † 77 † 135,770 † MAIN DATA SOURCES Estimated adult HIV prevalence rate: UNAIDS, 2008 Report on the Global AIDS Epidemic. Antenatal care coverage: UNICEF, The State of the World’s Children 2009. Annual number of births: UNICEF, The State of the World’s Children 2009. Estimated number of HIV-infected pregnant women: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Reported number of HIV-infected pregnant women who received ARVs for PMTCT: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Estimated percentage of HIV-infected pregnant women who received ARVs for PMTCT: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Low estimate 180,000 <100 12,000 <100 12,000 – <100 6,400 – – 6,300 – – <100 – – – 68,000 3,800 – 91,000 <100 <200 – 1,300 2,400 – 68,000 48,000 High estimate 260,000 <100 26,000 <200 15,000 – <500 15,000 – – 10,000 – – <100 – – – 92,000 6,700 – 110,000 <500 840 – 4,600 6,400 – 86,000 57,000 Reported number of HIV-infected pregnant women who received ARVs for PMTCT, 2007# 127,164 b 1a 9d 35 a 8,772 0 9 9,352 – 2 705 – – 1 4a 0a – 26,484 3,046 – 31,863 53 a 95 – 310 a 744 2 35,314 15,381 1,300,000 1,200,000 930,000 860,000 390,000 320,000 21,000 15,000 69,000 40,000 34,000 27,000 36,000 30,000 14,000 10,000 1,500,000 1,400,000 – – 1,400,000 1,000,000 450,000 29,000 97,000 44,000 45,000 18,000 1,600,000 – 446,000 403,000 43,000 <200 8,900 13,000 13,000 10,000 491,000 – 34 43 11 1 13 38 36 71 33 – 32 40 10 <1 9 30 29 56 31 – 37 47 13 – 22 48 43 >95 35 – – – – – – Estimated number of HIV-infected pregnant women, 2007 Estimate 220,000 <100 18,000 <200 13,000 – <200 10,000 – – 8,000 – – <100 – – – 78,000 5,200 – 100,000 <200 <500 – 2,300 3,900 – 76,000 52,000 – – NOTES – Data not available. * Data refer to the most recent year available during the period specified in the column heading. ** United Nations General Assembly Special Session on HIV/AIDS (2001) indicator. # Most countries have reported data for a full 12-month period in 2006 or 2007 (see note b). Fifteen countries reported data for 2006; these data reflect a 12-month period and the values are therefore not projected. a Reporting period is from Jan.–Dec. 2006. b Data were reported for a period of less than 12 months in 2007; values are projected to a 12-month period, based on the monthly value. Following are countries for which the numbers of HIV-infected pregnant women who received ARVs for PMTCT are projected, with months reported and reported values: Bahamas, Jan.–Sept. 2007: 58; Cameroon, Jan.–Oct. 2007: 6,263; Central African Republic, Jan.–June 2007: 1,857; Côte d’Ivoire, Jan.–July 2007: 1,890; Eritrea, Jan.–Oct. 2007: 140; Gambia, Jan.–Sept. 2007: 100; Guinea, Jan.–Sept. 2007: 509; Jamaica, Jan.–June 2007: 146; Kenya, Jan.– June 2007: 26,429; Myanmar, Jan.–Oct. 07: 1,067; Niger, Jan.–June 2007: 503; Panama: Jan.–Sept. 2007: 53; Paraguay, Jan.–Nov. 2007: 129; Rwanda, Jan.–Nov. 2007: 5,945; South Africa, Jan.–Sept. 2007: 95,373. Estimated percentage of HIVinfected pregnant women who received ARVs for PMTCT, 2007** Estimate 57 – <1 – 67 – – – – – 9 – – – – – – 34 – – 32 – – – – – – 47 29 Low estimate 49 1 <1 18 60 – 2 62 – – 7 – – 1 – – – 29 45 – 29 20 11 – 7 12 – 41 27 High estimate 69 3 <1 57 74 – 11 >95 – – 11 – – 3 – – – 39 79 – 35 76 68 – 24 31 – 52 32 c From 271 programme counties, Jan.–Sept. 2007. d Northern Sudan reported 3 for the period Aug.–Dec. 2007 and Southern Sudan reported 6 for the period Jan.–Dec. 2007, giving a total of 9. † Regional averages are calculated for only the population representing 50 per cent or more of the region’s total population of interest. UNITE FOR CHILDREN UNITE AGAINST AIDS 35 GOAL 2. Providing paediatric treatment in low- and middle-income countries* Estimated number of children (0–14 years old) living with HIV, 2007 Afghanistan Albania Algeria Angola Antigua and Barbuda Argentina Armenia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d’Ivoire Croatia Cuba Democratic People’s Republic of Korea Democratic Republic of the Congo Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia Iran (Islamic Republic of) Iraq 36 UNITE FOR CHILDREN Estimated number of HIV-infected pregnant women, 2007 Estimate Low estimate High estimate Estimate Low estimate High estimate – – – 17,000 – – – – – – – – – <200 5,400 – – – 15,000 – – – 10,000 15,000 4,400 45,000 – 14,000 19,000 – – – – 6,600 – – 52,000 – – – – 1,100 – 2,700 – – – <1,000 3,100 92,000 – 2,300 – – 17,000 – – 6,300 1,500 – 6,800 1,600 – – – – – – – 12,000 – – – – – – – <100 – – 4,700 – – – 13,000 – – – 8,400 12,000 4,000 38,000 – 12,000 14,000 – – – <100 5,600 – – 44,000 – – – 37,000 <1,000 – 2,200 – – – – 2,300 80,000 – 1,600 – – 15,000 – – 5,000 1,100 – 5,800 1,000 – – – – – – – 35,000 – – – – <200 – – – – <500 6,300 – – – 16,000 – – – 12,000 19,000 5,000 51,000 – 16,000 27,000 – – – – 7,700 – – 58,000 – – – 52,000 1,400 – 3,300 – – – 1,100 4,400 100,000 – 3,200 <1,000 – 19,000 – – 7,900 2,200 <1,000 8,100 3,000 – – – – – – <500 18,000 – 1,700 <100 <100 – – <500 – <100 <200 4,500 – <200 – 11,000 8,600 – – 8,300 7,800 1,600 34,000 – 11,000 18,000 <500 6,800 2,500 <100 4,400 – <200 28,000 – <100 – 38,000 820 – 1,600 <500 <200 650 710 2,500 66,000 <100 2,300 510 <100 14,000 – 5,300 6,200 1,500 <500 5,100 650 64,000 3,300 1,300 – – – <200 13,000 – 1,200 <100 <100 – – <200 – <100 <100 3,900 – <200 – 10,000 5,600 – – 6,800 5,100 1,200 22,000 – 9,800 10,000 <500 4,300 1,600 <100 3,400 – <100 21,000 – <100 – 33,000 610 – 1,200 <500 <200 <500 530 1,600 58,000 <100 1,600 <500 <100 12,000 – 3,200 5,000 1,000 <200 4,200 <500 37,000 2,100 940 – – – 660 22,000 – 2,400 <100 <200 – – <500 – <200 <500 5,300 – <500 – 12,000 13,000 – – 10,000 10,000 2,000 42,000 – 12,000 22,000 500 11,000 3,700 <100 5,400 – <500 34,000 – <200 – 46,000 1,000 – 2,200 800 <500 1,100 950 4,000 74,000 <100 3,500 800 <100 16,000 – 8,100 8,600 2,100 <500 6,100 1,200 92,000 5,300 1,800 – UNITE AGAINST AIDS Number of infants born to HIVinfected pregnant women started on cotrimoxazole prophylaxis, 2007 % of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis, 2007 0a – – – – – 0 2 – – 5a – 136 9 984 0a – 0 9,489 – – – – 814 a 203 1,030 31 a 443 a 63 a – 650 a – 0a 462 – 40 a – – 1 – 170 a 52 a 2a – – 2 111 – 150 k 388 a 2a 58 c – 21 – – 171 e 334 e 0 90 a – – 1,200 a 25 13 f – – – – – – – 0 3 – – 2 – >95 6 22 – – – 83 – – – – 10 13 3 – 4 0 – 10 – 0 10 – 28 – – 2 – 0 6 – – – 1 17 – 6 1 25 2 – 91 – – 3 5 0 27 – – 2 1 1 – Number of children (0–14 years old) receiving ART, 2007** 0 12 45 363 – 3,654 4 0 – – 1a – 69 65 542 0 22 1 9,496 6,815 – 3 658 1,198 2,541 1,694 23 417 148 – 766 3 1 462 – 52 a 1,785 5a 17 – 1,632 25 2 589 252 18 693 – 65 4,534 1 73 83 a 15 576 2 597 307 41 162 867 a 751 8,887 19 21 0 GOAL 2. Providing paediatric treatment in low- and middle-income countries* Estimated number of children (0–14 years old) living with HIV, 2007 Jamaica Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People’s Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Moldova, Republic of Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Qatar Republic of Korea Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka Sudan Suriname Estimated number of HIV-infected pregnant women, 2007 Estimate Low estimate High estimate Estimate Low estimate High estimate Number of infants born to HIVinfected pregnant women started on cotrimoxazole prophylaxis, 2007 – – – – – – – – – 12,000 3,100 – <500 91,000 – – 9,400 – <500 <100 – – – – – – 100,000 – 14,000 – – – 3,200 220,000 – – – – – – 1,100 – – – – – – – 19,000 – – – – – – 3,100 – – 4,000 – – <1,000 280,000 – 25,000 <200 – – – 130,000 – – – – – 11,000 2,300 – – 80,000 – – 7,800 – – – – – – – – – 87,000 – 12,000 – – – 2,500 170,000 – – – – – – <1,000 – – – – – – – 17,000 – – – – – – 2,500 – – 3,000 – – – 230,000 – 18,000 – <1,000 – – 180,000 – – – – – 13,000 6,300 – <1,000 100,000 – – 11,000 – <1,000 <200 – – <100 – – – 120,000 – 16,000 – – – 4,200 370,000 – – – – – – 1,200 – – – – – – – 21,000 – – – – – – 3,700 – – 5,300 – – 1,600 320,000 – 33,000 <500 <500 – <200 76,000 – – <100 <200 <100 12,000 3,100 – <500 73,000 1,300 <100 8,600 – <500 <200 3,100 – <100 <100 – <500 97,000 4,500 9,400 – 1,500 <200 3,300 190,000 – – – 2,300 – <500 1,900 <500 1,300 <200 – – <500 7,300 11,000 – – – – – – 4,400 <100 – 4,400 – – 940 220,000 <100 18,000 <200 <500 – <100 66,000 – – <100 <100 <100 11,000 2,400 – <500 64,000 770 <100 6,800 – <500 <100 2,000 – <100 <100 – <500 81,000 2,900 7,600 – 990 <100 2,100 130,000 – – – 1,500 – <500 1,800 <500 890 <200 – – <200 4,500 9,100 – – – – – – 3,000 <100 – 3,100 – – 510 180,000 <100 12,000 <100 640 – <500 86,000 – – <200 <500 <100 14,000 3,900 – 760 82,000 2,000 <100 11,000 – 770 <500 4,900 – <200 <100 – 550 120,000 7,100 11,000 – 2,300 <500 5,000 240,000 – – – 3,700 – 510 2,100 830 1,800 <500 – – <500 11,000 13,000 – – – – – – 6,300 <200 – 6,200 – – 1,700 260,000 <100 26,000 <200 – 0a 130 4,534 h – – – 16 – – 112 – 2a 8,803 – – 195 i – 18 – – – 0 0 – – – – – – 31 43 e – – – – – 0 – – 60 42 a – 0 – – 78 – – – – – – 3a – – 0a – 66 – – – – 1a 14 – UNITE FOR CHILDREN % of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis, 2007 – – 74 6 – – – 14 – – 4 – 0 12 – – 2 – 4 – – – 0 0 – – – – – – 2 26 – – – – – 0 – – 3 9 – 0 – – 29 – – – – – – – – – 0 – 2 – – – – 2 0 – Number of children (0–14 years old) receiving ART, 2007** 336 4 71 15,090 – – 26 36 9 1,553 92 – 0a 10,439 500 0 579 – 23 – 176 a – 19 0 1 58 6,320 287 a 5,283 – 51 45 104 15,345 – – 25 a 21 0 214 a 185 104 322 4 – – 196 330 a 4,350 – 2 – – 2 – 384 14 a – 12 a – – 5 32,060 0a – 58 UNITE AGAINST AIDS 37 GOAL 2. Providing paediatric treatment in low- and middle-income countries* Estimated number of children (0–14 years old) living with HIV, 2007 Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe SUMMARY INDICATORS Sub-Saharan Africa Eastern and Southern Africa West and Central Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS Low- and middle-income countries Developing countries World DEFINITIONS OF THE INDICATORS Estimated number of children living with HIV: Estimated number of children (0–14 years old) living with HIV as of 2007. Estimated number of HIV-infected pregnant women: Estimated number of pregnant women (15–49 years old) living with HIV as of 2007. Number of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis: Reported number of infants born to HIV-infected mothers started on cotrimoxazole prophylaxis within two months of birth. Percentage of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis: Calculated by dividing the number of HIVexposed infants started on cotrimoxazole prophylaxis by the estimated number of children born to HIV-infected pregnant women, assuming a ratio of one child to one HIV-infected mother. The denominator is the estimated number of HIV-infected pregnant women. Number of children receiving ART: Reported number of children (0–14 years old) living with HIV receiving ART as of 2007. 38 UNITE FOR CHILDREN Estimated number of HIV-infected pregnant women, 2007 Estimate Low estimate High estimate Estimate Low estimate High estimate Number of infants born to HIVinfected pregnant women started on cotrimoxazole prophylaxis, 2007 15,000 – – 14,000 – – 10,000 – – – – – – 130,000 – – 140,000 – – – – – – 95,000 120,000 14,000 – – 12,000 – – 8,400 – – – – – – 120,000 – – 130,000 – – – – – – 86,000 110,000 17,000 – – 17,000 – – 12,000 – <500 – – – – 150,000 – – 150,000 – – – – – – 110,000 140,000 13,000 – <200 10,000 – – 8,000 – – <100 – – – 78,000 5,200 – 100,000 <200 <500 – 2,300 3,900 – 76,000 52,000 12,000 – <100 6,400 – – 6,300 – – <100 – – – 68,000 3,800 – 91,000 <100 <200 – 1,300 2,400 – 68,000 48,000 15,000 – <500 15,000 – – 10,000 – – <100 – – – 92,000 6,700 – 110,000 <500 840 – 4,600 6,400 – 86,000 57,000 725 a 0 1 – – – 488 – – 0 0a 0a – – 3,325 l – – 70 a – – – – 0 11,884 9,975 1,800,000 † 1,300,000 † 480,000 † 28,000 † 110,000 † 41,000 † 55,000 † 11,000 † – 2,000,000 † 2,000,000 † 1,700,000 † 1,200,000 † 420,000 † 20,000 † 75,000 † 36,000 † 47,000 † 9,000 † – 1,900,000 † 1,900,000 † 2,000,000 † 1,400,000 † 640,000 † 36,000 † 140,000 † 49,000 † 70,000 † 14,000 † – 2,300,000 † 2,300,000 † 1,300,000 930,000 390,000 21,000 69,000 34,000 36,000 14,000 1,500,000 – – 1,200,000 860,000 320,000 15,000 40,000 27,000 30,000 10,000 1,400,000 – – 1,400,000 1,000,000 450,000 29,000 97,000 44,000 45,000 18,000 1,600,000 – – MAIN DATA SOURCES Estimated number of children living with HIV: UNAIDS, 2008 Report on the Global AIDS Epidemic. Estimated number of HIV-infected pregnant women: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Number of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Percentage of infants born to HIV-infected women started on cotrimoxazole prophylaxis: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. Number of children receiving ART: WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2008. UNITE AGAINST AIDS 51,200 46,800 4,460 81 1,240 956 579 3,690 57,800 – – NOTES * Typically this table would include the following estimates: Number of children living with HIV in need of ART; and Percentage of children in need receiving ART. These estimates are still under review and were not available at the time of publication of this report. – Data not available. ** United Nations General Assembly Special Session on HIV/AIDS (2001) indicator, as part of men and women with advanced HIV infection receiving antiretroviral combination therapy. a The latest reported data are to December 2006. c Data reported for the period September–December 2007. e Data reported for the period January–November 2007. f Data reported for the period March 2006–February 2007. h Data reported for the period April–September 2007. i Data reported for the period January–August 2007. k Data reported for the period January–October 2007. % of infants born to HIV-infected pregnant women started on cotrimoxazole prophylaxis, 2007 6 – 1 – – – 6 – – 0 – – – – 63 – – 52 – – – – – 16 19 – – – – – – – – – – – l Number of children (0–14 years old) receiving ART, 2007** 2,123 4 4 6,687 1 – 559 – – 3a 9 0 – 8,532 908 – 11,176 160 a 225 – 611 a 789 1 11,602 8,237 157,968 132,427 25,541 213 8,960 11,815 16,571 1,913 197,440 – – Ukrainian legislation states that virological tests for HIV diagnosis are provided to newborns at two and six months after birth. These data include the number of tests, not infants, because a system of monitoring is not in place to collect the number of infants tested. † Regional averages are calculated for only the population representing 50 per cent or more of the region’s total population of interest. GOAL 3. Preventing infection among adolescents and young people Knowledge and behaviours HIV prevalence among young people (15–24 years old), 2007 ** Male (%) Female (%) Afghanistan Albania Algeria Angola Antigua and Barbuda Argentina Armenia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Democratic People's Republic of Korea Democratic Republic of the Congo Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras – – 0.1 0.2 – 0.6 0.2 0.3 3.2 – – 1.3 0.3 0.5 0.3 0.1 0.2 – 5.1 1.0 – – 0.5 0.4 0.8 1.2 – 1.1 2.0 0.3 0.1 0.7 0.1 0.8 – 0.4 0.8 – 0.1 – – 0.7 – 0.3 0.4 – 0.9 0.8 0.3 0.5 0.1 1.3 0.2 0.1 0.4 – – 0.4 0.4 0.5 0.6 0.7 – – 0.1 0.3 – 0.3 0.1 0.1 1.5 – – 0.6 0.1 1.5 0.9 <0.1 0.1 – 15.3 0.6 – – 0.9 1.3 0.3 4.3 – 5.5 2.8 0.2 0.1 0.3 <0.1 2.3 – 0.2 2.4 – 0.1 – – 2.1 – 0.6 0.2 – 0.5 2.5 0.9 1.5 – 3.9 0.6 0.1 1.3 – 1.5 1.2 1.2 1.7 1.4 0.4 % of young people (15–24 years old) who have comprehensive knowledge of HIV (2002–2007*)** % of young people (15–24 years old) who had sex with more than one partner in the last 12 months (2002–2007*)** Male Female Male Female – – – – – – 15 5 – – – – – – 35 – 18 – – – – 15 – – 45 – 36 27 20 – – – – 35 – – 28 – – – 21 – – 34 – – – – – 33 – – – – 33 – – 23 – – 40 – – 6 13 – – – 23 5 – – 16 – 34 40 16 – 15 48 – – – 17 19 30 50 32 36 17 8 – – – – 26 – – 18 – 52 – 15 18 – 41 – 4y – – 37 20 – – 39 15 25 – – 17 18 50 34 30 – – – – – – 13 9 – – – – – – 10 – 19 – – – – – – – 5 – 33 – 12 – – – – 20 – – 20 – – – 14 – – 23 – – – – – 1 – – – – 6 – – 19 – 9 20 – – – – – – – 0 0 – – – – – – 1 – 1 – – – – – 1 1 0 5 4 – 1 – – 5 – 10 – – 5 – – – 3 – – 5 – – – – – <1 – – 1 – 2 – – 2 6 2 2 1 % of young people (15–24 years old) with multiple partners and who used a condom at last sex (2002–2007*)** Male – – – – – – 79 29 – – – – – – 45 – – – – – – – – – 75 – 80 – 26 – – – – 37 – – 62 – – – 22 – – 62 – – – – – – – – – – 61 x – – 39 – 62 51 – UNITE FOR CHILDREN Female – – – – – – – – – – – – – – 27 – – – – – – – 71 x – – 68 64 – 9 – – 36 – 22 – – 45 – – – 9 – – 34 – – – – – – – – 64 x – 43 x – – 28 58 – 23 27 % of young people (15–19 years old) who had sex before age 15 (2002–2007*)** Male Female – – – – – – 3 1 – – – – – – 13 – 15 – – – – – – – <1 – 46 – 11 – – – – 25 – – 17 – – – 18 – – 21 – – – – – 2 – – – – 5 – 15 18 – 11 42 – – – – – – – <1 <1 – – – – – – 13 – 6 1 – – – – 6 3 1 13 21 29 19 – – 14 – 24 – – 20 – – – 18 – – 14 – – – – 9 11 – – 4 – 7 – 7 20 22 8 15 10 UNITE AGAINST AIDS 39 GOAL 3. Preventing infection among adolescents and young people Knowledge and behaviours HIV prevalence among young people (15–24 years old), 2007 ** Male (%) Female (%) India Indonesia Iran (Islamic Republic of) Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Moldova, Republic of Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Qatar Republic of Korea Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles 40 UNITE FOR CHILDREN 0.3 0.3 0.2 – 1.7 – 0.2 – – – 0.2 0.2 0.1 5.9 0.4 – 0.2 2.4 0.6 – 0.4 – 0.9 1.8 0.3 – 0.4 0.1 – 0.1 2.9 0.7 3.4 – 0.5 0.3 0.9 0.8 – – – 0.1 – 1.1 0.6 0.7 0.5 – – <0.1 0.2 1.3 0.5 – – – – – – 0.3 0.1 – 0.3 0.1 0.1 – 0.9 – 0.1 – – – 0.1 0.1 0.1 14.9 1.3 – 0.1 8.4 0.3 – 1.1 – 0.5 1.0 0.2 – 0.2 – – 0.1 8.5 0.6 10.3 – 0.3 0.1 0.5 2.3 – – – 0.1 – 0.6 0.7 0.3 0.3 – – <0.1 0.2 0.6 1.4 – – – – – – 0.8 0.1 – UNITE AGAINST AIDS % of young people (15–24 years old) who have comprehensive knowledge of HIV (2002–2007*)** Male 36 0y – – – – – 47 – – – – – 18 27 – 16 42 – – 22 39 – – – – 54 y – – – 33 – 62 – 44 – 16 21 – – – – – – – – – 18 – – 1y – 54 – – – – – – 24 – – % of young people (15–24 years old) who had sex with more than one partner in the last 12 months (2002–2007*)** Female Male Female 20 1 – 3 60 3y 22 34 – – 20 – – 26 21 – 19 42 – – 18 27 – – – – 42 y 35 30 12 20 – 65 – 28 – 13 18 – – – 3 – – – – 19 12 – – 3y – 51 – – – – 44 – 19 42 – 2 – – – – – – 11 – – – – – 18 – – 19 6 – – 6 10 – – – – 17 – – – 29 – 11 – 2 – 2 8 – – – – – – – – – 6 – – – – 1 – – – – – – 6 – – <1 – – – – – – 2 – – 1 – – 5 – – 3 1 – – 2 5 – – – – 2 – <1 – 6 – 2 – <1 – <1 2 – – – – – – – – 1 – – – – – <1 – – – – 2 – 1 2 – % of young people (15–24 years old) with multiple partners and who used a condom at last sex (2002–2007*)** Male 32 – – – – – – 52 – – – – – 51 28 – 13 46 – – 28 23 x – – – – 60 – – – 30 – 82 – 59 x – 42 x 38 – – – – – – – – – 30 – – – – – – – – – – – 64 – – Female 17 x – – – – – – 9 – – – – – 31 16 – 2 48 – – 8 9x – – – – 30 – – – 20 – 74 – – – – 17 – – – – – – – – 38 x – – – – – – – – – – 57 x – 33 80 x – % of young people (15–19 years old) who had sex before age 15 (2002–2007*)** Male Female 3 – – – – – – 31 – – – – – 30 9 – 20 16 – – 6 25 – – – – 10 – – – 31 – 19 – 3 – 5 8 – – – – – – – – – 3 – – – – 15 – – – – – – 13 – – 8 – – – – – – 15 – – <1 – – 16 19 – 32 14 – – 24 15 – – – – 2 – <1 – 28 – 7 – 6 – 26 20 – – – – – – – – 5 1 – – – – 5 – – – – 9 – 9 1 – GOAL 3. Preventing infection among adolescents and young people Knowledge and behaviours HIV prevalence among young people (15–24 years old), 2007 ** Male (%) Female (%) Sierra Leone Singapore Solomon Islands Somalia South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe SUMMARY INDICATORS† Sub-Saharan Africa Eastern and Southern Africa West and Central Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS Low- and middle-income countries Developing countries World DEFINITIONS OF THE INDICATORS HIV prevalence among young people: Percentage of young men and women (15–24 years old) living with HIV as of end-2007. Comprehensive knowledge of HIV: Percentage of young men and women (15–24 years old) who correctly identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject the two most common local misconceptions about HIV transmission, and who know that a healthy-looking person can transmit HIV. Sex with more than one partner in the last 12 months: Percentage of young men and women (15–24 years old) who have had sexual intercourse with more than one partner in the last 12 months. % of young people (15–24 years old) who have comprehensive knowledge of HIV (2002–2007*)** Male Female % of young people (15–24 years old) who had sex with more than one partner in the last 12 months (2002–2007*)** % of young people (15–24 years old) with multiple partners and who used a condom at last sex (2002–2007*)** % of young people (15–19 years old) who had sex before age 15 (2002–2007*)** Male Female Male Female Male Female 0.4 0.2 – 0.6 4.0 <0.1 0.3 2.7 5.8 – 0.4 1.2 – – 0.8 – 0.3 0.1 – – – 1.3 1.5 – 0.5 0.6 0.1 – – 0.6 – 3.6 2.9 1.3 0.1 – 0.3 12.7 – 1.0 1.4 22.6 – 0.1 1.2 – – 2.4 – 1.0 <0.1 – – – 3.9 1.5 – 0.9 0.3 0.1 – – 0.3 – 11.3 7.7 – – – – – – – – 52 – – – – – – – – – – – – 38 43 – 40 – – – – – – 37 46 17 – – 4 – – – 41 52 7 2 46 27 – 28 – 54 – – 5 – 32 42 – 45 – 31 – – 44 – 34 44 – – – – – – – – 10 – – – – – – – – – – – – 9 16 – 17 – – – – <1 – 9 7 4 – – – – – – 3 2 – – – 1 – 3 – 3 – – – – 2 3 – 3 – <1 – – 0 – 2 1 – – – – – – – – 67 – – – – – – – – – – – – 45 64 – 39 – – – – – – 43 59 27 – – – – – – 80 51 x – – – 36 x – 50 – 67 – – – – 39 63 – 26 – – – – – – 42 x 38 x – – – – – – – – 5 – – – – – – – – – – – – 14 3 – 13 – – – – 0.3 – 16 5 25 – – – – – – – 7 – – – 1 – 12 – 5 – – – – 12 1 – 11 – – – – 1 – 12 5 1.1 1.5 0.7 0.1 0.3 0.2 0.5 0.8 – 0.4 0.4 3.2 4.5 1.9 0.2 0.2 0.1 0.4 0.5 – 0.7 0.6 30 38 23 – 36 7z – – – 30 z – 24 31 19 – 18 18 z – – – 19 z – 10 10 10 – 2 – – – – – – 2 2 2 – 0 – – – – – – 40 42 39 – 33 – – – – – – 26 26 26 – 17 – – – – – – 12 14 11 – 3 – – – – – – 16 13 18 – 8 – – – – – – Condom use with multiple partners: Percentage of young men and women (15–24 years old) who had more than one partner in the past 12 months and reported using a condom during their last sexual intercourse. Sex before age 15: Percentage of young people (15–19 years old) who say they had sex before age 15. MAIN DATA SOURCES HIV prevalence among young people: UNAIDS, 2008 Report on the Global AIDS Epidemic. Comprehensive knowledge of HIV: UNICEF global databases, 2008. Sex with more than one partner in the last 12 months: UNICEF global databases, 2008. Condom use with multiple partners: UNICEF global databases, 2008. Sex before age 15: UNICEF global databases, 2008. NOTES – Data not available. * Data refer to the most recent year available during the period specified in the column heading. ** United Nations General Assembly Special Session on HIV/AIDS (2001) indicator. † Regional averages are calculated only for the population representing 50 per cent or more of the region’s total population of interest. x Based on small denominators (typically 25–49 unweighted cases). y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country. Such data are included in the calculation of regional and global averages. z Excludes China. UNITE FOR CHILDREN UNITE AGAINST AIDS 41 GOAL 4. Protecting and supporting children affected by HIV and AIDS Orphaned and vulnerable children Afghanistan Albania Algeria Angola Antigua and Barbuda Argentina Armenia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Democratic People's Republic of Korea Democratic Republic of the Congo Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Ethiopia Fiji Gabon Gambia Georgia Ghana Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras India Indonesia 42 UNITE FOR CHILDREN Children who have lost one or both parents due to all causes, 2007 Estimate Low Estimate 2,100,000 – 570,000 1,200,000 – 610,000 50,000 190,000 6,600 – 5,000,000 2,700 190,000 5,500 340,000 22,000 300,000 – 130,000 3,200,000 – 95,000 690,000 600,000 600,000 1,100,000 – 280,000 540,000 160,000 17,000,000 790,000 27,000 210,000 – 36,000 1,200,000 – 99,000 530,000 4,500,000 42,000 – 170,000 200,000 1,400,000 130,000 32,000 280,000 5,000,000 22,000 67,000 48,000 72,000 1,100,000 – 360,000 380,000 110,000 23,000 380,000 170,000 25,000,000 4,400,000 – – – 50,000 – – – – – – – – – – 29,000 – – – 95,000 – – – 100,000 120,000 – 300,000 – 72,000 85,000 – – – <100 69,000 – – 420,000 – – – – 5,200 – – – – – 4,800 18,000 650,000 – 18,000 2,700 – 160,000 – – 25,000 5,900 – – – – – – – – 20,000 – – – – – – – – – – 22,000 – – – 81,000 – – – 62,000 100,000 – 230,000 – 58,000 42,000 – – – – 57,000 – – 320,000 – – – 270,000 1,900 – – – – – 3,800 12,000 540,000 – 11,000 1,300 – 130,000 – – 15,000 4,200 – – – – – UNITE AGAINST AIDS High Estimate Children whose mother has died due to any cause, 2007 Children whose father has died due to any cause, 2007 Children both of whose parents have died due to any cause, 2007 Orphan school attendance ratio (2002–2007*)** % of children whose households received external support (2004–2007*)** – – – 260,000 – – – – – – – – – – 40,000 – – – 110,000 – – – 130,000 150,000 – 390,000 – 86,000 270,000 – – – <200 84,000 – – 530,000 – – – 380,000 9,600 – – – – – 6,100 32,000 780,000 – 28,000 4,700 – 200,000 – – 39,000 8,300 – – – – – 1,100,000 – 220,000 600,000 – 93,000 8,400 42,000 1,200 – 2,000,000 <500 21,000 2,200 140,000 8,200 110,000 – 85,000 720,000 – 11,000 300,000 320,000 240,000 580,000 – 140,000 250,000 25,000 4,000,000 180,000 11,000 100,000 – 6,400 590,000 – 19,000 150,000 2,200,000 21,000 – 50,000 46,000 390,000 33,000 15,000 120,000 2,400,000 6,600 31,000 18,000 11,000 510,000 – 96,000 150,000 50,000 8,100 160,000 47,000 7,400,000 1,400,000 1,400,000 – 370,000 840,000 – 530,000 43,000 160,000 5,700 – 3,400,000 2,300 170,000 3,600 220,000 15,000 220,000 – 81,000 2,600,000 – 87,000 480,000 390,000 420,000 710,000 – 190,000 350,000 140,000 14,000,000 640,000 18,000 140,000 – 31,000 800,000 – 82,000 410,000 3,000,000 27,000 – 120,000 160,000 1,100,000 110,000 22,000 190,000 3,200,000 17,000 44,000 33,000 65,000 700,000 – 280,000 260,000 74,000 17,000 270,000 130,000 19,000,000 3,200,000 370,000 – 26,000 210,000 – 15,000 1,900 9,100 <500 – 380,000 <100 6,800 <500 26,000 1,800 20,000 – 37,000 110,000 – 2,700 83,000 120,000 55,000 190,000 – 51,000 61,000 2,700 560,000 25,000 1,900 31,000 – <500 180,000 – 2,100 29,000 740,000 5,800 – 6,600 5,400 56,000 4,600 5,200 34,000 630,000 1,400 8,400 2,800 2,700 130,000 – 16,000 32,000 16,000 2,200 50,000 6,700 1,200,000 230,000 – – – – – – – – – – 0.84 – – – 0.90 – 0.74 – – – – – 0.61 0.85 0.83 0.91 – 0.96 1.05 – – 0.85 – 0.88 – – 0.83 – – – 0.77 – – 0.96 – – – – 0.83 0.90 – – 0.87 – 1.04 – – 0.73 0.97 – 0.86 1.08 0.72 0.82 – – – – – – – – – – – – – – – – – – – – – – – – – 9 – 7 – – – – – – – – 9 – – – 9 – – – – – – – – – – – – – – – – – 8 13 5 – – – Children who have lost one or both parents due to AIDS, 2007 p p p y GOAL 4. Protecting and supporting children affected by HIV and AIDS Orphaned and vulnerable children Iran (Islamic Republic of) Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Lebanon Lesotho Liberia Libyan Arab Jamahiriya Madagascar Malawi Malaysia Maldives Mali Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Moldova, Republic of Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Nicaragua Niger Nigeria Niue Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Qatar Republic of Korea Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Solomon Islands Somalia Children who have lost one or both parents due to all causes, 2007 Estimate Low Estimate 1,300,000 – 53,000 – 470,000 2,500,000 – – 140,000 210,000 71,000 160,000 270,000 – 840,000 1,100,000 410,000 8,800 550,000 – 83,000 21,000 1,400,000 – 74,000 64,000 – 630,000 1,400,000 1,600,000 110,000 – 990,000 110,000 570,000 9,700,000 – – – 3,900,000 – 48,000 330,000 130,000 570,000 1,800,000 – 360,000 300,000 4,000,000 860,000 – – – – – – 350,000 130,000 – 350,000 24,000 – 590,000 – – – – – – – – – – – 110,000 15,000 – 3,400 550,000 – – 44,000 – 3,000 <500 – – – – – – 400,000 – 66,000 – – – 25,000 1,200,000 – – – – – – – – – – – – – – 220,000 – – – – – – 8,400 – – 16,000 – – 8,800 – – – – – 990,000 – – – – – 93,000 10,000 – 2,100 470,000 – – 27,000 – 1,500 – – – – – – – 280,000 – 50,000 – – – 18,000 640,000 – – – – – – – – – – – – – – 190,000 – – – – – – 4,600 – – 6,400 – – 4,900 High Estimate Children whose mother has died due to any cause, 2007 Children whose father has died due to any cause, 2007 – – – – – 1,400,000 – – – – – 120,000 87,000 – 6,000 640,000 – – 56,000 – 5,900 <1,000 – – – – – – 590,000 – 85,000 – – – 39,000 4,100,000 – – – – – – – – – – – – – – 250,000 – – – – – – 14,000 – – 26,000 – – 16,000 420,000 – 16,000 – 90,000 1,500,000 – – 34,000 90,000 22,000 100,000 130,000 – 360,000 540,000 110,000 3,900 220,000 – 30,000 4,000 320,000 – 13,000 19,000 – 230,000 780,000 570,000 63,000 – 440,000 29,000 260,000 4,900,000 – – – 1,400,000 – 10,000 130,000 38,000 160,000 600,000 – 32,000 44,000 460,000 540,000 – – – – – – 120,000 21,000 – 160,000 3,400 – 300,000 910,000 – 40,000 – 410,000 1,500,000 – – 120,000 140,000 52,000 110,000 180,000 – 560,000 740,000 310,000 5,500 380,000 – 58,000 17,000 1,100,000 – 64,000 49,000 – 440,000 920,000 1,100,000 65,000 – 640,000 84,000 350,000 6,400,000 – – – 2,700,000 – 39,000 240,000 93,000 430,000 1,300,000 – 330,000 270,000 3,700,000 600,000 – – – – – – 240,000 110,000 – 250,000 21,000 – 390,000 Children who have lost one or both parents due to AIDS, 2007 Children both of whose parents have died due to any cause, 2007 58,000 – 2,100 – 31,000 470,000 – – 7,500 17,000 2,900 49,000 45,000 – 75,000 230,000 13,000 <1,000 48,000 – 4,500 <1,000 34,000 – 3,600 4,000 – 32,000 300,000 120,000 17,000 – 95,000 3,900 43,000 1,700,000 – – – 200,000 – 1,200 38,000 5,100 25,000 81,000 – 3,900 11,000 220,000 290,000 – – – – – – 19,000 4,100 – 53,000 <500 – 100,000 UNITE FOR CHILDREN Orphan school attendance ratio (2002–2007*)** – 0.84 – – – 0.95 – – – – – 0.95 – – 0.75 0.97 – – 0.87 – – – – – – 0.96 p – – 0.80 – 1.00 – – – 0.67 0.64 p – – – – – – – – – – – – – – 0.82 – – – – – – 0.83 – – 0.83 – – 0.78 % of children whose households received external support (2004–2007*)** – – 15 – – – – – – – – – – – – 19 – – – – – – – – – – – – – – 17 – – – – – – – – – – – – – – – – – – – 13 – – – – – – – – – 1 – – – UNITE AGAINST AIDS 43 GOAL 4. Protecting and supporting children affected by HIV and AIDS Orphaned and vulnerable children SUMMARY INDICATORS† Sub-Saharan Africa Eastern and Southern Africa West and Central Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS Low- and middle-income countries Developing countries World DEFINITIONS OF THE INDICATORS Children who have lost one or both parents due to all causes: Estimated number of children (0–17 years old) as of 2007 who have lost one or both parents to any cause. Children who have lost one or both parents due to AIDS: Estimated number of children (0–17 years old) as of 2007 who have lost one or both parents to AIDS. Children whose mother/father has died due to any cause: Estimated number of children (0–17 years old) as of 2007 who have lost their biological mother/father to any cause. Children both of whose parents have died due to any cause: Estimated number of children (0–17 years old) as of 2007 who have lost both parents to any cause. 44 UNITE FOR CHILDREN Estimate Low Estimate 2,500,000 330,000 1,800,000 8,900 96,000 – 210,000 1,300,000 – 48,000 260,000 – 20,000 130,000 – – – 2,500,000 1,000,000 – 2,600,000 46,000 690,000 – 430,000 1,500,000 – 1,100,000 1,300,000 1,400,000 – – – 56,000 – – – – – 68,000 – – – – – – 1,200,000 – – 970,000 – – – – – – 600,000 1,000,000 47,500,000 24,900,000 22,700,000 5,900,000 37,400,000 30,100,000 9,400,000 7,600,000 – 130,000,000 145,000,000 11,600,000 8,700,000 3,000,000 – – – – – – – 15,000,000 High Estimate Children whose mother has died due to any cause, 2007 Children whose father has died due to any cause, 2007 1,100,000 – – – 48,000 – – – – – 50,000 – – – – – – 1,100,000 – – 850,000 – – – – – – 530,000 920,000 1,800,000 – – – 65,000 – – – – – 91,000 – – – – – – 1,400,000 – – 1,100,000 – – – – – – 660,000 1,100,000 1,400,000 70,000 840,000 2,400 74,000 – 64,000 300,000 – 19,000 110,000 – 5,800 36,000 – – – 1,500,000 110,000 – 1,400,000 6,200 170,000 – 96,000 460,000 – 740,000 960,000 1,600,000 270,000 1,200,000 6,800 58,000 – 150,000 1,000,000 – 32,000 170,000 – 16,000 96,000 – – – 1,700,000 930,000 – 1,700,000 41,000 550,000 – 350,000 1,000,000 – 780,000 900,000 510,000 12,000 210,000 <500 37,000 – 12,000 58,000 – 3,800 23,000 – <1,000 3,900 – – – 620,000 41,000 – 490,000 1,000 32,000 – 12,000 57,000 – 390,000 600,000 10,600,000 8,000,000 2,300,000 – – – – – – – 13,000,000 15,300,000 9,500,000 6,100,000 – – – – – – – 19,000,000 24,800,000 13,800,000 11,000,000 2,200,000 12,400,000 8,200,000 2,300,000 1,100,000 – 50,000,000 51,400,000 31,400,000 16,300,000 15,100,000 4,100,000 27,300,000 23,200,000 7,500,000 6,800,000 – 95,000,000 107,000,000 8,700,000 5,200,000 3,500,000 390,000 2,200,000 1,300,000 360,000 380,000 – 13,000,000 13,400,000 Children who have lost one or both parents due to AIDS, 2007 Orphan school attendance ratio: Percentage of children (10–14 years old) who have lost both biological parents and who are currently attending school as a percentage of non-orphaned children of the same age who live with at least one parent and who are attending school. Percentage of children whose households received external support: Percentage of orphaned and vulnerable children whose households received free basic external support in caring for the child. UNITE AGAINST AIDS Children both of whose parents have died due to any cause, 2007 MAIN DATA SOURCES Children who have lost one or both parents due to all causes: UNAIDS unpublished estimates, 2008. Children who have lost one or both parents due to AIDS: UNAIDS, 2008 Report on the Global AIDS Epidemic. Children whose mother/father has died due to any cause: UNAIDS unpublished estimates, 2008. Children both of whose parents have died due to any cause: UNAIDS unpublished estimates, 2008. Orphan school attendance ratio: UNICEF global databases, 2008. Percentage of children whose households received external support: UNICEF global databases, 2008. Orphan school attendance ratio (2002–2007*)** % of children whose households received external support (2004–2007*)** – – – – 0.97 – – 0.93 – – 0.94 – – – – – – 0.96 0.98 – 1.02 – – – – – – 1.03 y 0.95 – – – – 41 – – 21 – – 6 – – – – – – 11 – – – – – – – – – 16 31 83 92 76 – 73 – – – – 77 – – – – – – – – – – – – NOTES – Data not available. * Data refer to the most recent year available during the period specified in the column heading. ** United Nations General Assembly Special Session on HIV/AIDS (2001) indicator. p Proportion of orphans (aged 10–14) attending school is based on small denominators (typically 25–49 unweighted cases). y Data refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only a part of the country. Such data are included in the calculation of regional and global averages. † Regional averages are calculated only for the population representing 50 per cent or more of the region’s total population of interest. © UNICEF/HQ06-1108/Olivier Asselin South Africa Sri Lanka Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Republic of Tanzania Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe Children who have lost one or both parents due to all causes, 2007 UNITE FOR CHILDREN UNITE AGAINST AIDS 45 United Nations Children’s Fund 3 United Nations Plaza New York, NY 10017, USA Tel.: (+1 212) 326-7000 pubdoc@unicef.org www.unicef.org UNAIDS Secretariat 20, avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+41 22) 791-3666 Fax: (+41 22) 791-4187 unaids@unaids.org www.unaids.org World Health Organization 20, avenue Appia CH-1211 Geneva 27 Switzerland Tel.: (+ 41 22) 791-2111 Fax: (+ 41 22) 791-3111 info@who.int; publications@who.int www.who.int United Nations Population Fund 220 East 42nd Street, 23rd Fl. New York, NY 10017, USA Tel: (+1 212) 297-5146 www.unfpa.org Visit the Unite for Children, Unite against AIDS website: www.uniteforchildren.org or contact us by email: aidscampaign@unicef.org © United Nations Children’s Fund (UNICEF) ISBN: 978-92-806-4369-5 December 2008 UNITE FOR CHILDREN UNITE AGAINST AIDS 

Rapid assessment tool for Sexual & reproductive HealtH and Hiv linkageS a generic guide disclaimer © 2009 ippf, unfpa, WHo, unaidS, gnp+, icW and Young positives. all rights reserved. the publishers welcome requests to translate, adapt or reproduce the material in this document for the purpose of strengthening bi-directional linkages between sexual and reproductive health and Hiv/aidS policies, systems and services and for informing health care providers, their clients and the general public, as well as improving the quality of sexual and reproductive health and Hiv prevention, treatment, care and support. enquiries should be addressed to ippf, 4 newhams row, london, Se1 3uZ, united kingdom (fax: +44 207 939 8300; email: hivinfo@ippf.org); unfpa, 220 east 42nd Street, new York, nY 10017, uSa (tel: +1 212 297 5000; email: info@unfpa.org); WHo press, World Health organization, 20 avenue appia, 1211 geneva 27, Switzerland (fax: +41 22 791 4806; email: permissions@who.int); unaidS, 20 avenue appia, 1211 geneva 27, Switzerland (fax: +41 22 791 3666; email: unaids@unaids.org); gnp+, p.o. Box 11726, 1001 gS, amsterdam, the netherlands (fax: +31 20 423 4224; email: infognpplus. net); icW, international Support ofice, unit 6, Building 1, canonbury Yard, 190a new north road, london, n1 7BJ, united kingdom (fax: +44 20 7704 8070; email: info@icw.org) or Young positives, p.o. Box 15847, 1001 nH, amsterdam (fax: +31 20 616 0160; email: redactiejongpositief@hivnet.org) only authorized translations, adaptations and reprints may bear the emblems of ippf, unfpa, WHo, unaidS, gnp+, icW and Young positives. translations, adaptations and reproductions may be made without authorization so long as they are not used in conjunction with any commercial or promotional purposes, and so long as they do not use the emblems of the publishing organizations, and so long as they acknowledge the original source in line with the suggested citation below. the publishing organizations do not accept responsibility for any translations, adaptations and reproductions published by others. the publishers request print and electronic copies of all translations, adaptations and reproductions of this publication. the mention of speciic companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the publishing organizations in preference to others of a similar nature that are not mentioned. errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. all reasonable precautions have been taken by the publishers to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. the responsibility for the interpretation and use of the material lies with the reader. in no event shall ippf, unfpa, WHo, unaidS, gnp+, icW or Young positives be liable for damages arising from use of this publication. this publication does not necessarily represent decisions or the stated policy of ippf, unfpa, WHo, unaidS, gnp+, icW or Young positives. Suggested citation for unoficial translations or adaptations of this tool: rapid assessment tool for Sexual & reproductive Health and Hiv linkages: a generic guide, prepared and published by ippf, unfpa, WHo, unaidS, gnp+, icW and Young positives, 2009. published in london, united kingdom, September 2009. acknowledgements this guide was produced thanks to the experience, ideas and input of many different people and organizations. The key contributors were: • • • • • • ippf: kevin osborne unfpa: lynn collins, florence ebanyat WHo: laura guarenti, Sarah Johnson, Michael Mbizvo, Seipaiti Mothesbesoane-anoh, peter Weis unaidS: karusa kiragu gnp+: christoforos Mallouris Young positives: raoul fransen – dos Santos Reviewers included: terhi aaltonen, Sam anyimadu-amaning, narimah awin, esi awotwi, Hedia Belhadj, gladys Brew, leopoldina cairo, alicia carbonell, rebecca carl-Spencer, raquel child, catherine d’arcangues, alexandrine dazogbo, esperanza delgado, anna de guzman, galanne deressa, Barbara de Zalduondo, dudu dlamini, leticia doamekpor, akua ed-nignpense, peter fajans, charles fleischer-djoleto, etta forson, charlotte gardiner, dennia gayle, Marvi glerangle-ashun, ellen gyekye, Wesam Hassan, Helen Jackson, Joseph kaubat, Josiane khoury, Sophia kisting, Steve kraus, Hugues lago, Manjula lusti-narasimhin, Shawn Malarcher, purnima Mane, rhoda Manu, Maureen Marky, Sergio Maulen, rafael Mazin, asha Mohamud, alexis ntabona, rejoice nutakor, nuriye ortayli, cheick ouedraogo, rose owusu kakrah, Jewel Quallo-rosberg, gloria Quansah asare, patricia Quarshe-Yakuev, Suzanne reier, Julie Samuelson, dudu Simelane, lucy Stackpool Moore, Sara newer, Sally-ann ohene, koudaogo ouedraogo, Safdar kamal pasha, Jewel Quallo-rosberg, tin tin Sint, akiko takai, pulane tlebere, Mantsane tsoloane-Bolepo, paul f. a. van look, ouk vong vathiny, Sheryl vanderpoel, daniel Yayemain, Sibili Yelibi. robert Miller consulted on the development of the tool. Table of Contents section page Acknowledgements 3 Acronyms 5 Working Deinitions of Selected Terms 6 Introduction 8 Beneits 8 Principles 9 Purpose of the Tool 10 Background 10 Speciic Instruments 13 I. Policy 14 II. Systems 26 III. Clinical Service Delivery 38 a. Provider Interview 41 b. Client Exit Interview 66 Appendices 1. Sample Consent Form 76 2. Conducting a Desk Review 77 3. Budget Outline for Estimating Cost of Conducting a Two-Month Rapid Assessment 79 4. Health Workers’ Capacity to Perform SRH and HIV Functions 82 5. List of Selected Possible Next Steps for Utilizing the Assessment Findings 83 ra pi d assessment tool Acronyms AIDS acquired immunodeiciency syndrome ANC antenatal care ART antiretroviral therapy BCC Behaviour change communication CSO civil society organizations FBO faith-based organizations FP family planning GNP+ the global network of people living with Hiv HBC Home-based care HIV Human immunodeiciency virus IDU injecting drug users IEC information, education and communication ICW international community of Women living with Hiv/aidS IPPF international planned parenthood federation M&E Monitoring and evaluation MNH Maternal and newborn health MOH Ministry of Health MSM Men who have sex with men MTCT Mother-to-child transmission (of Hiv) NGO non-governmental organizations OI opportunistic infection OVC orphans and vulnerable children PEP post-exposure prophylaxis PHC primary health care PITC provider-initiated testing and counselling PLHIV people living with Hiv PMTCT prevention of mother-to-child transmission (of Hiv) RTI reproductive tract infection SRH Sexual and reproductive health STI Sexually transmitted infection SW Sex workers UN united nations UNAIDS Joint united nations programme on Hiv/aidS UNFPA united nations population fund VCT voluntary counselling and testing WHO World Health organization 04 / 05 Working Deinitions of Selected Terms The following working deinitions are proposed in order to facilitate consistent understanding and interpretation of the terms used in this Guide. 1 Bi-directionality: Both linking sexual and reproductive health (SrH) with Hiv-related policies and programmes and linking Hiv with SrH-related policies and programmes. 2 dual protection: a strategy that prevents both unintended pregnancy and sexually transmitted infections (Stis), including Hiv, through the use of condoms alone, or combined with other methods (dual method use).1 3 Health sector: the sector concerned with the provision, distribution and consumption of healthcare services and related products. Wide-ranging and encompassing public and private health services (including those for health promotion, disease prevention, diagnosis, treatment and care); health ministries; non-governmental organizations; community groups; professional organizations; as well as institutions that directly input into the healthcare system (e.g. the pharmaceutical industry and teaching institutions).2 4 Hiv and aidS programmes and policies: for the purposes of this tool, these include the complete spectrum of prevention, treatment, care and support activities, as well as the broad guidance which establishes appropriate and timely implementation and development of Hiv policy. core programmes and policies relate to and include Hiv counselling and testing, prophylaxis and treatment for people living with Hiv (opportunistic infections (ois) and antiretroviral therapy (art)), homebased care and psycho-social support, prevention for and by people living with Hiv, Hiv prevention for the general population, male and female condom provision, prevention of mother-tochild transmission (pMtct), and speciic services for key populations. 5 Hiv counselling and testing: forms the gateway to Hiv prevention, care, treatment and support for persons in need. all Hiv testing of individuals must be conidential, only be conducted with informed consent (meaning that it is both informed and voluntary) and be accompanied by counselling.3 provider-initiated testing and counselling (pitc) involves the routine offer of Hiv testing to all patients in health-care settings where Hiv is prevalent and antiretroviral treatment is available. people retain the right to refuse Hiv testing. at the same time, client-initiated Hiv testing for all people who want to learn their Hiv status through voluntary counselling and testing (vct) remains critical to the effectiveness of Hiv prevention. promotion of knowledge of Hiv status among any population that may have been exposed to Hiv through any mode of transmission is essential.4 6 integration: different kinds of SrH and Hiv services or operational programmes that can be joined together to ensure and perhaps maximize collective outcomes. this would include referrals from one service to another, for example. it is based on the need to offer comprehensive and integrated services.5 7 key populations: populations for which Hiv risk and vulnerability converge. Hiv epidemics can be limited by concentrating prevention efforts among key populations. the concept of key populations also recognizes that they can play a key role in responding to Hiv. key populations vary in different places depending on the context and nature of the local epidemic, but in most places, they include men who have sex with men (MSM), sex workers (SWs) and their clients, and injecting drug users (idus).6 8 linkages: the bi-directional synergies in policy, programmes, services and advocacy between SrH and Hiv.7 it refers to a broader human rights based approach, of which service integration is a subset. ra pi d assessment tool 9 prevention for and by people living with Hiv: for the purposes of this tool, this is a set of actions that help people living with Hiv (plHiv) to live longer and healthier lives. it encompasses a set of strategies that help plHiv to: • protect their own sexual and reproductive health and avoid other Stis; • delay Hiv disease progression; and • promote shared responsibility to reduce the risk of Hiv transmission. people living with Hiv and those who are Hiv negative both play an equal role in preventing new Hiv infections. key approaches for prevention for and by people living with Hiv include individual health promotion, access to Hiv and sexual and reproductive health services, community participation, advocacy and policy change. 10 risk and vulnerability: risk is deined as the probability or likelihood that a person may become infected with Hiv. certain behaviours create, increase, and perpetuate risk. examples include unprotected sex with a partner whose Hiv status is unknown, multiple sexual partnerships involving unprotected sex, and injecting drug use with contaminated needles and syringes. vulnerability results from a range of factors outside the control of the individual that reduce the ability of individuals and communities to avoid Hiv risk. these factors may include: (1) lack of knowledge and skills required to protect oneself and others; (2) factors pertaining to the quality and coverage of services (e.g. inaccessibility of services due to distance, cost or other factors); and (3) societal factors such as human rights violations, or social and cultural norms. these norms can include practices, beliefs and laws that stigmatize and disempower certain populations, limiting their ability to access or use Hiv prevention, treatment, care, and support services and commodities. these factors, alone or in combination, may create or exacerbate individual and collective vulnerability to Hiv.8 11 Sexual and reproductive health programmes and policies: for the purposes of this tool, these include core programmes and policies that relate to and include family planning (fp), maternal and newborn health (MnH),9 Stis, reproductive tract infections (rtis), promotion of sexual health, prevention and management of gender-based violence, prevention of unsafe abortion and management of post-abortion care. 12 Strategies for preventing Hiv infections in women and infants: • prevent primary Hiv infection among girls and women. • prevent unintended pregnancies among women living with Hiv. • reduce mother-to-child transmission of Hiv through antiretroviral drug treatment or prophylaxis, safer deliveries and infant feeding counselling. • provide care, treatment and support to women living with Hiv and their families.10 06 / 07 1. WHo, unfpa, unaidS and ippf (october 2005). Sexual and reproductive Health & Hiv/aidS: a framework for priority linkages. 2. WHo global Health Sector Strategy for Hiv/aidS, 2003-2007. providing a framework for partnership and action. iSBn 92 4 159076 9. 3. op. cit. 1. 4. WHo and unaidS (2007). guidance on provider-initiated Hiv testing and counseling in Health facilities. http://libdoc.who.int/ publications/2007/9789241595568_ eng.pdf 5. WHo, unaidS, unfpa, WHo (July 2008). gateways to integration: a case study series 6. op. cit. 1. 7. op. cit. 5. 8. unaidS (2008). report on the global aidS epidemic, geneva. 9. it is acknowledged that Hiv services extend through the infant and child period and some SrH programmes are linked to maternal and child health. 10. op. cit. 1. Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guide Introduction the importance of linking SrH and Hiv and aidS is now widely recognised. the majority of Hiv infections are sexually transmitted or are associated with pregnancy, childbirth and breast-feeding. the risk of Hiv transmission and acquisition can be further increased due to the presence of certain Stis. in addition, sexual and reproductive ill-health and Hiv share root causes, including poverty, limited access to appropriate information, gender inequality, cultural norms and social marginalisation 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 the Hiv epidemic.11 linkages between core Hiv services (prevention, treatment, care and support) and core SrH services (fp, MnH, the prevention and management of Stis, rtis, promotion of sexual health, prevention and management of gender-based violence, prevention of unsafe abortion and management of post-abortion care) in national programmes are thought to generate important public health beneits. in addition, perspectives on linkages need to be broad-based addressing not only the health sector and the direct impact on health, but also the structural and social determinants affecting both Hiv and SrH. there is international consensus around the need for effective linkages between responses to Hiv and SrH including recommendations for speciic actions at the levels of policy, systems, and services. these include: • glion call to action on family planning and Hiv/aidS in Women and children (May 2004) • new York call to commitment: linking Hiv/aidS and Sexual and reproductive Health (June 2004) • unaidS policy position paper ‘intensifying Hiv prevention’ (June 2005) • World Summit outcome (September 2005) • call to action: towards an Hiv-free and aidS-free generation (december 2005) • ungaSS political declaration on Hiv/aidS (June 2006) • consensus Statement: achieving universal access to comprehensive prevention of Mother-to-child transmission Services (november 2007) Beneits 12 Much remains unknown about which linkages will have the greatest impact, and how best to strengthen selected linkages in different programme settings. However, stronger bi-directional linkages between SrH and Hivrelated programmes could lead to a number of important public health, socioeconomic and individual beneits, such as: • 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 scarce resources • better understanding and protection of individuals’ rights • mutually reinforcing complementarities in legal and policy frameworks • enhanced programme effectiveness and eficiency and, • better utilization of scarce human resources for health. ra pi d assessment tool Principles 13 the following key principles represent a philosophical foundation and commitments upon which linkages policies and programmes must build: Address structural determinants: root causes of Hiv and sexual and reproductive ill-health need to be addressed. this includes action to reduce poverty, ensure equity of access to key health services and improve access to information and education opportunities. Focus on human rights and gender: Sexual and reproductive rights of all people including women and men living with Hiv need to be emphasized, as well as the rights of marginalized populations such as idus, MSM, and SWs. gendersensitive policies to establish gender equality and eliminate gender-based violence are additional requirements. Promote a coordinated and coherent response: promote attention to SrH priorities within a coordinated and coherent response to Hiv that builds upon the principles of one national Hiv framework, one broad-based multi-sectoral Hiv coordinating body, and one agreed countrylevel monitoring and evaluation system (three ones principle). Meaningfully involve PLHIV: Women and men living with Hiv need to be fully involved in designing, implementing and evaluating policies and programmes and research that affect their lives. Foster community participation: Young people, key vulnerable populations, and the community at large are essential partners for an adequate response to the described challenges and for meeting the needs of affected people and communities. Reduce stigma and discrimination: More vigorous legal and policy measures are urgently required to protect plHiv and vulnerable populations from discrimination. Recognise the centrality of sexuality: Sexuality is an essential element in human life and in the individual, family and community well-being. 08 / 09 11. adapted from op. cit. 1. 12. adapted from op. cit. 1. 13. adapted from op. cit. 1. Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guide Purpose of the Tool this generic tool covers a broad range of linkages issues, such as policy, systems and services. By design, it aims to provide a guide for assessing linkages that can be adapted as needed to regional or national contexts based on a number of factors. countries are encouraged to review the questions and the scope of the assessment and modify it according to the local situation. the objective of this adaptable tool is to assess Hiv and SrH bi-directional linkages at the policy, systems and service-delivery levels. it is intended also to identify gaps, and ultimately contribute to the development of country-speciic action plans to forge and strengthen these linkages. While this tool focuses primarily on the health sector it can be adapted to cover other sectors (education, social services, and labour). there is no single formula for approaching linkages. the modalities for linking SrH and Hiv vary according to a number of national factors including: • political commitment and approach to the issues • structure and functioning of the health system and of other sectors • sociocultural and socioeconomic context • dynamics of the Hiv epidemic within the country • status of sexual and reproductive health, and • availability of human and inancial resources at all levels. Background Who developed this tool? this tool on linkages was developed by ippf, unfpa, WHo, unaidS, gnp+, icW and Young positives. Who can use the indings? the results of the needs assessment tool are particularly relevant to policy-makers, programme managers, service providers, clients, donors and partners in health. How is this tool structured? this tool is divided into three sections: i. policy ii. Systems iii. Service delivery How should this tool be used? this tool can be used as a “standalone” activity or can be integrated into a larger review of the national response. it focuses on questions which can be answered in desk reviews and individual or group interviews (policy and Systems sections), and individual interviews of various service providers and clients (Service delivery section). these approaches can be supplemented with a range of other research methodologies, including: observations of services, focus group discussions among policy-makers, service providers, and clients, collection of data from clinic records, and “mystery client” surveys. the tool is suggested for use in an assessment of policies, systems and services related to SrH and Hiv linkages. the questions provide a guide to assessing these linkages but are not meant to be exhaustive. the assessment should include group interviews with the chief current and past policy and programme decisionmakers, donors, and development partners, and individual interviews with providers and clients from a wide range of services. these include SrH, Hiv, youth-friendly services, and male-oriented services provided by the Ministry of Health (MoH), aidS organizations, private sector organizations and ngos. attention must be paid to ensure that the assessment focuses equally on the SrH and Hiv components. the assessment should include members of the national Hiv coordination body. ra pi d assessment tool this guidance tool has been developed to address the SrH and Hiv requirements of all people. However, the SrH issues that need to be addressed may vary according to gender, Hiv status, age and other factors. users of this generic guide may need to adapt the questions within to appropriately suit speciic audiences. there are also a number of services speciic to men or women that have not been mentioned directly, for example: cervical cancer screening and management, erectile dysfunction treatments, prostate cancer diagnosis, and infertility treatments. nuanced responses to questions related to these kinds of services can be addressed in any variations of the tool. this guide also acknowledges that plHiv are not a homogeneous group and that addressing their SrH and Hiv needs will require a comprehensive response. their meaningful involvement in this rapid assessment is therefore a key part of its application. this rapid assessment tool amalgamates a number of related tools that have been developed and pilot tested by a range of organizations. it can be used in whole or in part to examine linkages at the policy, system and health-service level. a still more comprehensive approach might include development of tools to assess other sectors as well, for example the education and socialservice sectors, which are beyond the scope of this tool at the present time. Who should participate in group discussions or be interviewed? 14 illustrative examples of designated interviewees/group discussion participants follows: A Policy decision-makers and programme planners 1 director-general/executive head of health, Hiv & aidS, inance, social and education services 2 programme directors of various ministries, such as education, health, women, and youth 3 programme managers of planning, clinical services, primary health care (pHc), nursing, SrH, Sti, and Hiv 4 chairperson of the country coordinating Mechanism and national aidS committees 5 director and deputy directors of the national Hiv programme 6 representatives of private sector and professional organizations 7 parliamentarians B Civil society and community leaders 1 Women’s groups and their leaders 2 faith-based organizations 3 networks and organizations of people living with Hiv 4 Youth groups 5 representatives of key vulnerable and at-risk populations 6 community-based organizations 14. 10 / 11 this depends on the national health system structure which varies substantially between countries. Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guide C Donors and development partners E Clients of the following services 1 un organizations 1 family planning 2 Bilateral and multilateral agencies 2 Maternal and newborn care, including antenatal care (anc), and post-abortion care 3 international and national ngos D Service providers in the following settings where SRH and/or HIV services are available 1 Hospitals and pHc clinics, public and private 2 School-based services (schools as delivery points, e.g. referrals of orphans and vulnerable children (ovcs)) 3 crisis centres 4 Youth centres 5 Settings relevant for key populations (e.g. prisons for incarcerated persons, refugee camps for displaced populations) 6 areas, such as crisis centres, where civil services/rights are accessed and/or requested 3 Sti prevention, treatment and care 4 Hiv prevention, treatment, care and support 5 Hiv counselling and testing 6 pMtct services 7 community care and support programmes 8 Men’s services 9 idu treatment and support services How should the assessment be conducted? the following speciic steps are recommended: 1 Establish an assessment team: the team conducts the assessment and is made up of leaders from a variety of types of organizations, including Hiv, SrH, networks of plHiv, as well as representatives from key populations and clients of services who are committed to and interested in guiding and monitoring the assessment. this broad representation will help prevent the assessment from drifting towards a more limited focus on SrH or Hiv as opposed to the linkages between both. 2 Select a coordinator: the assessment team selects a coordinator to manage the assessment process. Health and social sciences and experience in both SrH and Hiv programming are an appropriate background for the coordinator. 3 Conduct a desk review: the coordinator, with assistance and advice from the assessment team conducts a desk review, i.e. collects and analyzes background documents (see appendix 2 for further information on conducting a desk review). 4 Outline the process of the linkages assessment: the coordinator arranges a meeting of the assessment team to: • review the objectives and the process of the assessment and seek consensus • obtain suggestions on the assessment process and commitment to participate in the assessment • review and add to the relevant documents/studies and evaluations investigated in the desk review • review the planned data collection process and the generic tool and adapt the tool as necessary to the appropriate context • determine tasks and responsibilities related to invitations and letters of request for cooperation ra pi d assessment tool • select appropriate individuals to participate in group interviews and a wide spectrum of servicedelivery sites for individual interviews of providers and clients • arrange for the tabulation and analysis of the data collected and for drafting the inal report, and • arrange for a follow-up meeting to discuss results of the assessment and recommendations for next steps, including dissemination, priority setting and an action plan. 5 Host group discussions with policy and programme stakeholders and programme managers: the coordinator holds group discussions to answer the questions with a variety of policy and programme stakeholders (for the policy section), and programme managers (for the Systems section). the coordinator arranges for the answers developed in the discussion groups to be recorded (typed). 6 Train interviewers and supervise ield interviews: the coordinator trains interviewers, organizes and supervises ield interviews with providers and clients of many types of services. 7 Analyse data and compile report and presentation: the coordinator supervises the input of data from the provider and client interviews, analyses the data and develops a report and a presentation on all indings highlighting linkage successes, gaps, and possible next steps. 8 Review indings and decide on next steps: the assessment team arranges a follow-up meeting with stakeholders to review the indings and plan next steps. these may include further dissemination of the indings, adjusting or developing new training programmes (see appendix 5 for the list of Selected possible next Steps for utilizing the assessment findings). Speciic Instruments the speciic instruments to be used as interview schedules or guides for a desk review are presented in the following sections, covering policies, systems and service delivery. General introduction the tool is generic and does not attempt to cover all aspects of SrH and Hiv in the country. • the assessment team should feel free to exclude, add, and modify any questions to make them more appropriate for the country (culturally, epidemiologically, socioeconomically, etc.). • the tool was developed in response to requests from countries for guidance. it can be modiied by countries as needed. 12 / 13 • after an analysis at the country level, it is expected that the results will inform country level action. at the same time, results from around the world will inform global and regional agendas. • deinitions of the services (SrH and Hiv) that the tool intends to assess can be found in the Working deinitions of Selected terms. i. policy oveRall question: WHat iS tHe level and effectiveneSS of linkageS BetWeen Sexual & reproductive HealtH and Hiv-related policieS, national laWS, operational planS and guidelineS? ra pi d assessment tool Suggested methodology for answering questions First conduct a desk review (See Appendix 2) making notes on some of the questions with factual information available in reports and other documentation. The desk review should serve as background material for the inal report. Then consider informally conducting a few key informant interviews which can help in setting the scene and preparing for the group discussion. Next hold a 2 or 3 day retreat with key policy-makers and stakeholders to develop and record consensus answers. 11 / 12 14 / 15 Preliminary Questionnaire Information 1a interviewee(s) titles(s) and positions(s) 1c interviewee(s) id no(s) 1b interviewee(s) institution(s) 1d date of interview or retreat dd/MM/YYYY 1e name of interviewer / desk reviewer (utilize consent form here as required for individual and/or group interviews. See appendix 1 for a Sample consent form.) 11 /17 16 / 12 A. Political Positions National Policies/Guidelines item # question 2a Are there any bi-directional linkages between SRH and HIV in the country? 2b (If yes), Which linkages exist? Response/comments possible prompts: provide evidence - e.g. statements, endorsement of international consensus documents, national SrH and aidS policies, plans and inancial support. is there a strategy developed and implemented to lobby for leadership support for integrated policies and services? is there a joint planning mechanism between Hiv and SrH departments? 3a Is there a national HIV strategy/policy?15 3b (If yes) Does it include SRH issues? possible prompts: family planning within your pMtct programme? fertility and reproductive choices for plHiv? programming for dual protection? contact tracing system? 3c (If yes) Have these been made into priorities? possible prompts: funding/costed? part of national plans? legislation? Monitored? 3d 15. (If yes) To what extent do HIV policies address the rights and SRH needs of PLHIV? For these questions there may be no single strategy/policy/guideline/protocol document. Information can be taken from one or several strategies as appropriate and relevant to the country context (e.g. antenatal care strategies, HIV strategies, family planning, etc.). item # question 4a Is there a national SRH strategy/policy? 4b (If yes) Does it include HIV prevention, treatment, care and support issues? possible prompts: vct within family planning? Bcc on Hiv within SrH services? pMtct within maternal health services? Hiv treatment for plHiv? 4c (If yes) Have these been made into priorities? possible prompts: funding/costed? part of national plans? legislation? Monitored? 5 How do the respective HIV and SRH strategies/policies address the following four illustrative structural vulnerability factors: 5a Gender inequalities? 5b Low level of engagement of men in responses? 5c HIV-related stigma and discrimination? 5d Social, legislative, policy and community attitudes towards key populations (e.g. MSM, SWs, IDUs, sexual minorities, migrants, refugees, displaced populations, young people)? Response/comments 11 / 12 18 19 item # question 6a List the service protocols, policy guidelines, manuals, etc, that are speciically geared towards increasing SRH and HIV linkages. possible prompts: clinical guidelines on SrH for women living with Hiv? pep for survivors of sexual assault? Male and female condoms? routine testing for Hiv and syphilis among pregnant women? 6b Are these protocols, policy guidelines, manuals, etc, being used? 7 This part of the questionnaire aims to determine the extent to which the legislative framework supports (or does not support) the implementation of SRH and HIV linkages. (This list not exhaustive; it is given as initial guidance.) 7a Are there laws against genderbased violence? 7b (If yes) How effectively are these laws enforced? 7c (If yes) Is the public well informed about the existence of these laws? 7d (If yes) Has there been an observable change (decrease/increase) in reporting of cases of gender-based violence since the implementation of the law? Response/comments item # question 8 What is the legal age for (and is it the same for men and women): 8a Marriage? 8b HIV testing (independent of consent/ approval from a parent or caretaker)? 8c Accessing SRH services? Does it depend on marital status? 8d Consent for sexual intercourse and how does this compare to the usual age of sexual debut? 9 To what extent are the above legal ages respected and/or monitored? 10 What are the laws affecting key groups (a. SWs, b. IDUs, c. MSM , d. other) and what is their impact? 11a Are there anti-discrimination laws protecting PLHIV? 11b (If yes) Has there been legal action by PLHIV against employees/colleagues/ communities/services based on discrimination on HIV status? 11c (If yes) What was the outcome of this legal action? Response/comments 11 / 12 20 21 item # question 11d (If yes) Are the law enforcement and judiciary agents trained in the implementation of these laws? 12 Have there been any cases or are there policies or legislation to criminalise HIV transmission and, if so, what is their impact? 13 Within the broader SRH operational plan, are there any explicit activities to improve access, coverage and quality of HIV services to: 13a General population? 13b Key populations (e.g. MSM, SWs, IDUs, young people)? 13c PLHIV? 13d Men? 13e Women? 14 Within the broader HIV operational plan are there any explicit activities to improve access, coverage and quality of SRH services to: 14a General population? 14b Key populations (e.g. MSM, SWs, IDUs, young people)? 14c PLHIV? Response/comments item # question 14d Men? 14e Women? 15a What are perceived to be the common elements of a rights-based approach within SRH and HIV-related services? 15b What are the differences? 15c What can be potential contentious/ conlicting topics? possible prompts: rights of plHiv to be sexually active and to bear children Mandatory vs. voluntary Hiv testing provider-initiated Hiv testing criminalization of Hiv transmission universal access to services right to life and physical integrity right to accurate and relevant information disclosure of Hiv status contact tracing other (specify) 16a Has a workplace policy been developed and adopted by the government? 16b (If yes) Has it been adapted to include SRH components, HIV components or both? 16c (If yes) Is there a monitoring tool for its implementation at all levels across the country and how widely is it used? Response/comments 11 / 23 22 12 item # question 17a What speciic SRH and HIV policies support condom (male and female) access? 17b (If there are some policies) Are these policies stand-alone or are they delivered within other programmes/policies? 17c (If there are some policies) Are these policies aimed at protection against unintended pregnancies? Against STIs, including HIV? Or both? 18 What speciic policies are there on conidentiality and disclosure for HIVrelated services whether administered through SRH or HIV-related programmes? possible prompts: Hiv testing for minors? disclosure to Hiv-positive children? disclosure to spouses/ family/ partners/ employers? referrals to other services. (How is it administratively done? does it obey and/or violate conidentiality?) Response/comments B. Funding/Budgetary Support item # question 19 17a Whatspeciic are theSRH mainand sources of funding for: What HIV policies support condom (male and female) access? 19a SRH? 19b HIV? 19c Linkages? Possible prompts: government? donors? private sector? communities? faith-based organizations? out-of-pocket family/client contribution? 20a Do donors support SRH and HIV- related work within the same programmes? or focus on each of the two separately? 20b Are there speciic donor-driven actions to integrate and/or improve the linkages of the two? 20c Are there speciic cases of donors putting restrictions on HIV programmes regarding SRH components or vice versa, are there any speciic cases of donors putting restrictions on SRH programmes regarding HIV? Response/comments 11 / 25 24 12 item # question 21a 17a Within the HIV budget, what is the support What speciic SRH and HIV policies proportion allocated to core SRH condom (male and female) access? services within HIV-related services? 21b Within the budgets for speciic SRH services, what is the proportion allocated to HIV prevention and care within SRH? possible prompts: is there a budget line item for sexual and reproductive health commodities (female and male condoms, other contraceptives, Sti medication, safer delivery kits, etc.) in the Hiv budget? is there a budget line item for Hiv commodities (antiretroviral medication, Hiv test kits, etc.) in the SrH budget? is there a budget line item for essential sexual and reproductive health commodities that are related to Hiv within the SrH budget (e.g. male and female condoms, Sti drugs)? Response/comments ii. systems oveRall question: to WHat extent do SYSteMS Support effective linkageS of SrH and Hiv? ra pi d assessment tool Suggested methodology for answering questions: The methodology for answering these questions is similar to the methodology recommended for answering the questions in the policy section. First conduct a desk review (see Appendix 2) making notes on some of the questions with factual information available in reports and other documentation. Then consider informally conducting a few key informant interviews which can help in setting the scene and preparing for the group discussion. Next, hold a 2- or 3-day retreat with programme managers to develop and record consensus answers. It is important to recruit managers from the local, district, and national levels as their perspectives may be different. 11 / 12 26 / 27 Preliminary Questionnaire Information 1a interviewee(s) titles(s) and positions(s) 1c interviewee(s) id no(s) 1b interviewee(s) institution(s) titles(s) 1d date of interview or retreat id no(s) dd/MM/YYYY 1d date of interview or retreat dd/MM/YYYY name of interviewer / desk reviewer positions(s) 1b interviewee(s) institution(s) 1e 1e name of interviewer desk reviewer 11 / 12 28 29 A. Partnerships item # question 2 Who are the major development partners for the SRH programme? 3 Who are the major development partners for the HIV programme? 4 Who are the major champions supporting (policy, inancial and/or technical) SRH and HIV linkages? 5 Is there any multi-sectoral technical group working on linkages issues? 6a What is the role of civil society in SRH programming (in particular networks of PLHIV)? 6b What is the role of civil society in HIV programming (in particular networks of PLHIV)? 6c What is the capacity of PLHIV organizations and networks? 7 Are the following elements of civil society involved in both the SRH and HIV responses? 7a PLHIV? 7b Young people? 7c Networks or associations of key populations (e.g. SWs, IDUs, MSM)? Response/comments item # question 8 How are organizations of young people involved in responses to HIV and in SRH programming? Response/comments possible prompts: part of situation analysis? part of planning? part of budgeting? part of implementation? part of evaluation? B. Planning, Management and Administration item # question 9a Is there joint planning of HIV and SRH programmes? 9b (If yes) How is joint planning of SRH and HIV programmes undertaken? (For example, dual protection in condom programming, the HIV National Strategic Plan, proposals for the Global Fund, integration of HIV into poverty reduction strategy papers). 9c (If yes) Are people from HIV programmes involved in the SRH planning process? possible prompt: does the SrH department of the MoH include members of the national Hiv coordinating body? 9d (If yes) Are people from SRH programmes involved in the HIV planning process? possible prompt: is there any collaboration between SrH and Hiv for programme management/implementation? Response/comments 11 / 31 30 12 item # question 10a Is there any collaboration between SRH and HIV for programme management/ implementation? 10b (If yes) Provide examples. possible prompts: coordination of activities? Monitoring activities? integrated supervision of activities? integrated budgets? 11a To what extent have SRH services integrated HIV and have HIV services integrated SRH? 11b What institutions are providing integrated services for HIV and SRH? possible prompts: government facilities? ngos? faith-based organizations? community-based organizations? private sector? Response/comments C. Stafing, Human Resources and Capacity Development item # question 12 What are some of the highest priority training needs, i.e. who needs to be trained on what subjects or skills? (See sample table in appendix 4 for health sector) 13 Does capacity building on SRH and HIV integrate guiding principles and values? possible prompts: avoidance of stigma and discrimination? gender sensitivity? Male involvement? attitudes towards key populations? attitudes towards plHiv? conidentiality? Youth-friendly services? reproductive rights and choices? 14a Are there training materials and curricula on SRH which include HIV prevention, treatment and care at programme and service-delivery levels and as part of pre-service training? 14b ... As part of in-service training? 14c Are there training materials and curricula on HIV which include SRH at programme and service-delivery levels and as part of pre-service training? 14d ... As part of in-service training? possible prompts: for community outreach workers? for health-care providers? Response/comments 11 / 33 32 12 item # question 15 Are curricula and training materials revised and updated regularly? 16 Does late primary and/or secondary education and/or teacher-training curricula incorporate SRH and HIV at the levels mentioned below? 16a Late primary? 16b Secondary education? 16c Teacher training? possible prompts: Safer sex? Sexual health? empowerment? Stigma? gender-based violence? condoms? rights? 17a In relation to staff for SRH and HIV programmes, what are the biggest challenges? possible prompts: retention? recruitment? task shifting? Workload and burnout? Quality? 17b How has the integration of services inluenced these challenges? 17c What solutions have you found to those challenges? Response/comments D. Logistics/Supplies item # question 18 To what extent do logistics systems support or hinder effective service-delivery integration? possible prompts: Separate supply system for Hiv and pHc/SrH? planning and supply of commodities (e.g. condoms, drugs) for both Hiv and SrH? Separate recording and monitoring of SrH and Hiv? Response/comments 11 / 35 34 12 E. Laboratory Support item # question 19 Do laboratory facilities serve the needs for both SRH and HIV services? possible prompts: Haemoglobin concentration? Blood grouping and typing? Sti diagnosis, including rpr/vdrl (for syphilis)? Hiv diagnosis, including rapid tests? cd4 count? Hiv viral load? liver function tests? urinalysis? random blood sugar? pregnancy testing? Response/comments F. Monitoring and Evaluation item # question 20a How do the monitoring and evaluation structures capture results of integration in SRH programmes? possible prompts: access to services? uptake of services? Quality? client satisfaction? client proile? 20b How do the monitoring and evaluation structures capture results of integration in HIV programmes? possible prompts: (as above) 21a What indicators are being used to capture integration between SRH and HIV and are they adequate in HIV programmes? possible prompts: Hiv clients receiving SrH services? SrH clients receiving Hiv services (e.g. % of fp clients offered Hiv counselling and testing)? (e.g. % of Hiv-positive clients who receive support to achieve their fertility choices or who receive support to address socio-economic challenges)? 21b What indicators are being used to capture integration between SRH and HIV and are they adequate in SRH programmes? possible prompts: (as above) Response/comments 11 / 37 36 12 item # question 22 To what extent does supportive supervision at the health service-delivery level support effective integration? possible prompt: is there a tool for integrated supervision available (e.g. checklist)? 23 Are data collected on SRH and HIV disaggregated by sex, age and HIV status? possible prompts: What are the respective ages for a) females and b) males with respect to: i) age of majority age at irst sexual intercourse? ii) legal age of marriage? iii) other demographic categories? Response/comments 16 iii. clinical seRvice deliveRy oveRall question: to WHat extent are Hiv ServiceS integrated into SrH ServiceS and SrH ServiceS integrated into Hiv ServiceS? 16. Services refer to clinical care, including health education within clinical care. ra pi d assessment tool Suggested methodology for answering questions: Visit a selection of at least 15 service delivery sites. Include a balance of SRH and HIV services. Include sites run by MOH, AIDS organizations, FBO, NGO and the private sector. Balance sites providing services to women and to men. 11 / 12 38 / 39 Preliminary Questionnaire Information 1a province/region 1e date of interview dd/MM/YYYY 1b district 1f type of sponsoring agency 1c facility/Ward 1g title and role of respondent 1d interviewee number 40 / 41 A. Provider Interview: (i) HIV integrated into SRH item # question Response/comments 2a Which of the following essential SRH services are offered at this facility? 1. family planning [read all options. tick all as appropriate] 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 8. unsure, don’t know   item # question Response/comments 2b Which of the following essential HIV services are integrated with SRH services at this facility? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support    5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision 8. pMtct (four prongs)   a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify) : 10. other services (specify): 11. no integration 12. unsure, don’t know   11 / 43 42 12 item # question Response/comments 3a Which of the following HIV services are included in family planning services? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support    5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision 8. pMtct (four prongs)   a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify): 10. other services (specify): 11. no integration (omit Q4a) 12. unsure, don’t know   item # question Response/comments 3b Which of the following HIV services are included in prevention and management of STI services? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support    5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision  8. pMtct (four prongs) a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify): 10. other services (specify): 11. no integration (omit Q4b) 12. unsure, don’t know   44 / 45 item # question Response/comments 3c Which of the following HIV services are included in maternal and newborn care services? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support   5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision 8. pMtct (four prongs)   a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify): 10. other services (specify): 11. no integration (omit Q4c) 12. unsure, don’t know   item # question Response/comments 3d Which of the following HIV services are included in the prevention and management of gender-based violence? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support    5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision 8. pMtct (four prongs)   a. 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify): 10. other services (specify): 11. no integration (omit Q4d) 12. unsure, don’t know   46 / 47 item # question Response/comments 3e Which of the following HIV services are included in prevention of unsafe abortion and management of post-abortion care services? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing)  b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling)  2. prophylaxis and treatment for plHiv (ois and Hiv)  3. Home-based care 4. psycho-social support   5. prevention for and by people living with Hiv  6. Hiv prevention information and services for general population  7. condom provision  8. pMtct (four prongs)  a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations a. idus (for example, harm reduction) b. MSM c. SWs    d. other key populations (specify): 10. other services (specify): 11. no integration (omit Q4e) 12. unsure, don’t know   item # question Response/comments 4a How does your facility offer HIV services within family planning? 1. located in the same service site with the same provider (read all options. tick all as appropriate) 1a. offered on the same day?  2. located within the same service site with a different provider   2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 4b How does your facility offer HIV services within prevention and management of STI services? (read all options. tick all as appropriate) 1. located in the same service site with the same provider  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   48 / 49 item # question Response/comments 4c How does your facility offer HIV services within maternal and newborn care services? 1. located in the same service site with the same provider (read all options. tick all as appropriate)  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 4d How does your facility offer HIV services within management of gender-based violence services? (read all options. tick all as appropriate) 1. located in the same service site with the same provider  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   item # question Response/comments 4e How does your facility offer HIV services within prevention of unsafe abortion and management of post-abortion care services? 1. located in the same service site with the same provider (read all options. tick all as appropriate)  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 5a In this facility, is there any follow-up to see whether clients act on referrals? 5b (If yes) How is followup carried out? 5c (If no) Why not? 1. Yes (>Q5b) 2. no (>Q5c)   3. don’t know  1. too busy  2. not necessary 3. clients usually return on their own 4. don’t know 5. other (specify):     11 / 51 50 12 item # question 6 How have SRH services been reoriented to accommodate clients living with HIV or vulnerable to HIV? possible prompts: links with networks of plHiv? capacity building? Support groups? Staff training with regards to attitudes? 7 Is there any structural collaboration (formal arrangement) with a community-based HIV organization? possible prompts: Monthly meetings Memorandum of understanding Response/comments (ii) SRH integrated into HIV item # question Response/comments 8 Which of the following essential HIV services are offered at this facility? 1. Hiv counselling and testing [read all options. tick all as appropriate]  (if yes) a. vct (clients come to request Hiv counselling and testing) b. provider-initiated testing and counselling (clients are routinely offered Hiv testing and counselling) 2. prophylaxis and treatment for plHiv (ois and Hiv) 3. Home-based care 4. psycho-social support     5. prevention for and by people living with Hiv  6. Hiv prevention, information and services for general population  7. condom provision  8. pMtct (four prongs)  a. prong 1: prevention of Hiv among women of childbearing age and partners  b. prong 2: prevention of unintended pregnancies in Hiv+ women  c. prong 3: prevention of Hiv transmission from an Hiv+ woman to her child  d. prong 4: care & support for the Hiv+ mother and her family  9. Speciic Hiv information and services for key populations  a. idus (for example, harm reduction) b. MSM c. SWs d. other key populations (specify):    10. other services (specify): 11. unsure, don’t know 12. none (> Q16)   52 / 53 item # question Response/comments 9 Which of the following essential SRH services are integrated with HIV services at this facility? 1. family planning [read all options. tick all as appropriate] 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none (> Q16) 10a Which of the following SRH services are included in HIV counselling and testing services? [read all options. tick all as appropriate]  8. unsure, don’t know  1. family planning  2. prevention and management of Stis  3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 8. unsure, don’t know   item # question Response/comments 10b Which of the following SRH services are included in prophylaxis and treatment (OI and HIV) services? 1. family planning [read all options. tick all as appropriate] 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 10c Which of the following SRH services are included in home-based care services? [read all options. tick all as appropriate]  8. unsure, don’t know  1. family planning  2. prevention and management of Stis  3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 8. unsure, don’t know   54 / 55 item # question Response/comments 10d Which of the following SRH services are included in psychosocial support services? 1. family planning [read all options. tick all as appropriate] 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 10e  8. unsure, don’t know  Which of the following SRH services are included in services for prevention for and by people living with HIV? 1. family planning  3. Maternal and newborn care  [read all options. tick all as appropriate] 4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  2. prevention and management of Stis  6. other (specify): 7. none 8. unsure, don’t know   item # question Response/comments 10f Which of the following SRH services are included in HIV prevention and information services for general population? 1. family planning 3. Maternal and newborn care  [read all options. tick all as appropriate] 4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  2. prevention and management of Stis   6. other (specify): 7. none 10g Which of the following SRH services are included in condom provision services? [read all options. tick all as appropriate]  8. unsure, don’t know  1. family planning  2. prevention and management of Stis  3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 8. unsure, don’t know   56 / 57 item # question Response/comments 10h Which of the following SRH services are included in PMTCT services? 1. family planning [read all options. tick all as appropriate] 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 10i Which of the following SRH services are included in speciic services for key populations? [read all options. tick all as appropriate]  8. unsure, don’t know  1. family planning  2. prevention and management of Stis  3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. other (specify): 7. none 8. unsure, don’t know   item # question Response/comments 11a How does your facility offer SRH services within HIV counselling and testing services? 1. located in the same service site with the same provider [read all options. tick all as appropriate]  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 11b How does your facility offer SRH services within services for prophylaxis and treatment for PLHIV (OIs and HIV)? [read all options. tick all as appropriate] 1. located in the same service site with the same provider  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   58 / 59 item # question 11c Does your facility offer SRH services within home-based care? Response/comments (If yes) Please specify the model of outreach utilised possible prompts: community based provision of SrH commodities within home-based care? SrH outreach programmes? plHiv peer educators conduct home visits? 11d How does your facility offer SRH services within psycho-social support? [read all options. tick all as appropriate] 1. located in the same service site with the same provider  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   item # question Response/comments 11e How does your facility offer SRH services within services for prevention for and by people living with HIV? 1. located in the same service site with the same provider [read all options. tick all as appropriate]  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 11f How does your facility offer SRH services within HIV prevention and information services for general population? [read all options. tick all as appropriate] 1. located in the same service site with the same provider  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   60 / 61 item # question Response/comments 11g How does your facility offer SRH services within condom provision services? 1. located in the same service site with the same provider [read all options. tick all as appropriate]  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 11h How does your facility offer SRH services within PMTCT services? 1. located in the same service site with the same provider [read all options. tick all as appropriate] 1a. offered on the same day?  2. located within the same service site with a different provider   2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility 5. other (specify):   item # question Response/comments 11i How does your facility offer SRH services within speciic services for key populations? 1. located in the same service site with the same provider [read all options. tick all as appropriate]  1a. offered on the same day?  2. located within the same service site with a different provider  2a. offered on the same day?  3. referred to a different service site within the facility  3a. offered on the same day? 4. referred to another facility   5. other (specify): 12a In this facility, is there any follow-up to see whether clients act on referrals? 12b (If yes) How is follow-up done? 12c (If no) Why not? 1. Yes (>Q12b) 2. no (>Q12c)   3. don't know  1. too busy  2. not necessary 3. clients usually return on their own 4. don't know 5. other (specify):    62 / 63 item # question 13 How have HIV services been assessed and reoriented to accommodate the SRH needs of clients living with HIV? possible prompts: prevention for and by people living with Hiv? discussions about reproductive rights and choices, and sexuality? 14 Is there any structural collaboration (formal arrangement) with an SRH organization? possible prompts: Monthly meetings Memorandum of understanding 15a Do you have protocols/ guidelines that support integrated service delivery? 15b (If yes) For which services? 15c (If yes) Are they used? Response/comments (iii) Overall Perspective on Linkages in SRH and HIV Services item # question 16 What do you believe are some of the policies and procedures in place that serve as the most important challenges and constraints to strengthening linkages between SRH and HIV services? 17 Please rate each of the following as to how large a constraint it is to offering linked SRH and HIV services at this facility. Would you say it was not a constraint, a small, a medium, or a large constraint? Response/comments Not a Constraint Small Medium Large Don't Know 17a Shortage of equipment for offering integrated services 1 2 3 4 5 17b Shortage of space for offering private and conidential services 1 2 3 4 5 17c Shortage of staff time 1 2 3 4 5 17d Shortage of staff training 1 2 3 4 5 17e Inappropriate/insuficient staff supervision 1 2 3 4 5 17f Low staff motivation 1 2 3 4 5 17g Some other constraint? (specify): ___________ 1 2 3 4 5 64 / 65 item # question 18 What do you believe are some of the most important policies and procedures in place that facilitate the strengthening of linkages between SRH and HIV services? 19 What do you think is or will be the likely impact of linking SRH and HIV services on the following service dimensions. Will they decrease, increase or not change the (read each dimension below)? Response/comments Decrease No change Increase Don't know 19a Costs of services (facility) 1 2 3 4 19b Cost of services (client) 1 2 3 4 19c Eficiency of services 1 2 3 4 19d Stigmatization of HIV clients 1 2 3 4 19e Stigmatization of SRH clients 1 2 3 4 19f Workload for providers 1 2 3 4 19g Time spent per client 1 2 3 4 19h Space and privacy 1 2 3 4 19i Need for equipment, supplies, and drugs 1 2 3 4 19j Other (please specify) __________ 1 2 3 4 thank you very much for your time and assistance! B. Client Exit Interview this interview is based on prior informed consent by the client (see appendix 1 for a sample consent form) 1a province/region 1b district 1c facility 1f Service from which client is exiting family planning Management of Stis Maternal and newborn care prevention of unsafe abortion and management of post-abortion care Hiv counselling and testing Management of oi or Hiv infection other (specify):       don't know    1d interview number 1g Sex of client female Male 1e date of interview dd/MM/YYYY 2 What is your age? 66 / 67 item question Response/comments 3 Please tell me what services you came for today? 1. family planning (do not read. listen and tick all that apply. probe: any others?) 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. Hiv counselling and testing 7. treatment preparedness 8. Hiv monitoring and/or treatment 9. Hiv prevention 10. condom services 11. pMtct 12. economic assistance 13. psycho-social support        14. nutrition support  15. routine gynaecological examination (including pap smear, breast exam, etc.)  16. don’t know  17. other (specify): 18. refused to answer  item question Response/comments 4 What services did you receive today (excluding those provided outside the facility by referral)? 1. family planning (do not read. listen and tick all that apply. probe: any others?) 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. Hiv counselling and testing 7. treatment preparedness 8. Hiv monitoring and/or treatment 9. Hiv prevention 10. condom services 11. pMtct 12. economic assistance 13. psycho-social support         14. nutrition support  15. routine gynaecological examination (including pap smear, breast exam, etc.)  16. don’t know  17. other (specify): 18. refused to answer  68 / 69 item question Response/comments 5a Were you referred to any other services than those for which you came? 1. Yes 5b Did you get all of the services you wanted today?  2. no  1. Yes  2. no (>Q5c & Q5d) 3. not sure   4. other (specify): 5c (If no) What other services would you have liked to get from this facility today? (do not read. listen and tick all that apply. probe: any others?) 1. family planning 2. prevention and management of Stis   3. Maternal and newborn care  4. prevention and management of gender-based violence  5. prevention of unsafe abortion and management of post-abortion care  6. Hiv counselling and testing 7. treatment preparedness 8. Hiv monitoring and/or treatment 9. Hiv prevention 10. condom services 11. pMtct 12. economic assistance 13. psycho-social support         14. nutrition support  15. routine gynaecological examination (including pap smear, breast exam, etc.)  16. don’t know  17. other (specify): 18. refused to answer  item question Response/comments 5d (If no) Why did you not receive all the services you wanted? 1. cost (do not read. listen and tick all that apply. probe: any others?) 2. not available 3. i didn’t have time    4. the nurse/doctor didn’t have time  5. i didn’t feel comfortable requesting the service  6. i didn’t know that that service was available to me  7. don’t know  8. other (specify): 6a Do you prefer sexual and reproductive health and HIV services at the same facility, or do you prefer different facilities? 9. refused to answer  1. prefer same facility/site  2. prefer a different facility/site 3. no preference 4. don't know 5. other (specify): 6b Why?    70 / 71 item question Response/comments 7a What do you think may be some of the possible beneits of receiving all these services from the same facility at one time? 1. reduce number of trips to facility (do not read. listen and tick all that apply. probe: any others?) 4. reduce fees 2. improve eficiency of services 3. reduce transportation costs     5. reduce waiting time  6. good opportunity to access additional services  7. reduce stigma for Hiv (if yes) probe: in what way? 8. don’t know   9. other (specify): 7b What do you think may be some of the possible disadvantages of receiving all these services from the same facility at one time? (do not read. listen and tick all that apply. probe: any others?) 1. fear of stigma and discrimination  2. fear of less conidentiality  3. embarrassment to talk about Hiv with provider of same village/ neighbourhood  4. increase client waiting time 5. provider will be too busy 6. decrease quality of services 7. don’t know 8. other (specify):     item question Response/comments 8a Do you prefer sexual and reproductive health and HIV services from the same provider or do you prefer referral to another provider? 1. prefer same provider 2. prefer referral to another provider 3. no preference 4. don't know     5. other (specify): 8b Why? 9 What do you think may be some of the possible beneits of receiving all these services from the same provider at one time? 1. reduce number of trips to facility (do not read. listen and tick all that apply. probe: any others?) 4. reduce fees 2. improve eficiency of services 3. reduce transportation costs 5. reduce waiting time 6. good opportunity to access additional services 7. reduce Hiv-related stigma (if yes) probe: in what way? 8. don’t know 9. other (specify):        72 / 73 item question Response/comments 10 What do you think may be some of the possible disadvantages of receiving all these services from the same provider at one time? 1. fear of stigma and discrimination (do not read. listen and tick all that apply. probe: any others?)  2. fear of less conidentiality  3. embarrassment to talk about Hiv with provider of same village/neighbourhood  4. increase client waiting time 5. provider will be too busy 6. decrease quality of services 7. don’t know     8. other (specify): 11 Please tell me which of the following your provider mentioned today? (read and tick all that apply.) 1. family planning  2. use of condoms to prevent unintended pregnancy  3. use of condoms to prevent Hiv/Sti 4. use of female condoms 5. Sti management 6. Hiv prevention 7. relationships 8. Sexuality       9. counselling and testing for Hiv  10. preventing transmission of Hiv to your “baby”  11. Breast cancer screening 12. cervical cancer screening 13. Hiv is treatable with art 14. care and support for plHiv 15. child health services 16. vaccination 17. labour and delivery 18. domestic or other violence         item question Response/comments 19. Women’s rights 20. Men’s health 21. Health needs of young people    22. anything else that interested you (specify): 12 If you could make only one suggestion for improving services at this facility, what would you suggest? 13 Do you have any suggestions about the integration of sexual and reproductive health and HIV services? 14a How satisied are you with the services you received today? 1. very dissatisied 2. Somewhat dissatisied 3. Mostly satisied 4. very satisied 5. don’t know 6. does not wish to answer 14b What might have helped you to be more satisied with the services you received today? thank you very much for your time and assistance!       11 / 75 74 12 Appendix 1. Sample Consent Form Informed Consent Interviewer: Read the consent statement below to the interviewee prior to conducting the interview. Hello! My name is in coordination with (partners) a working group is conducting an assessment on policies, systems, and services related to SrH and Hiv linkages. this information may help to improve policies, programmes and services. We would appreciate it if you could answer some questions. However, your participation in this study is voluntary and if you choose not to participate, you will not be penalized in any way. if you agree to participate and you change your mind later, you can also ask me to stop the interview whenever you want. if you participate, you will not beneit directly from your participation. But your participation may result in improved future sexual and reproductive health and Hiv policies and services. Your opinions and the information you give during the interview will remain conidential. the questionnaire will not have your name. this way, no one will be able to know that i interviewed you or what you said. finally, if you have any questions about this study at a later time, you can call this phone number May i continue with the questions? ____ Yes ____ no ra pi d assessment tool 76 / 77 Appendix 2. Conducting a Desk Review a desk review is a process for collecting, reviewing and analyzing what is known about a subject (such as linkages between SrH and Hiv) based on a broad review of published articles, surveys, research, plans and other written reports. it may also include “grey literature” such as unpublished trip reports and research studies from agencies working in the subject area. for the desk review of linkages, these documents include but are not limited to: Hiv ive-year national plans; national strategic frameworks; unaidS country reviews; MoH statistics; behaviour surveillance surveys; demographic and Health Surveys; situation analysis studies of SrH services and/or service provider assessment reports; reproductive health surveys; sexual behaviour surveys, Hiv and SrH training materials; and other documents. it is important to have documents covering the legal environment impacting plHiv, the rights and status of women and children, conidentiality of services, stigma and discrimination, and key groups such as MSM, SWs, and idus. important also are documents from the MoH and other prominent service providers, such as fBos and networks of plHiv which include policy statements; guidelines for service delivery; protocols for delivery of services; etc. (it is crucial to remember the importance of bidirectionality in the desk review and to gather material that covers the Hiv and the SrH programmes, agencies and services.) a careful collection and review of this health and Hiv programmatic and legal literature will provide overall introductory insights and facts on the state of linkages in SrH and Hiv policies, systems and service delivery in the country of interest. Many of the questions on policies and systems in the rapid assessment tool can be tentatively answered through a review of these documents and these should be recorded in the tools. these tentative answers can be checked with knowledgeable persons during the individual interviews or group discussions with stakeholders and programme managers. Appendix 2. Conducting a Desk Review Some more speciic guidance is provided below: What should be searched in the policies? To what policies should the desk review attend? explicit mention of key issues: • constitution • national laws • decentralized regional or provincial bylaws • Human rights as they relate to sexuality, including reproduction • key populations • Stigma and discrimination • gender equality and issues • decrees and local regulations • access to treatment • international declarations, conventions, commitments, agreements, policy statements signed and/or issued by the government • age of consent • Sectoral policies and strategic plans • treatment • donor policies (and how governments interact with donor policies) • informed consent • condoms/contraceptives/ commodities for all of the above • When was the policy/ statement created/voiced? • civil society policies/manifestos • How often? • decentralisation policies (depends from country to country) • By whom? • private sector policies • Written? verbal? • in what context? • opposition/ support? • plans/funds available for implementation? costed? in other words, for all the policies, whenever SrH is mentioned, check if Hiv is mentioned. and vice versa, whenever Hiv is mentioned check for SrH. accessibility statements • geographic • demographic • affordability for each policy look at decentralisation strategies. lastly, it is important to document ‘intangible’ policies/practices (e.g. attitudes towards key populations, early marriage, and sexuality vs. reproduction). ra pi d assessment tool 78 / 79 Appendix 3. Budget Outline for Estimating Cost of Conducting a Two-Month Rapid Assessment time in days 1. Personnel i. National Consultant desk review arranging group discussions holding group discussions training interviewers supervising ield interviews data analysis dissemination and next steps provide feedback to participants ii. Interviewers training ield interviews iii. Data Entry persons input from approx. 30-48 providers and 60-96 clients 2. Tool Adaption i. Stakeholders preparatory meeting venue hire per diems transport est. cost/day $ estimated cost $ Appendix 3. Budget Outline for Estimating Cost of Conducting a Two-Month Rapid Assessment time in days ii. Tool production translation printing dissemination 3. Field implementation i. Per diem for ield interviewing interviewer supervisor drivers ii. Vehicle rental and fuel 4. Retreat expenses for group persons x nights x groups 5. Misc (Tea, photocopy, etc.) 6.Data Management (computers and software) 7. Dissemination workshop and follow-up activities TOTAL est. cost/day $ estimated cost $ ra pi d assessment tool Notes and Assumptions Possible Eficiencies Sites, providers, clients: each ield interviewer will visit 5-8 facilities for 1 full day each. each will interview 10-16 providers/supervisors (2/ facility), and 20-32 clients (4/facility). • per diem expenses can be reduced signiicantly by including urban facilities in the capital for one interviewer. Since public transport can be used, this saves on car rental and petrol costs for one car and per diem costs for one driver. retreats: group discussions can best be held in retreat so as to allow focus on the task without interruptions of competing appointments, telephone calls, etc. 80 / 81 • the study can be implemented with only one vehicle if one team uses public transport in the city, and the two rural interviewers visit facilities that are relatively close together allowing one vehicle to deliver and pick up both interviewers. • a MoH, Hiv programme, WHo, or unfpa vehicle may be available, potentially eliminating the cost of vehicle rental. 1 counselling (specify type, e.g. family planning, sexuality, etc.) 2 family planning methods (specify type) 3 life-saving skills and emergency obstretric care 4 5 6 adolescent /youth-friendly health services (afHS) Sti syndromic management antenatal care, labour and delivery, postpartum care 7 Sti prevention counselling 8 gender-based violence counselling and related services 9 Hiv prevention counselling 10 Hiv pre and post-test counselling 11 Hiv testing 12 pMtct 13 antiretroviral provision 14 condom provision CHW community health workers C/D clinic/dispensary H/Asst Health assistants HC Health centre Hosp Hospital Lab tech & Lab asst laboratory technicians and assistants NA nursing aides PHN primary health nurse Appendix 4. Health Workers’ Capacity to Perform SRH and HIV Functions17 pRovincial/Regional, distRict and Facility levels CADRE OF HEALTH STAFF NUMBER AVAILABLE NUMBER AND % TRAINED IN SRH BY SKILLS Hosp HC C/D 1 physicians nurses Midwives clinical oficers/ Medical assistants Health assistants psychologists Sociologists counsellors anaesthetists pharmacists & pharmacist asst. lab tech & lab asst. nurse assts/na/pHn peer educators community- Based distribution agents/cHWs 2 3 4 NUMBER & % TRAINED IN BOTH SRH AND HIV NUMBER AND % TRAINED IN HIV BY SKILLS 5 6 7 8 9 10 11 12 13 14 82 / 83 ra pi d assessment tool Appendix 5. List of Selected Possible Next Steps for Utilizing the Assessment Findings 1 Hold a dissemination workshop to discuss the indings and recommendations. invite representatives from development partners (including donors) and from all systems (planning and administration, training, M&e, Bcc, etc.) from the MoH, and other civil society institutions implementing health and/or Hiv programmes, plHiv and key populations, and from other relevant sectors. provide attendees a copy of the report two weeks before the meeting. 2 review gaps noted in policy issues in individual meetings with senior policy decision-makers in the SrH and Hiv programmes, the Ministry of Justice, the Ministry of education and other appropriate sector leaders. 3 discuss implications of indings with personnel in charge of preservice and in-service training for the health services and Hiv programmes. Work with them to adjust curricula and methods to cover the importance of creating linkages between SrH and Hiv policies, systems and services. 4 Jointly review indings with Bcc staff from the Hiv and SrH programmes identifying how linkages can be strengthened in mass communication and public education programmes. 5 if the initial study was exploratory, plan a larger study to further investigate linkages on a national scale. 6 establish a national (or regional) task force to monitor progress on strengthening linkages, for example. it is based on the need to offer comprehensive services. 7 involve sectors outside of health such as education and social services – and explore how their programme activities can be linked with the SrH and Hiv programmes. Where policies are not conducive to linkages, take steps to correct. 17 . this appendix is illustrative and may be adapted in content and format as required. Extra space for question responses/comments 

Linking Sexual and Reproductive Health and HIV/AIDS Gateways to integration a case study from Serbia Investing in Youth: Reaching those most vulnerable to HIV © 2009 WHO, UNFPA, UNAIDS, IPPF Disclaimer All rights reserved. The publishers welcome requests to translate, adapt or reproduce the material in this document for the purpose of informing health care providers, their clients, and the general public, as well as improving the quality of sexual and reproductive health and HIV/AIDS care. Enquiries should be addressed to WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (fax: +41 22 791 4806; email: permissions@who.int), UNFPA, 220 East 42nd Street, New York, NY 10017, USA (tel: +1 212 297 5000; email: info@unfpa.org), UNAIDS, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3666; email: unaids@unaids.org) or IPPF, 4 Newhams Row, London, SE1 3UZ, United Kingdom (fax: +44 207 939 8300; email: HIVinfo@ippf.org). Only authorized translations, adaptations and reprints may bear the emblems of WHO, UNFPA, UNAIDS, IPPF. Translations, adaptations and reproductions may be made without authorization so long as they are not used in conjunction with any commercial or promotional purposes, and so long as they do not use the emblems of the publishing organizations, and so long as they acknowledge the original source in line with the suggested citation below. The publishing organizations do not accept responsibility for any translations, adaptations and reproductions published by others. The publishers request print and electronic copies of all translations, adaptations and reproductions of this publication. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the publishing organizations in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the publishers to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO, UNFPA, UNAIDS, IPPF be liable for damages arising from use of this publication. This publication does not necessarily represent the decisions or the stated policy of WHO, UNFPA, UNAIDS, IPPF. Suggested citation for unofficial translations or adaptations of this tool: Linking Sexual and Reproductive Health and HIV/AIDS, Gateways to Integration: A case study from Serbia, prepared and published by WHO, UNFPA, UNAIDS, IPPF, 2009. Printed in London, United Kingdom, September 2009. Acknowledgements 2 Acronyms and abbreviations 2 Linking Sexual and Reproductive Health and HIV/AIDS Global commitments to strengthen linkages 3 Identifying and meeting the challenges 4 Tools to make it happen 4 Turning theory into practice 5 A case study from Serbia Vital statistics at a glance 6 Evolution of service provision: First steps toward integration 7 STI/HIV Centre: A six step model of care 8 At the clients' convenience: HIV counselling and testing at night 10 From theory to practice 11 Young people as service providers 11 Addressing judgemental attitudes 11 Satellite clinic for high school students: Reaching vulnerable young people 11 Raising awareness: Taking the message to where the students are 12 Outreach with sex workers: The ‘power of prevention’ 13 Reaching young people with disabilities 14 “Prejudiced? Me? But I’m a professional!” 15 Expanding the model 16 Challenges: Organizational, structural and policy constraints 17 Investing in the future: Conclusions and lessons learned 18 Contact details for more information 20 Endnotes 20 Gateways to integration: a case study from Serbia 1 A case study from Serbia Acknowledgements This case study is part of a series of joint publications of WHO, UNFPA, UNAIDS and IPPF on the issue of strengthening linkages between sexual and reproductive health and HIV/AIDS. The document is based on country experiences and is the result of a joint effort of national experts and a group of public health professionals at WHO, UNFPA, UNAIDS and IPPF. The publishing organizations would like to thank all partners for contributing their experience, for reviewing numerous drafts and for valuable advice at all stages. Special thanks go to the following people who provided technical input and support for this publication: Main author: Susan Armstrong. Main contributors: Lynn Collins (UNFPA) and Kevin Osborne (IPPF) Reviewers: From ISH: Dragan Ilic and Mila Paunic. From WHO: Manjula Lusti-Narasimhan, Michael Mbizvo and Jos Perriens. From UNFPA: Ramiz Alakbarov, Christina Bierring, Aleksander Bodiroza, Josiane Khoury, Steve Kraus, Alexei Sitruk and Sylvia Wong. From UNAIDS: Anindya Chatterjee, Barbara De Zalduondo, Emma Fowlds and Mahesh Mahalingam. The Joint UN Team on AIDS in Serbia. From IPPF: Andy Guise, Jon Hopkins, Dieneke ter Huurne, Divinia Sebastian and Ale Trossero. Acronyms and abbreviations AIDS Acquired Immune Deficiency Syndrome HIV Human Immunodeficiency Virus IPPF International Planned Parenthood Federation ISH Institute for Students’ Health SOAAIDS STI AIDS Netherlands (an expertise centre for HIV/AIDS and other STIs) STI Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WHO World Health Organization 2 Gateways to integration: a case study from Serbia Linking Sexual and Reproductive Health and HIV/AIDS The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding, all of which are fundamental elements of sexual and reproductive health care. In addition, sexual and reproductive health problems share many of the same root causes as HIV/AIDS, such as poverty, gender inequality, stigma and discrimination, and marginalization of vulnerable groups. Despite this, services for sexual and reproductive health and for HIV/AIDS still largely exist as separate, vertical programmes. Global commitments to strengthen linkages Building blocks To raise awareness of the pressing need for more widespread linkages between sexual and reproductive health and HIV/AIDS, UNFPA and UNAIDS, in collaboration with Family Care International, held a high-level consultative meeting in June 2004 with government ministers and parliamentarians from around the world, ambassadors, leaders of United Nations and other multilateral agencies, non-governmental and donor organizations, as well as young people and people living with HIV. The meeting resulted in The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health,i which challenges the sexual and reproductive health and HIV/AIDS communities to examine how they might improve collaboration. An earlier meeting, held in Glion, Switzerland (May, 2004), and initiated by WHO and UNFPA, took a close look at the role of family planning in reducing HIV infection among women and children. This conference resulted in The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children.ii In December 2005, a global partners’ meeting was convened to discuss progress in implementing a comprehensive approach to prevention of mother-to-child transmission. This consultation also stressed the importance of linking sexual and reproductive health and HIV/AIDS services, and led to a Call to Action: Towards an HIV-free and AIDSfree Generation,iii as did the most recent PMTCT consultation in Johannesburg November 2007, resulting in a Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services.iv Linking HIV/AIDS and sexual and reproductive health was included as one of the Essential Policy Actions for HIV Prevention in the UNAIDS policy position paper on Intensifying HIV Prevention, which was issued in 2005.v Framework for universal access The above commitments culminated in the Political Declaration on HIV/AIDS arising from the 2006 Review of the United Nations Special Session on HIV/AIDS (UNGASS), which also stressed how vital it is to link HIV/AIDS with sexual and reproductive health.vi Following the commitment by G8 members1 and, subsequently, heads of states and governments at the 2005 United Nations World Summit, the UNAIDS Secretariat and its partners have been defining a concept and a framework for Universal Access to HIV/AIDS Prevention, Treatment and Care by 2010.vii Efforts towards universal access underline the importance of strengthened linkages between sexual and reproductive health and HIV/AIDS. 1 G8 summits: Since 1975, the heads of state or government of the major industrial democracies have been meeting annually to deal with the major economic and political issues facing their domestic societies and the international community as a whole. G8 countries are France, United States, United Kingdom, Germany, Japan, Italy, Canada and the Russian Federation. Gateways to integration: a case study from Serbia 3 Linking Sexual and Reproductive Health and HIV/AIDS The potential benefits of linking sexual and reproductive health and HIV/AIDS include: • improved access to sexual and reproductive health and HIV services • increased uptake of services • better sexual and reproductive health services, tailored to meet the needs of women and men living with HIV • reduced HIV/AIDS-related stigma and discrimination • improved coverage of under-served and marginalized populations, including sex workers, people who use drugs and men who have sex with men • greater support for dual protection against unintended pregnancies and sexually transmitted infections, including HIV • improved quality of care • enhanced programme effectiveness and efficiencyviii Another aim of linking sexual and reproductive health and HIV/AIDS is to accelerate progress towards achieving the goals agreed at the International Conference on Population and Developmentix and the Millennium Development Goals,x especially those that aim to reduce poverty, promote gender equality and empower women, improve maternal health, combat HIV/AIDS, and attain universal access to sexual and reproductive health. Identifying and meeting the challenges Linking sexual and reproductive health and HIV/AIDS policies and services presents many challenges for those on the front line of health care planning and delivery. These include:xi • making sure that integration does not overburden existing services in a way that compromises service quality, by ensuring that integration actually improves health care provision • managing the increased workload for staff who take on new responsibilities • allowing for increased costs initially when setting up integrated services and training staff • combating stigma and discrimination from and towards health care providers, which has the potential to undermine the effectiveness of integrated services no matter how efficient they are in other respects • adapting services to attract men and young people, who tend to see sexual and reproductive health, and especially family planning, as ‘women’s business’ • reaching those who are most vulnerable but least likely to access services, such as young people • providing the special training and ongoing support required by staff to meet the complex sexual and reproductive health needs of HIV-positive people effectively • motivating donors to move from parallel to integrated services, and sustaining support for integrated policies and services Tools to make it happen Several tools prepared by IPPF, UNFPA, UNAIDS and WHO offer guidance on how to link sexual and reproductive health with HIV/AIDS. These include: • Sexual and Reproductive Health and HIV/AIDS – a framework for priority linkages xii • Linking Sexual and Reproductive Health and HIV/AIDS – an annotated inventory xiii • Sexual and Reproductive Health of Women Living with HIV/AIDS – guidelines on care, treatment, and support for women living with HIV/AIDS and their children in resource-constrained settings xiv • Integrating HIV Voluntary Counselling and Testing Services 4 Gateways to integration: a case study from Serbia into Reproductive Health Settings – stepwise guidelines for programme planners, managers and service providers xv • Meeting the Sexual and Reproductive Health Needs of People Living with HIV xvi • Gateways to Integration – a series of case studies of country-level experiences on how to link and integrate servicesxvii • Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool xviii • Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guidexix Linking Sexual and Reproductive Health and HIV/AIDS Turning theory into practice The process of linking sexual and reproductive health and HIV/AIDS needs to work in both directions: this means that traditional sexual and reproductive health services need to integrate HIV/AIDS interventions, and also that programmes set up to address the AIDS epidemic need to integrate more general services for sexual and reproductive health. While there is broad consensus that strengthening linkages should be beneficial for clients, only limited evidence is published regarding real benefits, feasibility, costs and implications for health systems. This publication presents one of a series of country experiences, set against a different public health, socio-economic and cultural background, embedded in radically different legal and health care environments and using different entry points as they strive to strengthen linkages between sexual and reproductive health and HIV/AIDS. The case studies featured in this series have been chosen to demonstrate this two-way flow and to reflect the diversity of integration models. While these case studies focus primarily on service delivery components, structures/systems and policy issues are also important ingredients of the linkages agenda. The case studies are not intended to be a detailed critique of the programmes or to represent ‘best practice’ but to provide a brief overview that shows why the decision to integrate was taken, by whom, and what actions were needed to make it happen. The intention is to share some of the experience and lessons learned that may be useful to others who wish to consider actions to strengthen the integration of these two health care services. They are real experiences from the field, with important achievements but also with real limitations and shortcomings. One of these shortcomings lies in the nomenclature currently being used. There is currently no globally accepted definition of the terms ‘linkages’, ‘mainstreaming’ and ‘integration’ in the context of sexual and reproductive health and HIV. At times in these case studies the terms are used by different organizations in a variety of settings in different ways. While we propose the following definitions, it should be noted that the different implementing partners have not used these consistently: Mainstreaming: Mainstreaming HIV/AIDS means all sectors and organizations determining: how the spread of HIV is caused or contributed to by their sector, or their operations; how the epidemic is likely to affect their goals, objectives and programmes; where their sector/organization has a comparative advantage to respond – to limit the spread of HIV and to mitigate the impact of the epidemic and then taking action. Linkages: The policy, programmatic, services and advocacy synergies between sexual and reproductive health and HIV/AIDS. Integration: Refers to different kinds of sexual and reproductive health and HIV/AIDS services or operational programmes that can be joined together to ensure collective outcomes. This would include referrals from one service to another. It is based on the need to offer comprehensive services. Gateways to integration: a case study from Serbia 5 A case study from Serbia Vital statistics at a glance Estimated population (2008) 7,365,507 Adult population aged 15 to 49 (2007) 4,841,000 Life expectancy at birth: Men Women Crude birth rate (2007) Total fertility (2006) 70 75 12.8/1,000 population 1.8 HIV prevalence rate in adults aged 15 to 49 (2007) <0.2% Estimated number of people living with HIV (2007) 6,400 Estimated number of adults aged 15 and over living with HIV (2007) 6,400 Estimated number of women aged 15 and over living with HIV (2007) Deaths due to AIDS (2007) Contraceptive prevalence rate (2005) Births attended by skilled health personnel (2006) <1,500 <100 41.2% 99% Sources: Census of Population, Households and Dwellings. Statistical Office of the Republic of Serbia, 2008. Available at http://webrzs.stat.gov.rs/axd/en/index.php; Serbia: Epidemiological Fact Sheets on HIV/AIDS. UNAIDS, UNICEF, WHO, 2008 Update. Available at http://www.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_RS.pdf; Serbian Health Indicator Database. Institute of Public Health of Serbia “Batut” (2009). Available from www.batut.org.rs/english.html Please note: This case study outlines the process the Institute for Students’ Health used to integrate SRH and HIV programmes and services. It does not necessarily reflect the current response to HIV in Serbia. 6 Gateways to integration: a case study from Serbia A case study from Serbia Evolution of service provision: First steps toward integration The Institute for Students’ Health (ISH) – a government institution – was established in Belgrade in 1922 to serve a population of 6,000. Today, Belgrade has one of the largest student populations of any city in Europe. The ISH caters for a population of 110,000 students plus university staff and provides a wide range of curative and preventive health services. With many young people away from home for the first time, and engaged in or on the threshold of intimate relationships, sexual and reproductive health is a major focus. Students receive no sex education in school and this is a taboo subject in most homes, so the emphasis at the ISH is on equipping young people with the knowledge and skills to adopt healthy sexual behaviour. Between 2006 and 2008, 3,000 young people a year accessed a number of HIV prevention services – including voluntary counselling and testing – at the ISH Centre in Belgrade. The Centre also offers non discriminatory sexual and reproductive health and HIV services for key populations, such as men who have sex with men, sex workers and people who use drugs. From 2006 to 2008 the number of people who use drugs accessing services at the Centre quadrupled and it became the preferred voluntary counselling and testing centre in Belgrade for men who have sex with men. In 1988, the director of the Institute, an epidemiologist whose major academic interest is HIV, and a colleague set up the first HIV counselling centre in Serbia at the ISH. Whereas today around two-thirds of HIV infections are sexually transmitted, at that time the HIV epidemic in Serbia was relatively new and, as in neighbouring countries, was driven mainly by injecting drug use among young people. The two men had no specialist counselling training, but built on their personal experiences of working with young people, their commitment to the issue and an awareness that something had to be done. Due to a number of factors, most importantly the political instability and conflict following the breakup of Yugoslavia in the early 1990s, the progress towards integration stagnated. Only in the late 1990s did the doctors recognize the need for closer collaboration with their colleagues offering other services at the ISH, such as treatment for sexually transmitted infections (STIs), gynaecology and family planning. Their colleagues welcomed the initiative as a way of better meeting the multiple needs of their clients, and together they developed new patterns of working. This involved sharing their specialist knowledge and skills with each other in an informal training programme. Those who were comfortable dealing with HIV issues taught those who were more experienced working with other STIs, and vice versa. In this way everyone developed basic knowledge and understanding of each other’s work whilst remaining clinically active within their specialist areas. This initiative also involved streamlining referrals, and meeting regularly to exchange information, share concerns and discuss cases. Over the years this initiative has developed into an integrated programme of sexual and reproductive health and HIV services that reaches far beyond the ISH. It has drawn in a myriad of other players, and is a model of cooperation between governmental and non-governmental organizations. For example, the ISH partnered with various non-governmental organizations to train voluntary testing counsellors and provide voluntary counselling and testing services to some of the populations most at risk, such as sex workers and drug users. What makes this work particularly remarkable is that much of it was achieved under difficult circumstances. The Bosnian-CroatianSerbian war in the 1990s saw the complete disintegration of a former way of life, the redrawing of national boundaries, and isolation from the international community. This led to a lack of political stability, high unemployment and increased levels of poverty. The improvement in the economic and political situation in Serbia – with the number of people living below the poverty line falling from 10.6% in 2002 to 8.8% in 2006xx – has increased opportunities for integration. Gateways to integration: a case study from Serbia 7 A case study from Serbia STI/HIV Centre: A six step model of care Building on the steps towards integration made in the late 1990s, the decision was made in 2002 to physically integrate sexual and reproductive health and HIV services and create a combined centre for HIV and STI prevention. The main reason for the decision was to better secure privacy for clients of the HIV clinic. The HIV clinic was moved to a small building behind the Institute with its own entrance – and the STI/HIV Centre became a reality. The Centre is equipped with two counselling rooms, and a reception area where large amounts of information materials and condoms are made freely available. Step 1 – Upgrading skills Step 2 – Securing Funding In the same year as the establishment of the STI/HIV Centre, when Serbia emerged from international isolation, staff at the HIV clinic were able to receive training in basic knowledge and skills for voluntary counselling and testing. This enabled them to set up services that conformed to international standards. One of the challenges faced by the newly established STI/HIV Centre was to secure funding for its activities. Although the Centre is attached to the ISH, it initially received no government money, and was supported by donor funding channelled through the International Aid Network – a partner in the enterprise. The funding situation improved in 2007 when the ISH and International Aid Network signed a memorandum of understanding on cooperation and joint financing. Today, nine people trained as counsellors work in shifts at the STI/HIV Centre. Some of the staff trained in counselling are doctors and nurses who also work at the ISH, and three are clinical psychologists from the International Aid Network, a local human rights non-governmental organization that works mainly with refugees. The team of counsellors is supported by a team of gynaecologists, dermatovenereologists and general practitioners from the ISH, which run specialist clinics at the Centre on different days. Step 3 – Expanding Services Since its opening, the STI/HIV Centre has offered counselling and testing for HIV and Hepatitis B and C, and diagnosis and treatment of other STIs. Blood samples are sent to the pathology laboratory in the ISH and clients are asked to return for their results the same day or the next. Less than 0.3% fail to do so. This is a real indicator of the quality of the counselling and service provided and the importance of returning test results swiftly. Though most clients access the Centre for its voluntary counselling and testing services, the staff use this as an opportunity to counsel clients on behaviour change, and as an entry point for other sexual and reproductive health services. The STI/HIV Centre has mechanisms in place to refer clients to the ISH next door for other services, such as family planning or mental health. 8 Gateways to integration: a case study from Serbia A case study from Serbia Step 4 – Mentoring Staff The STI/HIV Centre at the ISH offers ongoing psychosocial support for people living with HIV as well as their partners, family and friends. The voluntary testing counsellor is often the only person who knows a client’s status, and the only person to whom the client is able to confide. The work is inherently stressful, which led the Catholic Agency for Overseas Development to introduce the idea of regular group supervision for counsellors as a vitally important measure to protect their mental health. No one wears a uniform or a white lab coat when working at the Centre. This is a deliberate policy to abolish hierarchy and to put clients more at ease when talking with health professionals. The subliminal message that everyone working at the Centre deserves equal respect is very important for team spirit, morale and group dynamics. Step 5 – Reaching key populations Step 6 – Building partnerships Capitalizing on the STI/HIV Centre, strengthened staff capacity and new partnerships, the ISH started to expand its activities beyond its traditional client base of students. As a government institution, the ISH would not have been able to do this alone, as it is mandated to provide services only for its target population of students. But one of the benefits of the partnership with the International Aid Network is that it allows the Centre to reach out to clients beyond this group. The Centre now runs programmes – directly or through affiliates such as the Jugoslav Association Against AIDS – for high school students, sex workers and young people with disabilities. Early on, the management of the STI/HIV Centre recognised the importance of working in partnerships with other organizations. And in fact there have been many benefits, including access to donor funding, delivering a comprehensive package of services for clients through referral systems, and reaching out to populations beyond their traditional client base. Gateways to integration: a case study from Serbia 9 A case study from Serbia At the clients’ convenience: HIV counselling and testing at night It is just before 8pm on Saturday evening. A group of doctors, nurses and psychologists, casually dressed, are sitting around or leaning against desks, arms folded, in a large room at the STI/HIV Centre. They are chatting, laughing, drinking strong coffee or fruit juice, and shelling peanuts. Through the open window comes the sound of rain pattering on pavements and a cool draught of air freshens the room after a sunny day. A delivery man comes in with big boxes of pizza. Outside in the waiting area, a TV is showing a football match, and a large low coffee table is covered with information leaflets. The seats around the wall are yet to be occupied. This is the night testing clinic, which is open for voluntary counselling and testing from 8pm to midnight once a month. The service is widely advertised in the media, and within minutes of the doors opening, clients start to arrive. They are greeted informally before being ushered into a private room by one of the counsellors. At one point in the evening, a counsellor goes to the waiting room with a box of condoms to replenish the supplies on the table. A young man sitting there, arms casually draped across the back of the chair, tells her with a smile: “We don’t use those things, that’s why we’re here!” By midnight, more than 40 clients have come for testing. They are mostly young, but not all students, and from a mixture of backgrounds. Just before the doors close, two young Roma arrive. This is a cause for quiet satisfaction. Roma are among the most marginalized and hard-to-reach populations in Serbia and the voluntary counselling and testing staff are trying to build a word of mouth reputation for kindness, respect and confidentiality that will reach out to marginalized groups such as these. As it runs outside normal working hours, the night voluntary counselling and testing clinic is a good opportunity for people from other agencies who are training as counsellors to gain practical experience. Everyone contributing their expertise here is working on a voluntary basis. 10 Gateways to integration: a case study from Serbia Most of the people who come for night testing are in the age range of 16 to 30 years, and belong to population groups particularly vulnerable to HIV infection such as people who use drugs, men who have sex with men, and sex workers. By contrast, those who attend the regular day clinic tend to seek services to check their HIV status before marriage and include couples who want children, as well as young people whose behaviour puts them at risk of HIV. In the first half of 2005, 11 new HIV infections were diagnosed at the night clinic, all among men who have sex with men. This was twice as many new HIV infections as were detected in the whole of 2004. Staff members working at the night clinic take the opportunity during counselling to advocate for behaviour change and also to encourage clients to make use of the sexual and reproductive health services available at the Centre. A case study from Serbia From theory to practice As the ISH is an institute for students, it uses every opportunity to invest in young people and get them involved in sexual and reproductive health services – not just as clients, but as service providers as well. Young people as service providers Serbia has a large network of youth peer educators, mainly trained by UNFPA and UNICEF, who work with a variety of non-governmental organizations. A mobile team of young people has been trained in counselling skills at the STI/HIV Centre. They take information and education to young people wherever they are, and members use a variety of strategies to communicate their message. They organize parties where condoms and information materials are distributed and there are competitions with prizes to test people’s knowledge of HIV and sexual and reproductive health issues. As well as these outreach services, the youth mobile team runs a telephone hotline on HIV and sexual and reproductive health issues. Addressing judgemental attitudes An essential condition for working with clients is that counsellors examine and overcome their own judgemental attitudes. “I used to have a big problem with homophobia,” admits one peer educator. He was forced to confront this by his fellow peer educators during impassioned discussions. But what has influenced him most to change his attitudes, he says, is working with marginalized young people and realizing how much they all have in common. However, prejudice and the instinct to judge are so widespread that young peer educators and counsellors working with sensitive issues frequently face suspicion or hostility from the general public – sometimes even from their own families. Many find it hard to get permission from teachers to talk to children in schools. And combating prejudice is only half the battle. Homosexual acts and drug use are illegal in Serbia and fear of prosecution also inhibits people from accessing services. Therefore the anonymity of the telephone service is welcomed by stigmatized people, such as those who use drugs and men who have sex with men, who find it particularly hard to access information and services. Satellite clinic for high school students: Reaching vulnerable young people Close to the ISH is a residence for high school students from all over Serbia, where the Institute has set up a satellite clinic for reaching vulnerable young people below university age. There is a special need to develop services for this population because in Serbia’s traditional health care system, 14 to 18-year-olds who live away from home have particular difficulty accessing health services. The clinic has been given space by the residence administration but gets its medical supplies from the ISH, which is also a direct referral centre. Head of the clinic is a general practitioner with special training in youth counselling and voluntary counselling and testing, who also volunteers at the STI/HIV Centre. Moreover, she is a mother of three teenage daughters herself. So when students arriving at the residence come in for their required medical check-up, she takes this opportunity to counsel them on sexual relationships, contraception and infection prevention, and to tell them about the Centre. She and her colleagues make sure that the clinic is an inviting place for young people, with freshly painted white walls, potted plants and colourful rugs, and lots of information materials they can take away. Gateways to integration: a case study from Serbia 11 A case study from Serbia Providing sexual and reproductive health services for minors raises ethical questions, but at present there are no specific laws in Serbia to guide service providers, and each institution has its own rules. Most are prepared to give information and counselling on contraception and HIV to minors without seeking parental consent, and some also provide contraceptives without involving parents or guardians in the decision. The ISH will perform an HIV test for a minor, but its protocol originally stipulated that it could only give a positive result to someone under-age in the presence of their parent or guardian, who would also receive post-test counselling. This initial policy was later changed so that voluntary counselling and testing for minors could take place with two counsellors, and that a positive result could be given to the child if both counsellors think it is in the child’s best interest. Raising awareness: Taking the message to where the students are “Most young people arriving at university have very little knowledge about sexual and reproductive health,” says the gynaecologist, who holds a clinic at the STI/HIV Centre. That is why he goes out to student residences, cafés and theatres – anywhere that students gather in their free time – to give presentations about family planning and STI prevention. The main objective of these sessions is to tackle the issue of abortion which, although legal, is often procured secretively from poorly equipped practitioners leading to physical and psychological problems for one in three to one in five women. Abortion is commonplace in Serbia, with an incidence of around 82 per 1,000 women aged 15 to 49 years.xxi Assisted by a nurse, the gynaecologist starts the presentation with provocative questions designed to stimulate 12 Gateways to integration: a case study from Serbia audience participation, such as: “Do you agree that a man is not a man if he is a virgin?” They then describe the different methods of contraception, with the pros and cons for both pregnancy and STI prevention, illustrating their talk with examples and case histories to give the information a human face. They also make sure that the students know about the STI/HIV Centre and its services. In 2004, the team reached over 1,600 young people in 41 presentations – a figure exceeded within the first six months of 2005. Attendance at the Centre always rises after one of these presentations. About four times a year the Centre will build on outreach information, education and communication activities by taking voluntary counselling and testing services out to ‘Student City’ – a dormitory complex in Belgrade that houses around 5,000 young people. A case study from Serbia Outreach with sex workers: The ‘Power of Prevention’ ISH was the initial home of the Jugoslav Association Against AIDS. This non-governmental organization was set up in 1991 by a group of doctors – including those working for the ISH, and the former professor of Public Health at Belgrade University – when they realized that, because of the war at that time, they were not going to get any more help from the international community in dealing with HIV in Serbia. There was official denial of the epidemic and at first they ran workshops with teachers, school children, doctors and a host of others to raise awareness of HIV and how to prevent its spread. The founding members ran the whole operation as volunteers using their own resources to fund activities. But in recent years the Jugoslav Association Against AIDS has won support from a number of foreign donors, and has been able to expand its training programme and develop other activities. In September 2004, with funding from the Dutch government and technical support from SOAAIDS, a Netherlands-based STI/HIV prevention organization, the Jugoslav Association Against AIDS started a programme to deliver sexual and reproductive health and HIV services to female sex workers in Belgrade. Before the programme – known as the ‘Power of Prevention’ – was launched, SOAAIDS took a group of eight people from the Association to see how outreach among sex workers is handled in Amsterdam, and to share their experiences. As a result, the programme started using a team of young outreach workers to make contact with sex workers in the city’s ‘hotspots’. The aim is to give the sex workers information, supplies and support to avoid unintended pregnancy and infection. The outreach workers talk with them, distribute information and condoms, and counsel them to seek health care, if required. The STI/HIV Centre provides counselling and STI treatment services for sex workers. In addition, the Jugoslav Association Against AIDS has managed to motivate, inform and train a small core of doctors and nurses in three of the city’s sixteen municipal clinics who will treat their clients on occasion. But they take professional risks in doing so as sex workers rarely possess the official health documentation that confirms their citizenship and entitlement to government services, so treating them can be illegal. The Jugoslav Association Against AIDS has therefore bought a van that it has equipped as a mobile clinic, staffed by a doctor and a counsellor, which goes out to the hotspots to provide services directly. It has won support from a small hotel owner, who rents rooms to sex workers and their clients, to open a drop-in centre where they can get information, condoms and counselling. However, even the mobile clinic is taking risks: the law does not allow people working for non-governmental organizations to provide medical services, even if they are professionally qualified to do so, and there are very real possibilities that mobile clinic staff could be arrested. However, the staff rely on the fact that the recent national HIV strategy,xxii which recognizes the need for ‘harm reduction’ among people selling sex, will afford some protection from prosecution. Sex work is illegal in Serbia and police treatment of people engaged in sex work is harsh. Girls are afraid to carry condoms which might incriminate them, and are wary about trusting outreach workers who approach them. The Jugoslav Association Against AIDS has the tacit agreement of the police that they will keep away from the scene when the mobile clinic Gateways to integration: a case study from Serbia 13 A case study from Serbia or outreach teams are operating. And the organization recently held a training workshop for policemen and women to try to encourage greater understanding of and respect for sex workers and other vulnerable people living on the margins of society. But changing entrenched attitudes and behaviour is a slow process and the outreach workers – who are mostly students carefully selected and trained by the Jugoslav Association Against AIDS – enter a world of palpable violence and fear when they go out to the hotspots twice a week. The Jugoslav Association Against AIDS insists that they always work in pairs, a male and female together, and that they report to their supervisor before leaving for and returning from the field. It is stressful work and the twelve-person outreach team meets in a room at the ISH every Wednesday evening for group supervision, during which they share experiences and seek advice from each other. At a recent meeting, for example, one team reported how they had been caught up in a police raid and had had to make a snap decision about whether to run with the sex workers or stand their ground. Taking the view that to have stayed behind to talk to the police might have been seen as colluding with them, they ran with the girls. Outreach workers also frequently tell of the threat they feel from “pimps” observing them from the shadows as they talk with the sex workers. Reliable information on sex work in Serbia is scarce, but the Jugoslav Association Against AIDS and its partners estimate that there are about 3,000 people engaged in sex work in Belgrade. The outreach workers are in regular contact with around 100 people in six of the known hotspots. The Jugoslav Association Against AIDS recognizes its limits and focuses its efforts on reaching out to sex workers. But it works closely with other nongovernmental organizations in Belgrade that provide services for other marginalized people such as those who use drugs and men who have sex with men. 14 Gateways to integration: a case study from Serbia Reaching young people with disabilities Special efforts have been made with the youth friendly services to reach out to excluded populations such as young people with disabilities. A group of doctors run workshops for parents of children with learning difficulties to discuss issues about sexuality and relationships, family planning and disease prevention, and the range of services available. They have also provided special services for hearing-impaired children. But these initiatives have been sporadic and difficult to sustain as government support and funding have been affected by political instability and frequent changes within ministries. A case study from Serbia “Prejudiced? Me? But I’m a professional!” Health staff tend to believe their training has equipped them to treat any patient, regardless of status or lifestyle, with the same professionalism. But they do not realise that their attitudes and prejudices are often apparent in subtle ways to their clients. Training workshops for health professionals in counselling or youth friendliness, therefore, always include representatives of stigmatized groups such as men who have sex with men, people who use drugs and sex workers, and participants are required to explore issues about prejudice and exclusion together as equals. The training has had a remarkable effect on the ability of health professionals to communicate with, and support, young people of all persuasions. The Jugoslav Association Against AIDS holds workshops for health professionals to prepare them for working empathetically with stigmatized people. These workshops are very effective at getting people to think deeply about the inhibitions, fears and prejudices that might come between themselves and their clients. Gateways to integration: a case study from Serbia 15 A case study from Serbia Expanding the model Belgrade has 16 municipal clinics that provide basic sexual and reproductive health care, and the Centre is working, in collaboration with UNICEF, to introduce its model of integrated HIV and sexual and reproductive health services into these clinics. While UNICEF focuses on giving staff skills in communicating with children and adolescents, the Centre trains them in HIV and how to integrate this knowledge into their regular sexual and reproductive health work. To date, doctors and nurses running the adolescent sexual and reproductive health services in three municipalities have undergone training and have transformed their working practices. Three paediatricians and a gynaecologist have trained as voluntary testing counsellors, getting their practical experience by volunteering to work in the night voluntary counselling and testing programme. They carry out pre-test counselling at their own clinics before referring their young clients to the STI/HIV Centre to take an HIV test and receive post-test counselling. The training and introduction of new services, especially for HIV, have involved a good deal of extra work for no additional pay, and there was some resistance to this at first. However, everyone who has taken up the challenge is pleased that they did. 16 Gateways to integration: a case study from Serbia A case study from Serbia Challenges: Organizational, structural and policy constraints In addition to the tough socioeconomic conditions in which they work, the ISH and its partners face a variety of challenges and constraints. Organizational: • The non-governmental organization sector is very new in Serbia. It has little grassroots support and its work is often controversial as it has grown up largely in the context of human rights issues and working with vulnerable groups. Also, as nongovernmental organizations with outside support tend to pay slightly better salaries than local jobs, this sometimes causes resentment from the general public. • There is no such thing as charitable status in Serbia, so nongovernmental organizations pay high taxes on all donations, including non-cash items such as computers. This creates difficulties in negotiations with donors who are generally not happy about contributing indirectly to state finances. • Fragmentation of funding is a problem. Donors tend to support discrete items in the budget, which makes fundraising and accounting difficult and time-consuming. To help alleviate this problem, some non-governmental organizations (including the Jugoslav Association Against AIDS) have formed a network that collaborates on key activities such as fundraising. Policy and Legislative: Structural: • The illegal status of sex work drives it underground and makes it hard to reach those engaged in sex work with information and services. It also inhibits sex workers from carrying condoms which might incriminate them. This has wider public health implications. Moreover, the tacit agreement health providers have with the police to respect their work provides minimal protection in Serbia where government officials change frequently. • Stigma and discrimination inhibit support for work addressing the concerns of men who have sex with men, sex workers and people who use drugs. • A lack of reporting systems have resulted in a shortage of the data often needed to support funding proposals. • The policy environment regarding sexual and reproductive health and HIV is threadbare. There is no quality control of testing kits, condoms, drugs and so on, and there is a lack of regulations and guidelines on such matters as voluntary counselling and testing, and family planning. However, the national strategy to fight HIV, which involved a widely consultative drafting process supported by funding from the Global Fund to fight AIDS, Tuberculosis and Malaria, was accepted by the government in December 2004. • Sex education is not on the school curriculum, although the ISH has long been advocating for this and has had intermittent tacit support from some government officials. Gateways to integration: a case study from Serbia 17 A case study from Serbia Investing in the future: Conclusions and lessons learned Despite a decade of war in the Balkans, and political and socio-economic conditions unfavourable to innovation and change, the Institute for Students’ Health has been prepared to push out the boundaries to create a model of care that meets the needs of its target populations in a more convenient and user-friendly manner, whilst offering health professionals more effective and satisfying ways of working. Crucial to the achievements of the ISH have been vision, inspiring leadership and political will – such as the kind of commitment and passion that compel people to work for no pay and to fund their activities themselves, if necessary. Many health care providers comment that working with young people is inspiring because of their openness to change and because it is an investment in the future. In order to integrate services it may be necessary for public sector health staff to go beyond the boundaries of their job descriptions. This requires clear objectives, diplomacy and willingness to make personal sacrifices. The ISH staff who established and now work at the STI/HIV Centre give some of their time and skills free of charge. They have overcome a number of obstacles raised by their status as public servants by creating or working in partnership with non-governmental organizations that have a broader remit. The ISH takes pains to foster good relationships with the non-governmental sector in general by, among other things, providing office space to nongovernmental organizations such as the Jugoslav Association Against AIDS, and making its meeting rooms available to various groups for workshops, group supervision and other activities. As a pioneer of integrated sexual and reproductive health and HIV services in Serbia, the ISH has many valuable lessons to share from its experience. 18 Gateways to integration: a case study from Serbia When building capacity to provide integrated services, getting the various specialists to share their knowledge and skills with each other is an efficient and costeffective method of training and serves also to enhance mutual understanding and a spirit of cooperation in multi-disciplinary teams. The ISH has shown that, even when resources are extremely limited, building capacity to provide integrated services does not need to present an insurmountable obstacle. The Institute has found that abolishing the traditional hierarchical structure among staff enhances the process of skills sharing and team building, and is good for morale. None of the staff wear a uniform or a white coat at the STI/HIV Centre. This makes for a more relaxed atmosphere that helps put clients at ease as well as sending out the subliminal message that everyone working there is of equal status and deserves equal respect. A case study from Serbia Work in the sensitive field of sexual and reproductive health and HIV is inherently stressful and measures to protect service providers from burnout are essential, both for the health of the individual and the sustainability of the programme. All staff involved in counselling, whether at the STI/HIV Centre or as members of the sexual and reproductive health and HIV outreach teams, come together weekly for group supervision in which members of the same team share their experiences, concerns and insights. These are formal sessions, facilitated by a professional psychologist, psychiatrist or counsellor. Individual supervision is also available for staff needing it. Caring for the care-givers is an important principle at the ISH. Therefore supervision is now a systematic and integral part of HIV and sexual and reproductive health services, and is taught in the Institute’s training programmes for counsellors. Because of taboos and personal inhibitions, people are often reluctant to seek out sexual and reproductive health and HIV information and services, so providers need to use their imagination to reach potential clients. Simply providing services is not enough to ensure that the people who need them will use them. This is especially so with sexual and reproductive health and HIV services where the issues are so sensitive. Service providers need, therefore, to be proactive and give thought to how they reach potential clients. Taking education programmes to where students gather, and running telephone counselling services, are among the strategies used to good effect by the ISH to encourage people to attend. Making services as convenient as possible to clients is another way of overcoming barriers to access, and here the night-time voluntary counselling and testing sessions have been a major success. Working effectively with vulnerable people, especially from stigmatized groups, requires service providers to examine their own attitudes critically and overcome harmful prejudices. Marginalized people such as sex workers, men who have sex with men and people who use drugs are especially vulnerable to HIV and other sexual and reproductive health problems. Gaining their trust and confidence in health services means, first and foremost, that service providers treat them with respect. An effective way to promote this is to bring health professionals and representatives of stigmatized groups together as equals in training programmes. Another way is to help health workers, through training, to be comfortable with the language and expressions used by marginalized groups to describe their behaviour. Gateways to integration: a case study from Serbia 19 A case study from Serbia Contact details for more information: Institute for Students’ Health Belgrade Krunska 57 Street Belgrade 11000 Serbia Phone: +381112433488 Email: drilic@sezampro.rs Endnotes i The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health, UNFPA & UNAIDS, 2004. xiii The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, UNFPA & WHO, 2004. xiv ii Call to Action: Towards an HIV-free and AIDS-free Generation, Prevention of Motherto-Child Transmission (PMTCT) High Level Global Partners Forum, Abuja, Nigeria, 2005. iii Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services, High Level PMTCT Global Partners Forum, Johannesburg, South Africa, 2007. iv v Intensifying HIV Prevention: UNAIDS Policy Position Paper, UNAIDS, 2005. vi Political Declaration on HIV/AIDS, United Nations General Assembly Special Session on HIV/AIDS. New York, United Nations, 2006. For example see the background paper on the concept of Universal Access prepared for the Technical Meeting for the Development of a Framework for Universal Access to HIV/AIDS Prevention, Treatment and Care in the Health Sector, WHO, Geneva, 2005. vii Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages, WHO, UNFPA, UNAIDS & IPPF, 2005. viii Programme of Action adopted at the International Conference on Population and Development, Cairo, 1994. ix Resolution adopted by the General Assembly, United Nations Millennium Declaration, New York, 2000. x See also Family Health International. Integrating services. Network, 2004, 23(3) p8. xi xii WHO, UNFPA, UNAIDS & IPPF, Op. cit. 20 Gateways to integration: a case study from Serbia Linking Sexual and Reproductive Health and HIV/AIDS. An annotated inventory. WHO, UNFPA, UNAIDS & IPPF, 2005. Sexual and Reproductive Health of Women Living with HIV/AIDS, Guidelines on care, treatment and support for women living with HIV/AIDS and their children in resourceconstrained settings, UNFPA & WHO, 2006. Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health Settings, Stepwise guidelines for programme planners, managers and service providers, UNFPA & IPPF, 2004. xv Meeting the Sexual and Reproductive Health Needs of People Living with HIV. Guttmacher Institute, UNAIDS, UNFPA, WHO, Engender Health, IPPF, ICW & GNP+, In Brief, 2006 Series, No. 6. xvi Gateways to Integration, UNFPA, IPPF, UNAIDS, WHO, 2008. xvii Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool, WHO, 2006. xviii xix Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages: A Generic Guide, ICW, GNP+, IPPF, UNAIDS, UNFPA, WHO, Young Positives, 2008. xx ‘How many people are poor in Serbia?’ 2007 Serbian Government statistics Available from http://www.prsp.sr.gov.yu/engleski/kolikoje.jsp xxi Abortion Problem in Serbia. Rasevic, M, Institute of Social Sciences, Demographic Research Center, Belgrade, Serbia, 2006. National Strategy for the Fight Against HIV/AIDS, Ministry of Health, Republic of Serbia, 2005. xxii Despite a decade of war in the Balkans, and political and socio-economic conditions unfavourable to innovation and change, the Institute for Students’ Health has been prepared to push out the boundaries to create a model of care that meets the needs of its target populations in a more convenient and user-friendly manner whilst offering health professionals more effective and satisfying ways of working. As a pioneer of integrated sexual and reproductive health and HIV services, the Institute for Students’ Health has many valuable lessons to share from its experience. 

A case study from Kenya Linking Sexual and Reproductive Health and HIV/AIDS Gateways to integration a case study from Kenya Antiretroviral delivery within a sexual and reproductive health setting: Transition from traditional to pioneering role © 2008 WHO, UNFPA, UNAIDS, IPPF Disclaimer All rights reserved. The publishers welcome requests to translate, adapt or reproduce the material in this document for the purpose of informing health care providers, their clients, and the general public, as well as improving the quality of sexual and reproductive health and HIV/AIDS care. 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Printed in London, United Kingdom, July 2008. Acknowledgements 2 Acronyms and abbreviations 2 Linking Sexual and Reproductive Health and HIV/AIDS Global commitments to strengthen linkages 3 Identifying and meeting the challenges 4 Tools to make it happen 4 Turning theory into practice 5 A case study from Kenya Providing ARVs in a sexual and reproductive health setting: Transition from traditional to pioneering role 6 Interconnected health needs: The case for mainstreaming HIV/AIDS 7 Voluntary counselling and testing: Complex and sensitive issues 8 Nakuru: A model of integrated services 9 Care without walls: Community outreach 10 Antiretroviral therapy: Training and treatment 12 Taking treatment out to the community: Follow-up care and support 13 Services for young people: A pressing need 14 The legal and policy environment: Additional constraints 15 The challenge of sustainability: On the knife-edge of survival 16 Plausible, possible and practical: Conclusions and lessons learned 18 Contact details for more information 20 Endnotes 20 Gateways to integration: a case study from Kenya 1 A case study from Kenya Acknowledgements This case study is part of a series of joint publications by UNFPA, WHO, UNAIDS and IPPF on the issue of strengthening linkages between sexual and reproductive health and HIV/AIDS. The document is based on country experiences and is the result of a joint effort of national experts and a group of public health professionals at UNFPA, WHO, IPPF and UNAIDS. The publishing organizations would like to thank all partners for contributing their experience, for reviewing numerous drafts and for valuable advice at all stages. Special thanks go to the following people who provided technical input and support for this publication: Main author: Susan Armstrong. Main contributors: Peter Weis (WHO), Lynn Collins (UNFPA) and Kevin Osborne (IPPF). Reviewers: From Family Health Options Kenya: Linus Ettyang, Esther Muketo, Rufus Murerwa and Joachim Osur. From WHO: Catherine d’Arcangues, Manjula Lusti-Narasimhan, Michael Mbizvo, Jos Perriens, and Paul Van Look. From UNFPA: Ramiz Alakbarov, Hedia Belhadj, Yves Bergevin, Christina Bierring, Akinyele E. Diaro, Josiane Khoury, Steve Kraus, Esther Muia, Kemal Mustafa, Alexei Sitruk and Sylvia Wong. From UNAIDS: Anindya Chatterjee, Barbara de Zalduondo, Emma Fowlds and Mahesh Mahalingam. From IPPF: Andy Guise, Jonathan Hopkins, Wilfred Ochan and Ale Trossero. Acronyms and abbreviations AIDS Acquired Immune Deficiency Syndrome FHOK Family Health Options Kenya GTZ Deutsche Gesellschaft für Technische Zusammenarbeit HIV Human Immunodeficiency Virus IPPF International Planned Parenthood Federation UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WHO World Health Organization 2 Gateways to integration: a case study from Kenya Linking Sexual and Reproductive Health and HIV/AIDS The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding, all of which are fundamental elements of sexual and reproductive health care. In addition, sexual and reproductive health problems share many of the same root causes as HIV/AIDS, such as poverty, gender inequality, stigma and discrimination, and marginalization of vulnerable groups. Despite this, services for sexual and reproductive health and for HIV/AIDS still largely exist as separate, vertical programmes. Global commitments to strengthen linkages Building blocks To raise awareness of the pressing need for more widespread linkages between sexual and reproductive health and HIV/AIDS, UNFPA and UNAIDS, in collaboration with Family Care International, held a high-level consultative meeting in June 2004 with government ministers and parliamentarians from around the world, ambassadors, leaders of United Nations and other multilateral agencies, non-governmental and donor organizations, as well as young people and people living with HIV. The meeting resulted in The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health,i which challenges the sexual and reproductive health and HIV/AIDS communities to examine how they might improve collaboration. An earlier meeting, held in Glion, Switzerland (May, 2004), and initiated by WHO and UNFPA, took a close look at the role of family planning in reducing HIV infection among women and children. This conference resulted in The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children.ii In December 2005, a global partners’ meeting was convened to discuss progress in implementing a comprehensive approach to prevention of mother-to-child transmission. This consultation also stressed the importance of linking sexual and reproductive health and HIV/AIDS services, and led to a Call to Action: Towards an HIV-free and AIDS-free Generation,iii as did the most recent PMTCT consultation in Johannesburg November 2007, resulting in a Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Motherto-Child Transmission Services.iv Linking HIV/AIDS and SRH was included as one of the Essential Policy Actions for HIV Prevention in the UNAIDS policy position paper on Intensifying HIV Prevention, which was issued in 2005.v Framework for universal access The above commitments culminated in the Political Declaration on HIV/AIDS arising from the 2006 Review of the United Nations Special Session on HIV/AIDS (UNGASS), which also stressed how vital it is to link HIV/AIDS with sexual and reproductive health.vi Following the commitment by G8 members1 and, subsequently, heads of states and governments at the 2005 United Nations World Summit, the UNAIDS Secretariat and its partners have been defining a concept and a framework for Universal Access to HIV/AIDS Prevention, Treatment and Care by 2010.vii Efforts towards universal access underline the importance of strengthened linkages between sexual and reproductive health and HIV/AIDS. 1 G8 summits: Since 1975, the heads of state or government of the major industrial democracies have been meeting annually to deal with the major economic and political issues facing their domestic societies and the international community as a whole. G8 countries are France, United States, United Kingdom, Germany, Japan, Italy, Canada and Russian Federation. Gateways to integration: a case study from Kenya 3 Linking Sexual and Reproductive Health and HIV/AIDS The potential benefits of linking sexual and reproductive health and HIV/AIDS include: • improved access to sexual and reproductive health and HIV services • increased uptake of services • better sexual and reproductive health services, tailored to meet the needs of women and men living with HIV • reduced HIV/AIDS-related stigma and discrimination • improved coverage of under-served and marginalized populations, including sex workers, injecting drug users and men who have sex with men • greater support for dual protection against unintended pregnancies and sexually transmitted infections, including HIV • improved quality of care • enhanced programme effectiveness and efficiencyviii Another aim of linking sexual and reproductive health and HIV/AIDS is to accelerate progress towards achieving the goals agreed at the International Conference on Population and Developmentix and the Millennium Development Goals,x especially those that aim to reduce poverty, promote gender equality and empower women, improve maternal health, combat HIV/AIDS, and attain universal access to sexual and reproductive health. Identifying and meeting the challenges Linking sexual and reproductive health and HIV/AIDS policies and services presents many challenges for those on the front line of health care planning and delivery. These include:xi • making sure that integration does not overburden existing services in a way that compromises service quality, by ensuring that integration actually improves health care provision • managing the increased workload for staff who take on new responsibilities • allowing for increased costs initially when setting up integrated services and training staff • combating stigma and discrimination from and towards health care providers, which has the potential to undermine the effectiveness of integrated services no matter how efficient they are in other respects • adapting services to attract men and young people, who tend to see sexual and reproductive health, and especially family planning, as ‘women’s business’ • reaching those who are most vulnerable but least likely to access services, such as young people • providing the special training and ongoing support required by staff to meet the complex sexual and reproductive health needs of HIV-positive people effectively • motivating donors to move from parallel to integrated services, and sustaining support for integrated policies and services. Tools to make it happen Several tools prepared by IPPF, UNFPA, UNAIDS and WHO offer guidance on how to link sexual and reproductive health with HIV/AIDS. These include: • Sexual and Reproductive Health and HIV/AIDS – a framework for priority linkages xii • Linking Sexual and Reproductive Health and HIV/AIDS – an annotated inventory xiii • Sexual and Reproductive Health of Women Living with HIV/AIDS – guidelines on care, treatment, and support for women living with HIV/AIDS and their children in resource-constrained settings xiv • Integrating HIV Voluntary Counselling and Testing Services 4 Gateways to integration: a case study from Kenya into Reproductive Health Settings – stepwise guidelines for programme planners, managers and service providers xv • Meeting the Sexual and Reproductive Health Needs of People Living with HIV xvi • Gateways to Integration – a series of case studies of country-level experiences on how to link and integrate servicesxvii • Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool xviii • Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guidexix Linking Sexual and Reproductive Health and HIV/AIDS Turning theory into practice The process of linking sexual and reproductive health and HIV/AIDS needs to work in both directions: this means that traditional sexual and reproductive health services need to integrate HIV/AIDS interventions, and also that programmes set up to address the AIDS epidemic need to integrate more general services for sexual and reproductive health. While there is broad consensus that strengthening linkages should be beneficial for clients, only limited evidence is published regarding real benefits, feasibility, costs and implications for health systems. This publication presents one of a series of country experiences, set against a different public health, socio-economic and cultural background, embedded in radically different legal and health care environments and using different entry points as they strive to strengthen linkages between sexual and reproductive health and HIV/AIDS. The case studies featured in this series have been chosen to demonstrate this two-way flow and to reflect the diversity of integration models. While these case studies focus primarily on service delivery components, structures/systems and policy issues are also important ingredients of the linkages agenda. The case studies are not intended to be a detailed critique of the programmes or to represent ‘best practice’ but to provide a brief overview that shows why the decision to integrate was taken, by whom, and what actions were needed to make it happen. The intention is to share some of the experience and lessons learned that may be useful to others who wish to consider actions to strengthen the integration of these two health care services. They are real experiences from the field, with important achievements but also with real limitations and shortcomings. One of these shortcomings lies in the nomenclature currently being used. There is currently no globally accepted definition of the terms ‘linkages’, ‘mainstreaming’ and ‘integration’ in the context of sexual and reproductive health and HIV. At times in these case studies the terms are used by different organizations in a variety of settings in different ways. While we propose the following definitions, it should be noted that the different implementing partners have not used these consistently: Mainstreaming: Mainstreaming HIV/AIDS means all sectors and organizations determining: how the spread of HIV is caused or contributed to by their sector, or their operations; how the epidemic is likely to affect their goals, objectives and programmes; where their sector/organization has a comparative advantage to respond – to limit the spread of HIV and to mitigate the impact of the epidemic and then taking action. Linkages: The policy, programmatic, services and advocacy synergies between sexual and reproductive health and HIV/AIDS. Integration: Refers to different kinds of sexual and reproductive health and HIV/AIDS services or operational programmes that can be joined together to ensure collective outcomes. This would include referrals from one service to another. It is based on the need to offer comprehensive services. Gateways to integration: a case study from Kenya 5 A case study from Kenya Vital statistics at a glance Estimated population (2005) 34,256,000 Adult population aged 15 to 49 years (2005) 16,662,000 Life expectancy at birth: Men Women Crude birth rate (2005) 51 years 50 years 39.5/1,000 population Total fertility rate (2004) HIV prevalence rate in adults aged 15 to 49 years (2005): 5 6.1% (5.2 – 7.0%) Estimated number of people living with HIV (2005) 1,300,000 Estimated number of adults aged 15 years and over living with HIV (2005) 1,200,000 Estimated number of women aged 15 years and over living with HIV (2005) 740,000 Deaths due to AIDS (2005) 140,000 Estimated number of adults in need of antiretroviral therapy (2005) 240,000 Estimated number of people receiving antiretroviral therapy (2005) 66,000 Percentage of young people aged 15 to 24 years who used a condom last time they had sex with a casual partner: Men Women 47% 25% Percentage of young people aged 15 to 24 years who had sex before age 15 years: Men Women 30.9% 14.5% Contraceptive prevalence rate (2003) 39.3% Births attended by skilled health personnel (2003) 42% Sources: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. UNAIDS, UNICEF, WHO: www.who.int and www.unaids.org/en/CountryResponses/Countries/kenya.asp: Kenya Country Profile, May 2007xx (Check UNAIDS website for updated data available from end of July 2008). 6 Gateways to integration: a case study from Kenya Providing antiretroviral treatment in a sexual and reproductive health setting: Transition from traditional to pioneering role Family Health Options Kenya (FHOK), registered in 1962, is a Member Association of IPPF and is the second largest supplier of contraceptives in the country after the Government. FHOK grew out of a grassroots movement started in the 1950s by a number of people concerned about the effects of Kenya’s high birth rate on development, and who formed a network of volunteers to promote family planning at the community level. A case study from Kenya FHOK today is a non-profit organization still governed by its volunteer members – there are around 5,000 volunteers in branches across Kenya. The annual delegates conference, made up of representatives from the grassroots branches, is the policy making body of FHOK. To make sure that FHOK represents and services all stakeholders, there is a stipulation that at least half the delegates must be women, and each branch must send a young person to represent the interests of their peer group. FHOK’s formal debut into the HIV/AIDS field started in 1999, coinciding with the President of Kenya’s declaration that AIDS is a “national disaster.”xxi The Association looked at where traditional sexual and reproductive health services and HIV/AIDS services overlapped then made decisions based on the capacity and resources of each clinic to pinpoint what HIV/AIDS services they could provide. Currently: FHOK runs nine clinics across the country that serve around 120,000 clients per year. Over the years these clinics have transformed their programmes from basic family planning services to provide more comprehensive family health services, with an emphasis on sexual and reproductive health care. Kenya’s health infrastructure is extremely poor and in many areas the FHOK clinic is one of the few health facilities available, so the Association works closely with the Ministry of Health to try to extend coverage. As the AIDS epidemic has taken hold, FHOK clinics have become more and more involved in providing services for people living with HIV. • all clinics offer programmes which aim to prevent mother-to-child transmission of HIV as part of their maternal health services • eight of the nine FHOK clinics provide voluntary counselling and testing for HIV • five of the nine clinics provide antiretroviral therapy to people living with HIV. FHOK’s antiretroviral therapy programme is part of the Models of Care project initiated by the GTZ, which is working with IPPF to develop models of integration across sexual and reproductive health and HIV/AIDS care.xxii FHOK’s programme is a pioneer in the field – offering antiretroviral therapy in a sexual and reproductive health setting. Interconnected health needs: The case for mainstreaming HIV/AIDS Teenage pregnancy is a serious problem, and maternal mortality remains extremely high at 560 deaths per 100,000 live birthsxxiii. In addition, the high incidence of sexually transmitted infections, which increase the risk of HIV transmission, is a cause for concern. Services for sexual and reproductive health and HIV/AIDS must march in step for genuine progress to be made on either front. This will require a change in mindset of health care providers and donors alike, in the sense that sexual and reproductive health and HIV/AIDS are inter-connected and should therefore be addressed using an integrated approach. Gateways to integration: a case study from Kenya 7 A case study from Kenya Voluntary counselling and testing: Complex and sensitive issues Expanding access The civil-society community recognized the importance of expanding access to client-initiated voluntary counselling and testing services. FHOK’s clinics were ideally placed for this: the Association was already offering treatment for sexually transmitted infections and opportunistic infections and believed it had the space and relevant staff to take on voluntary counselling and testing. It sent a number of family planning nurses to train as voluntary counselling and testing counsellors, trained laboratory technicians to conduct the tests, and started offering free voluntary counselling and testing services in its clinics in 2001. Developing policy In setting up HIV counselling and testing, FHOK also had to explore and develop policies about such vital and sensitive issues as: • confidentiality • informed consent • how to ensure clients’ privacy when attending clinics • how to counsel clients about disclosing a positive test result • parental consent in the case of minors seeking voluntary counselling and testing. Some of these issues are particularly complex and delicate. For example, disclosure can increase the risk of violence and stigmatization, especially for young women, and this is an additional factor that service providers need to consider. The policies developed by FHOK corresponded with those of the Ministry of Health’s National AIDS Control Programme, through which HIV clinical services in Kenya are supervised. Increasingly diverse client base As the service became more widely known, FHOK found that the demand for sexual and reproductive health services offered at its clinics increased, along with the steadily increasing demand for HIV counselling and testing. Crucially, it also brought men into the clinics. The Association soon found its regular staff had become overloaded in some clinics and had to recruit more staff. Meeting the needs of young people FHOK has a number of youth centres that provide recreational activities, libraries and vocational training opportunities as well as voluntary counselling and testing. There, young people of any age can be offered HIV counselling, but anyone less than 15 years must, by national policy, have the consent of a parent or guardian to be tested for HIV. In 2005, four young people already 8 Gateways to integration: a case study from Kenya experienced in peer education for sexual and reproductive health were trained to run voluntary counselling and testing services. It soon became apparent that providing information created demand, and therefore it was important to be able to provide services to meet these demands. On their own initiative, they started a mobile HIV counselling and testing service that goes out at least twice a month, and operates out of a tent if no other suitable venue is available. The main aim of the mobile service is to encourage responsible sexual behaviour among young people – offering voluntary counselling and testing is, therefore, seen as part of the wider campaign to provide sexual and reproductive health services for young people. The mobile unit uses rapid tests and provides pre- and post-test counselling. The counselling addresses HIV prevention, including safer sex counselling, and correct and consistent condom use, and is linked to condom distribution – free of charge for all those who need them. The unit uses a number of different rapid tests. Anyone who tests positive to two of the three different tests used is informed of the result. They are then referred for a confirmatory test at the FHOK clinic. At the clinic they can also be registered for other HIV services, such as continuing counselling, care, antiretroviral therapy for those who meet medical eligibility criteria, and treatment for opportunistic infections as necessary. A case study from Kenya Nakuru: A model of integrated services FHOK’s clinic at Nakuru provides a good example of the Association’s work in practice. The clinic annually serves a population of about 8,000 clients – mostly extremely poor people living in overcrowded settlements where scores of families may share a single tap and latrine. The town straddles a major highway which is a trucking route to neighbouring countries. This is a highrisk environment for HIV transmission, since the loneliness, transience and relative freedom of the trucking lifestyle are associated with casual liaisons which help to fuel the demand for sex work. Unsurprisingly, the HIV infection rate recorded by the voluntary counselling and testing unit, which opened in Nakuru in 2003, is higher at 8.3% than the national average. As well as its original function offering family planning services, the clinic now offers general outpatient services, and has changed its name to the Family Care Medical Centre. Clients can attend for any reason, but every opportunity is taken to raise the topic of sexual and reproductive health and to advocate for voluntary counselling and testing. More than 300 people a month seek HIV counselling and testing, and in 2004 nearly 1,000 clients sought treatment for HIV-related opportunistic infections, which is offered as part of general outpatient services. Reaching out to men: Developing an inclusive approach Recognizing that its clientele was almost exclusively female, FHOK made an effort in the mid-1990s to encourage male involvement in family planning by opening three clinics for men only. The initiative was an eyeopener. The Association realized that the traditional messages and activities of family planning tended to be female-oriented, and that the very real needs and concerns of men were neglected. It noticed over time that in the places where the male involvement project was operating (but not elsewhere): • there was an increase in the number of men accompanying their partners to the main FHOK clinic • there was a significant reduction in the number of women who would leave their appointment cards on file at the clinic out of fear that their partner would discover they were using contraception • more and more women were taking away condoms, even when not accompanied by their partners – an indication of increased acceptance of family planning by men, and easier communication between couples which is a vital component of healthy sexual relationships. Valuable lessons were learned about how to create a more ‘inclusive’ image for sexual and reproductive health and to make FHOK’s regular services more male-friendly. These included the need to: • develop information materials targeted at men (which, importantly, have the effect of empowering them in family decision-making, too) • advocate for family planning and other sexual and reproductive health services in places where men gather, such as football clubs and barbers’ shops • make sure that clinic opening times are convenient for men After four years, separate male clinics were no longer considered necessary and were closed. It was at this point that the Nakuru clinic changed its name to the Family Care Medical Centre, to reflect both its new orientation as well as the comprehensive nature of the sexual and reproductive health services it provides, including HIV/AIDS prevention, treatment and care. Gateways to integration: a case study from Kenya 9 A case study from Kenya Care without walls: Community outreach Many people cannot afford the time or travelling cost to attend a health facility. The Nakuru clinic therefore offers services to these populations through community outreach. Volunteers Some 50 community health volunteers and community-based distributors have been trained by FHOK and others to raise awareness of family planning, educate people about other sexual and reproductive health issues, and distribute condoms. They refer clients to FHOK for other contraceptive methods, and for diagnosis and treatment of sexually transmitted infections. Once a month, a nurse from the clinic accompanies one of the outreach teams to offer sexual and reproductive health services in the community. As an incentive, and to enable often very poor people to give their time, volunteers get a small fee if clients referred by them attend the family planning clinic. Over recent years, volunteers have also been trained in basic facts about HIV/AIDS, and HIV prevention is now an integral part of all sexual and reproductive health outreach activities. Community health workers advocate for voluntary counselling and testing and, in 2004, in collaboration with the HIV/AIDS support group ‘Tumaini na Fadhili’,xxiv and with technical assistance from FHOK, they began offering homebased care as well. People living with HIV have also been trained to join the team of community health workers. They do HIV-related work such as home-based care, nutritional counselling and psychosocial support in addition to other sexual and reproductive health work. Networking To try to provide for the comprehensive needs of its clients, the clinic actively networks with other non-governmental organizations which have complementary services and skills to offer. Clinic colleagues also collaborate with their clients’ own community support organizations who become their partners at grassroots level. Situated in a busy market-place, the Nakuru clinic has an air of community ownership. It offers space to a puppetry troupe that is engaged in sexual and reproductive health and HIV education. It is also a regular meeting place for a ‘post-test club’ – about 320 people living with, or affected by HIV, who gather for group support and counselling from Tumaini na Fadhili on issues such as good nutrition, safer sexual behaviour and home care. The clinic works closely with the provincial general hospital, on which it relies for advanced laboratory services and for referral of clients it does not have the capacity to treat. 10 Gateways to integration: a case study from Kenya Stigma and discrimination In every country, very real fears about stigma and discrimination inhibit people from seeking HIV services, whether it is going for testing, accessing health care for opportunistic infections or AIDS, or attending HIV-positive support groups. Kenya is no different in this respect. FHOK, in collaboration with its non-governmental organization partners, addresses these issues with sustained education about HIV and AIDS, and advocacy which raises awareness about the need to respect the human rights of people living with HIV. Other practical steps include making sure that the entrance and waiting areas are the same for all clients so that there is no way of singling out people who come to the clinic for HIV-related services. In addition, all members of staff are trained, and reminded at every opportunity, about the importance of confidentiality and fighting stigma. A case study from Kenya Partners at the grassroots: Communal self-help The sun is beating on the tin roof and heating the air on the veranda of the small local mosque where a group of women in bright headscarves is gathered on wooden benches for an education session on tuberculosis and HIV. They are members of the Kufaana self-help group, established in Rhonda, one of Kenya’s biggest slum settlements, on the outskirts of Nakuru. Soon after the President declared AIDS an emergency, the people in Rhonda realized they were not going to get the help they had hoped for from outside, and that they had better organize themselves to address the disease that was silently destroying their community. Each week, the 40 members contribute 10 shillings (about 13 US cents) to a communal account to fund projects. Kufaana members have received training and support from FHOK and others in peer counselling, condom distribution and home care for people living with HIV. Talking about their lives, the women gathered on the hot veranda say it is easier these days to talk about condoms with men: they are all educated about HIV and they draw strength and support from their friends in the group. Some say they wish female condoms were more accessible –at around 100 shillings (US$1.30) each, they cost more than a family has to live on for a day. And yes, they are all in favour of family planning, but the reality is, they say shaking their heads, that even getting to the clinic for advice and consultation is beyond the means of most of them. It is a long walk to where public transport begins, and then there is the bus fare and the long hours lost to earning a living. Extreme poverty limits what Kufaana members can do for people dying of AIDS, too, even with training in home care. In this settlement, there are days without water in the communal tap, so even rehydrating someone with diarrhoea is a challenge. Gateways to integration: a case study from Kenya 11 A case study from Kenya Antiretroviral therapy: Training and treatment In 2002, the Kenyan Government started providing antiretroviral therapy through specialist comprehensive care centres set up in the major hospitals. Unfortunately, coverage of the comprehensive care centres is limited and the services are overstretched. In addition, comprehensive care centres are stigmatizing, especially for newly diagnosed HIV-positive clients: anybody who walks into these clinics is making a public announcement about their HIV status. Expanding access FHOK, which works closely with the Ministry of Health, decided to use its facilities to expand access to antiretroviral therapy. By the end of 2005, four clinics, including the one at Nakuru, were providing antiretroviral therapy as part of the IPPF/GTZ Models of Care project. Motivation to offer the new treatment programme also came from FHOK’s own staff: clinic managers, at a quality of care workshop, identified the need to include antiretroviral therapy in the comprehensive package of sexual and reproductive health and HIV services offered by their clinics. The initial goal was to recruit 100 clients (25 in each clinic) in the first year, and to prove FHOK’s ability to provide in antiretroviral therapy before seeking support to expand provision from the Global Fund to Fight AIDS, Tuberculosis and Malaria and other donors. A core group of doctors, nurses, laboratory staff and pharmacists have received specialist training and passed on their skills to others working alongside them in the clinics. The Ministry of Health has offered further training to clinical staff in Nakuru, on paediatric HIV care. 12 Gateways to integration: a case study from Kenya The clinic doctor does the initial assessment. Clients who meet the clinical criteria for treatment are started on antiretrovirals, and supported through this process. Seventeen clients were already accessing antiretrovirals through this clinic by June 2006 and the numbers continue to rise. The clinic works closely with the provincial general hospital which manages complicated cases and performs more advanced diagnostic tests, such as CD4 and viral load counts, where required. The clinic offers antiretroviral therapy services without charge and, together with the other FHOK clinics, now receives free antiretroviral supplies from the Government. The biggest challenge to uptake of services, however, is the fee for laboratory tests: even though the fees are discounted to half the commercial rate, the costs are still out of reach for the majority of clients. A case study from Kenya Taking treatment out to the community: Follow-up care and support Once treatment is established, and there are no problems with taking the medication, clients are then cared for by a nurse who has the authority to write repeat prescriptions for their drugs. The community volunteers (some of whom are living with HIV themselves) play an important role too, by providing psychosocial support, nutritional counselling and, vitally, in encouraging adherence to treatment and discussing prevention strategies for people living with HIV. Volunteers also help by delivering drugs to clients who have difficulty attending the clinic, just as they do with contraceptive supplies and condoms and with medication for general home-based care. The clinics rely on their partners within communities, including the volunteers, to help identify and recruit people in need of antiretroviral therapy. Community health volunteers: Motivation and role Seated in the sunshine outside the provincial hospital’s sexually transmitted infection clinic, Mary talks of her work as a volunteer with FHOK.xxv Mary, a working nurse, felt compelled to use her skills to help people who rarely receive health care, and joined FHOK in 1991 to do sexually transmitted infection outreach among sex workers in her spare time. Trained in syndromic management of sexually transmitted infections, she went out to diagnose and, where possible, treat these infections among sex workers and their clients, to counsel about safer sex and to distribute condoms. More recently, Mary trained in voluntary counselling and testing and to deliver home-based care for people living with HIV, and she is hoping to become involved in the antiretroviral therapy programme too. This work is very close to her heart. As well as bringing up her own three children, Mary is raising three nephews and nieces whose parents have died of AIDS. Gateways to integration: a case study from Kenya 13 A case study from Kenya Services for young people: A pressing need Statistics The pressing need for sexual and reproductive health services for young people in Kenya is evident as the following statistics show. • Almost 25% of the population is aged 15 to 24 years. • The median age of first sexual intercourse for women aged 25 to 29 years is 16.5 years. • In rural areas, up to 21.8% of young women began childbearing aged 15 to 19 years. • The HIV prevalence for young women aged 15 to 24 years is estimated between 12.5 and 18.7% (and 4.8 to 7.2% for young men of the same age). • Only 52% of young women aged 15 to 24 years know that they can protect themselves from HIV by consistent condom use. Source: UNFPA Kenya profile – www.unfpa.org Information and life skills There has been impassioned public debate about what kind of information and services are appropriate for young people, and a new adolescent sexual and reproductive health policy was recently adopted by the Government. It allows information and life skills to be taught in schools, but not as part of the statutory curriculum. FHOK has taken a bold lead and, as long ago as the early 1980s, started producing educational fact sheets for young people. This initiative was followed by training young people as peer educators to provide information on sex and sexuality, family planning, prevention of sexually transmitted infections and HIV, and to distribute condoms. Though the legal age of consent to sexual intercourse has recently been raised from 14 to 16 years, condoms can still be legally distributed to young people below this age. FHOK now has a number of youth counselling centres, supported by funding from IPPF and UNFPA, where members aged between 10 and 24 years can access clinical services on site or be referred to an FHOK clinic. At the Nairobi youth centre in Eastleigh, for example, a nurse is available three afternoons a week, and there is a voluntary counselling and testing unit staffed by the youth counsellors who also run the mobile testing facility. During the last quarter of 2004, 313 males and 222 females sought HIV testing. During the whole year the unit saw 2,025 clients, compared with 1,500 clients in 2003. The information, personal counselling and clinical services offered at the centres are part of a more general programme of activities that attract young people. All activities are geared toward developing life skills. At the Nairobi youth centre, for example, there is a library, a video 14 Gateways to integration: a case study from Kenya room and an opportunity to take part in drama activities. Training in knitting, sewing, hairdressing, catering and computer skills is on offer for young women only, to encourage more girls to attend (at present about one-third of youth centre members are female), and to ensure they are given a chance to learn skills without competition from the more confident boys. Peer education All members can train as peer educators too, and are responsible for outreach activities at schools and on the streets. In the third quarter of 2004, nearly 20,000 out-of-school young people and 10,000 young people in schools were reached with sexual health information, and 1,600 female and more than 12,300 male condoms were distributed. Given the socio-economic situation and level of need in Kenya, peer counselling can be extremely stressful. The key to avoiding burnout is effective networks – having somewhere to refer a client when the counsellor can give no further help. He or she can, for example, refer a girl who has been raped to the Nairobi Women’s Hospital, refer someone living with HIV to Women Fighting AIDS in Kenya or to the local Médecins Sans Frontières project, and refer those with drug problems to rehabilitation programmes. A case study from Kenya The legal and policy environment: Additional constraints FHOK operates in a difficult legal and policy environment. Sex work and homosexuality are illegal, which encourages stigma and secrecy and makes these behaviours more difficult to address directly in health information materials. It also leaves health providers and clients unsure of their boundaries and vulnerable to the whims of the police and the courts. Abortion Advocacy Abortion is also illegal except when necessary to save the woman’s life. FHOK operates entirely within the law, by offering counselling to women with unintended pregnancies and treating the complications of unsafe abortion. However, this willingness to work on abortion subsequently led to a substantial withdrawal of funds for all areas of FHOK’s activity due to a shift in donor conditionality. FHOK makes provision in its budget to lobby decision makers and policy makers about sexual and reproductive health issues. It also participated in a workshop for religious leaders who were asked to acknowledge the needs of young people in their congregations and their special vulnerability to HIV, and to think about ways to protect young people’s health. Health providers cannot avoid the issue, no matter how controversial. More than half of all acute gynaecological admissions are for complications arising from unsafe abortions, and one in three maternal deaths is abortion-related. In early 2005, FHOK and partner organizations, as well as concerned individual professionals, set up the Reproductive Health and Rights Alliancexxvi which aims to: • advocate for informed debate about abortion and the creation of laws and policies that protect women’s reproductive health rights • reduce the rates of unsafe abortion by all means possible • protect care providers who are under threat from anti-choice campaigners and their supporters Gateways to integration: a case study from Kenya 15 A case study from Kenya The challenge of sustainability: On the knife-edge of survival Donor constraints Operating in an environment of widespread chronic poverty, FHOK faces a constant challenge to keep services going. Because of cutbacks in funding it has had to close clinics and withdraw support from nearly 1,000 trained community-based distributors, depriving more than 100,000 people of services. In 1999, in an effort to ease its dependence on donors, it started charging fees for some of its services, and clinics are now required to draw up business plans. As a matter of principle, fees are waived for the poorest clients, voluntary counselling and testing remains free for everyone, and youth programmes are also fully supported. This means, however, that no clinic manages to recover more than 70% of its costs, and FHOK remains heavily reliant on outside support. A major challenge in trying to run comprehensive services is that different donors have their own agendas and tend to earmark funds for specific purposes. A further challenge is posed by the fact that donors now tend to offer shorter contracts than they used to, which makes long-term planning difficult. Staff cannot be sure of their jobs from year to year, which affects morale, and there is a steady loss of good people – often trained at the expense of FHOK – to other non-governmental organizations, particularly international agencies. Cash flow vulnerability With such tight financial margins, FHOK’s services are extremely vulnerable to interruptions in cash flow. Changes made by some donors in their accounting periods, and in their rules and conditions of funding, have left the Association without support for its youth programme for months at a time, and without money to pay the small stipends and expenses of some community volunteers. Living on a knife-edge of survival, many volunteers have been forced to drop out of the FHOK network. FHOK juggles funds to try to keep its youth peer educators in the field at all costs. 16 Gateways to integration: a case study from Kenya As far as antiretroviral therapy is concerned, FHOK is well aware of the absolute imperative to avoid interruptions in treatment. It therefore opened a dialogue with the Ministry of Health to enable the Government to recognize the benefits of integration and to support the innovative model of HIV care. The fruits of this advocacy have been impressive: the Ministry of Health has registered FHOK clinics to receive free antiretroviral therapy supplies from the Government, in line with other public facilities. A case study from Kenya The need for comprehensive services: John’s storyxxvii John tested HIV-positive in 1996 at the age of 19 years, when he was hospitalized with a mysterious illness. The support of other people living with HIV gave him the courage to challenge the fear and misunderstanding of his family, and when he moved to Nakuru he joined the support group at FHOK and trained as a youth peer educator. Nobody advocates more passionately than him for behaviour change and safer sex. John became HIV-positive very soon after becoming sexually active. Many people believe marriage is out of the question for HIV-positive people, according to John, but in Nakuru he met and married a woman who had been a sex worker and who is also HIV-positive. He has talked with her about the need for people living with HIV to practise safer sex to avoid re-infection. The young couple strongly desired a child. They received excellent counselling from FHOK about pregnancy and preventing mother-to-child transmission. However, during emergency delivery of the baby two months early at the local hospital, he believes the antiretroviral prophylaxis was forgotten, and he and his wife live in fear of having their one-year-old daughter tested for HIV. Although John is not yet in need of antiretroviral therapy, his wife is, and the family used to struggle to meet the cost of treatment at their local comprehensive care centre – about 500 shillings (US$6.50) a month for the drugs alone – until the Government made treatment free in December 2005. Gateways to integration: a case study from Kenya 17 A case study from Kenya Plausible, possible and practical: Conclusions and lessons learned In a country with a serious generalized AIDS epidemic, it makes sense on every level to link sexual and reproductive health and HIV/AIDS services. To create an enabling environment for linked services, donors need to review the terms and conditions of their funding and allow greater flexibility in how money is spent. The only real question is – how? Too often donor funds are earmarked for specific purposes only – for HIV or sexual and reproductive health activities. This makes budgeting and accounting for integrated services extremely difficult and imposes a heavy administrative burden that undermines the efficiency of the programme. There is a pressing need for greater coordination among donors and for a general review of their criteria and procedures for funding in the light of new objectives. FHOK has sought to answer this in varying ways in its different clinics, depending on the needs of their client populations and the clinics’ own resources. A notable characteristic of FHOK is the openness of its staff to change and to adapt their services and working practices to meet the evolving needs of their clients. In a situation where many people have difficulty attending health facilities, the Association has developed a model of ‘care without walls’, where the clinics are the hub of communitybased services, and it has important lessons to share about integrating services for sexual and reproductive health and HIV/AIDS. FHOK has demonstrated that providing antiretroviral therapy within sexual and reproductive health settings is plausible, possible and practical. The strong network of community health volunteers attached to FHOK’s clinics provides an excellent infrastructure to deliver antiretroviral therapy and good prospects of reaching poor and marginalized communities with life-saving treatments. Making it happen required vision, commitment and hard work. In addition, a number of key steps that built on FHOK’s existing strengths were undertaken including specialist training of staff, procuring drugs and organizing logistics, and setting up partnerships with government hospitals for laboratory services and referral of clients. 18 Gateways to integration: a case study from Kenya Providing services for HIV/AIDS at sexual and reproductive health clinics attracts new clients and creates opportunities for promoting sexual and reproductive health to a wider population. Attendance at FHOK’s clinics increased, sometimes dramatically, once HIV counselling and testing was introduced. The tendency since then has been for demand for sexual and reproductive health care to increase alongside demand for HIV/AIDS services. The key to encouraging takeup of sexual and reproductive health and HIV/AIDS services is to advise clients about all services offered when they attend the clinic for any purpose. A case study from Kenya In order to achieve their core aims, and to maximize the public health impact, sexual and reproductive health and HIV programmes should take specific steps to meet the needs and concerns of men as well as women in providing services. Sexual and reproductive health – especially family planning – tends to be seen as ‘women’s business’, which inhibits men from attending clinics. In Nakuru, FHOK countered this by opening special male sexual and reproductive health clinics for a period, and subsequently removing all unintended sexist bias in its main clinic, providing information targeted at men, ensuring opening times were convenient for both male and female clients, and renaming the clinic the Family Care Medical Centre. These actions have had a dramatic effect. They have enabled and encouraged men to share responsibility for family planning with their partners, and they have facilitated communication between sex partners, which is vital for protecting health and preventing the spread of HIV. The best way to promote sexual and reproductive health among young people and to raise awareness of HIV is to make information and services available as part of a wider programme that addresses their social needs, and helps empower them to make healthy choices. FHOK’s youth centres provide opportunities to engage in a wide range of recreational and skillstraining activities that are a major attraction to young people, especially those from impoverished environments. As well as creating an ideal setting for educating and communicating with young people, such centres make it easy and comfortable for them to access care. By providing space for community groups to meet, or a base for their activities, clinics can strengthen the links with their client population to their mutual benefit. Among its many benefits, such an arrangement provides opportunities for health education and training that encourage and enable people to take greater responsibility for their own health; it helps foster mutual understanding and trust between service providers and their client population; it gives focus and support to communities wanting to organize activities; and it allows for peer support among people with common concerns. In addition, it fosters a sense of ownership of health services by the people they are designed to serve. Providing space for communitybased organizations to meet is also a good way of encouraging collaboration and partnerships with and among groups involved with sexual and reproductive health and HIV/AIDS. Gateways to integration: a case study from Kenya 19 A case study from Kenya Contact details for more information: Family Health Options Kenya (FHOK) Family Health Plaza Off Langata / Mbagathi Road Junction PO Box 30581 00100 Nairobi Kenya Phone: + 254-20-604296/7 Fax: + 254-20-603928 Email: info@fhok.org Endnotes The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health, UNFPA & UNAIDS, 2004. i The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, UNFPA & WHO, 2004. ii Call to Action: Towards an HIV-free and AIDS-free Generation, Prevention of Motherto-Child Transmission (PMTCT) High Level Global Partners Forum, Abuja, Nigeria, 2005. iii Meeting the Sexual and Reproductive Health Needs of People Living with HIV. Guttmacher Institute, UNAIDS, UNFPA, WHO, Engender Health, IPPF, ICW & GNP+, In Brief, 2006 Series, No. 6. xvi Gateways to Integration, UNFPA, IPPF, UNAIDS, WHO, forthcoming. xvii Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool, WHO, 2006. xviii iv Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services, High Level PMTCT Global Partners Forum, Johannesburg, South Africa, 2007. xix v Kenya: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. UNAIDS, UNICEF, WHO, 2006 Update. Intensifying HIV Prevention: UNAIDS Policy Position Paper, UNAIDS, 2005. vi Political Declaration on HIV/AIDS, United Nations General Assembly Special Session on HIV/AIDS. New York, United Nations, 2006. For example see the background paper on the concept of Universal Access prepared for the Technical Meeting for the Development of a Framework for Universal Access to HIV/AIDS Prevention, Treatment and Care in the Health Sector, WHO, Geneva, 2005. vii Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages, WHO, UNFPA, UNAIDS & IPPF, 2005. viii Programme of Action adopted at the International Conference on Population and Development, Cairo, 1994. ix Resolution adopted by the General Assembly, United Nations Millennium Declaration, New York, 2000. x See also Family Health International. Integrating services. Network, 2004, 23(3) p8. xi xii WHO, UNFPA, UNAIDS & IPPF, Op. cit. Linking Sexual and Reproductive Health and HIV/AIDS. An annotated inventory. WHO, UNFPA, UNAIDS & IPPF, 2005. xiii Sexual and Reproductive Health of Women Living with HIV/AIDS, Guidelines on care, treatment and support for women living with HIV/AIDS and their children in resourceconstrained settings, UNFPA & WHO, 2006. xiv Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health Settings, Stepwise guidelines for programme planners, managers and service providers, UNFPA & IPPF, 2004. xv 20 Gateways to integration: a case study from Kenya Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages: A Generic Guide, ICW, GNP+, IPPF, UNAIDS, UNFPA, WHO, Young Positives, 2008. xx President Daniel Arap Moi declared HIV/AIDS a “national disaster” on 25 November 1999. See www.kenyaaidsinstitute.org xxi Models of Care Project: Linking HIV/AIDS Treatment, Care and Support in Sexual and Reproductive Health Care Settings. Examples in Action. IPPF, 2005. xxii WHO/UNICEF/UNFPA/World Bank Maternal Mortality Estimates 2005. http://www.who.int/reproductive-health/ publications/maternal_mortality_2005/ mme_2005.pdf xxiii This means ‘hope, love, care and support’ in Kiswahili. xxiv Name has been changed to protect confidentiality. xxv These include FHOK, IPPF, the Kenya Medical Association, the Kenya Nursing Council, the Obstetric and Gynaecological Society of Kenya, the Planned Parenthood Federation of America, IPAS, the National Nurses Association of Kenya, the Federation of Women Lawyers Kenya (FIDA Kenya), and the Kenya Human Rights Commission. xxvi Name has been changed to protect confidentiality. xxvii John* tested HIV-positive in 1996 at the age of 19 years, when he was hospitalized with a mysterious illness. The support of other people living with HIV gave him the courage to challenge the fear and misunderstanding of his family, and when he moved to Nakuru he joined the support group at FHOK and trained as a youth peer educator. Nobody advocates more passionately than him for behaviour change and safer sex. * Name has been changed to protect confidentiality 

A case study from Haiti Linking Sexual and Reproductive Health and HIV/AIDS Gateways to integration a case study from Haiti Voluntary HIV counselling and testing: An entry point for comprehensive sexual and reproductive health services © 2008 WHO, UNFPA, UNAIDS, IPPF Disclaimer All rights reserved. The publishers welcome requests to translate, adapt or reproduce the material in this document for the purpose of informing health care providers, their clients, and the general public, as well as improving the quality of sexual and reproductive health and HIV/AIDS care. Enquiries should be addressed to WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (fax: +41 22 791 4806; email: permissions@who.int), UNFPA, 220 East 42nd Street, New York, NY 10017, USA (tel: +1 212 297 5000; email: info@unfpa.org), UNAIDS, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3666; email: unaids@unaids.org) or IPPF, 4 Newhams Row, London, SE1 3UZ, United Kingdom (fax: +44 207 939 8300; email: HIVinfo@ippf.org). Only authorized translations, adaptations and reprints may bear the emblems of WHO, UNFPA, UNAIDS, IPPF. Translations, adaptations and reproductions may be made without authorization so long as they are not used in conjunction with any commercial or promotional purposes, and so long as they do not use the emblems of the publishing organizations, and so long as they acknowledge the original source in line with the suggested citation below. The publishing organizations do not accept responsibility for any translations, adaptations and reproductions published by others. The publishers request print and electronic copies of all translations, adaptations and reproductions of this publication. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the publishing organizations in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the publishers to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO, UNFPA, UNAIDS, IPPF be liable for damages arising from use of this publication. This publication does not necessarily represent the decisions or the stated policy of WHO, UNFPA, UNAIDS, IPPF. Suggested citation for unofficial translations or adaptations of this tool: Linking Sexual and Reproductive Health and HIV/AIDS, Gateways to Integration: A case study from Haiti, prepared and published by WHO, UNFPA, UNAIDS, IPPF, 2008. Printed in London, United Kingdom, July 2008. Acknowledgements 2 Acronyms and abbreviations 2 Linking Sexual and Reproductive Health and HIV/AIDS Global commitments to strengthen linkages 3 Identifying and meeting the challenges 4 Tools to make it happen 4 Turning theory into practice 5 A case study from Haiti Evolution of service provision: Meeting the needs of under-served communities 6 All services under one roof: Rationale for integration 9 HIV testing: A gateway to access other services 10 Condoms: Promoting correct and consistent use 10 Sexually transmitted infections: Assessment and screening 11 Integrating family planning services: A compelling need 11 Family planning for people living with HIV: Issues about reproductive rights 12 Maternal health services: Issues about childbearing 13 Survivors of sexual violence: Skilled specialist services 15 Sexual and reproductive health services for young people: Building trust 16 Measures of success: Effect on demand for services 16 Integrated services under one roof: Conclusions and lessons learned 17 Some recommendations for health planners and service providers: Potential for scaling up 19 Contact details for more information 20 Endnotes 20 Gateways to integration: a case study from Haiti 1 A case study from Haiti Acknowledgements This case study is part of a series of joint publications by UNFPA, WHO, UNAIDS and IPPF on the issue of strengthening linkages between sexual and reproductive health and HIV/AIDS. The document is based on country experiences and is the result of a joint effort of national experts and a group of public health professionals at UNFPA, WHO, IPPF and UNAIDS. The publishing organizations would like to thank all partners for contributing their experiences, for reviewing numerous drafts and for valuable advice at all stages. Special thanks go to the following people who provided technical input and support for this publication: Main author: Susan Armstrong. Main contributors: Peter Weis (WHO), Lynn Collins (UNFPA) and Kevin Osborne (IPPF). Reviewers: From GHESKIO: Marie Deschamps and Jean William Pape. From WHO: Karoline Fonck, Manjula Lusti-Narasimhan, Rudolph Magloire, Michael Mbizvo, Jos Perriens, Patricio Rojas and Paul Van Look. From UNFPA: Ramiz Alakbarov, Hedia Belhadj, Christina Bierring, Michel Brun, Raquel Child, Hernando Clavijo, Jose Ferraris, Josiane Khoury, Steve Kraus, Monique Rakotomalala, Harold Robinson, Alexei Sitruk, Maria Antonia Urbina and Sylvia Wong. From UNAIDS: Anindya Chatterjee, Barbara de Zalduondo, Emma Fowlds and Mahesh Mahalingam. From IPPF: Andy Guise, Jonathan Hopkins and Ale Trossero. Acronyms and abbreviations AIDS Acquired Immune Deficiency Syndrome AZT Azidothymidine – also known as Zidovudine® or Retrovir® GHESKIO Groupe Haïtien d’Étude du Sarcome de Kaposi et des Infections Opportunistes HIV Human Immunodeficiency Virus IPPF International Planned Parenthood Federation PAHO Pan American Health Organization PEP Post-Exposure Prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PLHIV People living with HIV PMTCT Prevention of Mother-to-Child Transmission STI Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund VCT Voluntary HIV Counselling and Testing WHO World Health Organization 2 Gateways to integration: a case study from Haiti Linking Sexual and Reproductive Health and HIV/AIDS The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding, all of which are fundamental elements of sexual and reproductive health care. In addition, sexual and reproductive health problems share many of the same root causes as HIV/AIDS, such as poverty, gender inequality, stigma and discrimination, and marginalization of vulnerable groups. Despite this, services for sexual and reproductive health and for HIV/AIDS still largely exist as separate, vertical programmes. Global commitments to strengthen linkages Building blocks To raise awareness of the pressing need for more widespread linkages between sexual and reproductive health and HIV/AIDS, UNFPA and UNAIDS, in collaboration with Family Care International, held a high-level consultative meeting in June 2004 with government ministers and parliamentarians from around the world, ambassadors, leaders of United Nations and other multilateral agencies, non-governmental and donor organizations, as well as young people and people living with HIV. The meeting resulted in The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health,i which challenges the sexual and reproductive health and HIV/AIDS communities to examine how they might improve collaboration. An earlier meeting, held in Glion, Switzerland (May, 2004), and initiated by WHO and UNFPA, took a close look at the role of family planning in reducing HIV infection among women and children. This conference resulted in The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children.ii In December 2005, a global partners’ meeting was convened to discuss progress in implementing a comprehensive approach to prevention of mother-to-child transmission. This consultation also stressed the importance of linking sexual and reproductive health and HIV/AIDS services, and led to a Call to Action: Towards an HIV-free and AIDSfree Generation,iii as did the most recent PMTCT consultation in Johannesburg November 2007, resulting in a Consensus Statement: Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services.iv Linking HIV/AIDS and SRH was included as one of the Essential Policy Actions for HIV Prevention in the UNAIDS policy position paper on Intensifying HIV Prevention, which was issued in 2005.v Framework for universal access The above commitments culminated in the Political Declaration on HIV/AIDS arising from the 2006 Review of the United Nations Special Session on HIV/AIDS (UNGASS), which also stressed how vital it is to link HIV/AIDS with sexual and reproductive health.vi Following the commitment by G8 members1 and, subsequently, heads of states and governments at the 2005 United Nations World Summit, the UNAIDS Secretariat and its partners have been defining a concept and a framework for Universal Access to HIV/AIDS Prevention, Treatment and Care by 2010.vii Efforts towards universal access underline the importance of strengthened linkages between sexual and reproductive health and HIV/AIDS. G8 summits: Since 1975, the heads of state or government of the major industrial democracies have been meeting annually to deal with the major economic and political issues facing their domestic societies and the international community as a whole. G8 countries are France, United States, United Kingdom, Germany, Japan, Italy, Canada and Russian Federation. 1 Gateways to integration: a case study from Haiti 3 Linking Sexual and Reproductive Health and HIV/AIDS The potential benefits of linking sexual and reproductive health and HIV/AIDS include: • improved access to sexual and reproductive health and HIV services • increased uptake of services • better sexual and reproductive health services, tailored to meet the needs of women and men living with HIV • reduced HIV/AIDS-related stigma and discrimination • improved coverage of under-served and marginalized populations, including sex workers, injecting drug users and men who have sex with men • greater support for dual protection against unintended pregnancies and sexually transmitted infections, including HIV • improved quality of care • enhanced programme effectiveness and efficiencyviii Another aim of linking sexual and reproductive health and HIV/AIDS is to accelerate progress towards achieving the goals agreed at the International Conference on Population and Developmentix and the Millennium Development Goals,x especially those that aim to reduce poverty, promote gender equality and empower women, improve maternal health, combat HIV/AIDS, and attain universal access to sexual and reproductive health. Identifying and meeting the challenges Linking sexual and reproductive health and HIV/AIDS policies and services presents many challenges for those on the front line of health care planning and delivery. These include:xi • making sure that integration does not overburden existing services in a way that compromises service quality, by ensuring that integration actually improves health care provision • managing the increased workload for staff who take on new responsibilities • allowing for increased costs initially when setting up integrated services and training staff • combating stigma and discrimination from and towards health care providers, which has the potential to undermine the effectiveness of integrated services no matter how efficient they are in other respects • adapting services to attract men and young people, who tend to see sexual and reproductive health, and especially family planning, as ‘women’s business’ • reaching those who are most vulnerable but least likely to access services, such as young people • providing the special training and ongoing support required by staff to meet the complex sexual and reproductive health needs of HIV-positive people effectively • motivating donors to move from parallel to integrated services, and sustaining support for integrated policies and services. Tools to make it happen Several tools prepared by IPPF, UNFPA, UNAIDS and WHO offer guidance on how to link sexual and reproductive health with HIV/AIDS. These include: • Sexual and Reproductive Health and HIV/AIDS – a framework for priority linkages xii • Linking Sexual and Reproductive Health and HIV/AIDS – an annotated inventory xiii • Sexual and Reproductive Health of Women Living with HIV/AIDS – guidelines on care, treatment, and support for women living with HIV/AIDS and their children in resource-constrained settings xiv • Integrating HIV Voluntary Counselling and Testing Services 4 Gateways to integration: a case study from Haiti into Reproductive Health Settings – stepwise guidelines for programme planners, managers and service providers xv • Meeting the Sexual and Reproductive Health Needs of People Living with HIV xvi • Gateways to Integration – a series of case studies of country-level experiences on how to link and integrate servicesxvii • Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool xviii • Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guidexix Linking Sexual and Reproductive Health and HIV/AIDS Turning theory into practice The process of linking sexual and reproductive health and HIV/AIDS needs to work in both directions: this means that traditional sexual and reproductive health services need to integrate HIV/AIDS interventions, and also that programmes set up to address the AIDS epidemic need to integrate more general services for sexual and reproductive health. While there is broad consensus that strengthening linkages should be beneficial for clients, only limited evidence is published regarding real benefits, feasibility, costs and implications for health systems. This publication presents one of a series of country experiences, set against a different public health, socio-economic and cultural background, embedded in radically different legal and health care environments and using different entry points as they strive to strengthen linkages between sexual and reproductive health and HIV/AIDS. The case studies featured in this series have been chosen to demonstrate this two-way flow and to reflect the diversity of integration models. While these case studies focus primarily on service delivery components, structures/systems and policy issues are also important ingredients of the linkages agenda. The case studies are not intended to be a detailed critique of the programmes or to represent ‘best practice’ but to provide a brief overview that shows why the decision to integrate was taken, by whom, and what actions were needed to make it happen. The intention is to share some of the experience and lessons learned that may be useful to others who wish to consider actions to strengthen the integration of these two health care services. They are real experiences from the field, with important achievements but also with real limitations and shortcomings. One of these shortcomings lies in the nomenclature currently being used. There is currently no globally accepted definition of the terms ‘linkages’, ‘mainstreaming’ and ‘integration’ in the context of sexual and reproductive health and HIV. At times in these case studies the terms are used by different organizations in a variety of settings in different ways. While we propose the following definitions, it should be noted that the different implementing partners have not used these consistently: Mainstreaming: Mainstreaming HIV/AIDS means all sectors and organizations determining: how the spread of HIV is caused or contributed to by their sector, or their operations; how the epidemic is likely to affect their goals, objectives and programmes; where their sector/organization has a comparative advantage to respond – to limit the spread of HIV and to mitigate the impact of the epidemic and then taking action. Linkages: The policy, programmatic, services and advocacy synergies between sexual and reproductive health and HIV/AIDS. Integration: Refers to different kinds of sexual and reproductive health and HIV/AIDS services or operational programmes that can be joined together to ensure collective outcomes. This would include referrals from one service to another. It is based on the need to offer comprehensive services. Gateways to integration: a case study from Haiti 5 A case study from Haiti Vital statistics at a glance Estimated population (2005) 8,528,000 Adult population aged 15 to 49 years (2005) 4,358,000 Life expectancy at birth: Men 53 years Women 56 years Crude birth rate (2005) 29.8/1,000 population Total fertility rate (2004) 3.9 HIV prevalence rate in adults aged 15 to 49 years (2005) 3.8% (2.2-5.4%) Estimated number of PLHIV (2005) 190,000 Estimated number of adults aged 15 years and over living with HIV (2005) 180,000 Estimated number of women aged 15 years and over living with HIV (2005) 96,000 Deaths due to AIDS (2005) 16,000 Estimated number of adults in need of antiretroviral therapy (2005) 32,000 Estimated number of people receiving antiretroviral therapy (2005) 7,000 Contraceptive prevalence rate (2000) Births attended by skilled health personnel (2000) 28.1% 24% Sources: Haiti: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. UNAIDS, UNICEF, WHO, 2006 Update. Available at www.who.int and www.unaids.org/en/CountryResponses/ Countries/haiti.asp : UNAIDS Haiti Country Situation Analysis, June 2007xx (Check UNAIDS website for updated data available from end of July 2008). 6 Gateways to integration: a case study from Haiti Evolution of service provision: Meeting the needs of under-served communities Haiti has one of the oldest AIDS epidemics and one of the highest rates of HIV infection in the world outside of sub-Saharan Africa. In the early 1980s, Haitians en masse were subjected to stigma and discrimination with reports of people being met at international airports by immigration officials in full protective clothing, shunned by colleagues and friends alike, with children of HIVpositive parents being turned away from schools. In May 1982, a group of doctors, who became aware of AIDS through the unusual illnesses they were seeing among their patients, started GHESKIO initially as a research institute with support from the Ministry of Health. (GHESKIO is the acronym for Groupe Haïtien d’Étude du Sarcome de Kaposi et des Infections Opportunistes – the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections.) A case study from Haiti In 1985, GHESKIO began providing voluntary HIV counselling and testing (VCT) services and treatment for opportunistic infections in Cité de Dieu, one of the poorest neighbourhoods of Port au Prince, where health problems, including HIV/AIDS, are widespread. GHESKIO gradually integrated a wide range of sexual and reproductive health services, including family planning, and expanded coverage to the two adjacent neighbourhoods, both equally poor, of Cité Eternel and Cité Soleil. VCT is now the gateway to a full range of clinical sexual and reproductive health and HIV/AIDS services introduced sequentially as the needs became apparent and operational research showed what was feasible (see Figure 1). Today, the GHESKIO centre, with some 230 staff, serves a population of around 1.5 million in Cité de Dieu and the two neighbourhoods of Cité Eternel and Cité Soleil. Services include VCT, treatment for sexually transmitted infections (STIs), tuberculosis, diarrhoeal diseases and malaria, and sexual and reproductive health care. Services are open to adults, infants and young people. In 1985, the year that VCT was introduced, around 100 clients came for HIV testing, most of whom were referred by hospitals. In 2004, 23,313 clients attended the voluntary counselling and testing clinic, the great majority on their own initiative and not referred via the health system. On average, 70% of clients are self-referred and 20% are referred by public institutions. About 100,000 clients a year now use the GHESKIO centre for a whole range of services, although 90% of clients initially visit GHESKIO for VCT. Of the 24,000 new individuals who visit the centre annually, 60% are women, 90% are of reproductive age, 16% are HIV-positive and 10% have syphilis. In addition, 8,000 of them are adolescents or young adults aged 15 to 24 years. The centre also offers services and support for women who have been raped. The conditions under which GHESKIO operates are daunting, characteristic of a country beset by poverty and political instability. Integrating sexual and reproductive health and HIV/AIDS services Introduction of additional GHESKIO services: • 1985 VCT and treatment for opportunistic infections • 1988 Distribution of condoms to prevent STIs including HIV • 1989 Diagnosis and treatment of tuberculosis • 1991 Diagnosis and treatment of STIs • 1993 Family planning • 1999 Antiretroviral therapy and maternal health programme, including PMTCT • 2000 Care for survivors of sexual violence and youth programme Gateways to integration: a case study from Haiti 7 A case study from Haiti Figure 1: Voluntary counselling and testing: the gateway to a range of sexual and reproductive health and HIV/AIDS services VCT registration: Pregnant women: Same day results and post-test counselling HIV pre-test counselling: ↪ ↖ Questionnaire to evaluate: • HIV/AIDS knowledge • behaviour • health status ↖ ↪ ↖ • 1985: 100 clients, mostly hospital referrals • 2004: 23,313 clients, 66% self-referrals HIV-positive pregnant women: Referred for PMTCT: • social worker • nurse • doctor • paediatrician HIV-negative pregnant women: Referred for routine ante-natal care HIV testing: In addition, screening for: • syphilis • tuberculosis, if a cough persists for more than three weeks Other HIV-positive clients: ↖ ↖ ↪ Return within two weeks for: Referred for: • antiretroviral treatment (if eligible) • home care – education of family care-givers • nutritional support • HIV post-test counselling • HIV test result ↪ 8 Gateways to integration: a case study from Haiti Family planning ↖ Doctor Other HIV-negative clients: Information about: • vaccine trials • youth programme A case study from Haiti All services under one roof: Rationale for integration GHESKIO’s decision to offer sexual and reproductive health services integrated with its existing HIV/AIDS programme, all under one roof, was motivated partly by the following factors: • the great majority of HIV infections in Haiti are contracted sexually • without intervention, about a third of infants born to women living with HIV become HIV-positive themselves, and, in Haiti, AIDS is responsible for 20% of infant deathsxxi • although improving, stigma and lack of necessary professional skills result in many PLHIV being denied access to sexual and reproductive health care in other health facilities • people do not have the time or money to go from one place to another to meet their different health needs. Multi-skill approach In order to meet the diverse needs of its clients in the most efficient and holistic manner, GHESKIO has chosen to use the ‘multi-skill approach’ which means that all medical staff are trained to be able to work in any of the Centre’s clinics. Not only does this mean that staff can, and do, stand in for each other if necessary, but it also helps enormously by promoting understanding among colleagues and has been the key to successful integration of services at the Centre. Capacity building is also a core part of GHESKIO’s mission. All colleagues are encouraged to undergo training, with an emphasis on continuous education. An important aspect of training, in addition to providing clinical knowledge on HIV/AIDS and sexual and reproductive health, is building the capacity to address issues about stigma and discrimination, and the skills needed for outreach work. People living with HIV are also involved in training activities, and become peer counsellors or take on other roles. Influencing policy and practice GHESKIO has played a major role in influencing policy and practice in the Haitian national health system. This is particularly apparent in the way it has developed its model of integrated services targeting the endemic and most common diseases, such as tuberculosis, HIV, STIs, diarrhoeal diseases and malaria. Integrating sexual and reproductive health services into the voluntary counselling and testing network – to prevent unintended pregnancies and prevent mother-to-child transmission of HIV – has significantly increased access to services. This model of service provision is now being used in 22 public and private health centres and hospitals nationwide. Through its operational research and training unit, GHESKIO plays a major role in developing guidelines, treatment protocols, and strategic plans to fight endemic diseases, as well as training medical and paramedical personnel. It is one of the main referral centres for training on HIV, STIs, tuberculosis, diarrhoeal diseases, and HIV counselling and testing. Curricula are updated annually with technical assistance from national and international partners. GHESKIO also offers services outside its main Centre through a network of health institutions created in partnership with the Ministry of Health, with the support of UNFPA, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) and the French Government. GHESKIO supports outreach activities to follow up PLHIV after they have received their HIV test results. Those who are HIV-negative but at risk – for example, people with syphilis or other STIs, and people with an HIV-positive partner – are also monitored and encouraged to return to the clinic regularly for follow-up counselling, and treatment if necessary. Outreach workers are trained at GHESKIO and then monitored by an outreach team which includes a field worker, nurse and social worker, under the overall supervision of a Community Advisory Board. Gateways to integration: a case study from Haiti 9 A case study from Haiti HIV testing: A gateway to access other services Since GHESKIO is a dedicated centre for VCT, HIV testing is the gateway to access other services. Clients who decline HIV testing receive care for the condition that brought them to the clinic, but are then formally referred to other institutions for continued care, and provided with further information about the advantages of HIV testing. Once clients are registered with GHESKIO and have been tested for HIV, they can continue to use the other services as necessary. Around 70% of VCT clients are self-referrals; the remaining clients are referred from other health services. All HIV testing is performed strictly on the basis of informed consent, and pre- and posttest counselling sessions are extremely thorough. Pregnant women and rape survivors receive their results and post-test counselling on the same day; the timing for providing HIV test results and posttest counselling for all other clients is within a week. Disclosure of an HIV-positive test result to the client is always done during face-to-face individual counselling. The goal is to manage the clients’ stress and assist them to accept their status and to return for services, preferably with his/her partner. Around 5 to 10% fail to return within two weeks for their test result. If the clients agree to disclose their HIV status to their sexual partner(s) or members of their family, GHESKIO staff offer to assist with face-to-face disclosure support. All GHESKIO’s clinical services are underpinned by information and education aimed at increasing awareness and knowledge of HIV and other infections, and promoting healthy behaviour. Young people who attend the clinic are encouraged to join the youth programme, where they are offered intensive sexual and reproductive health education and free condoms. 10 Gateways to integration: a case study from Haiti Condoms: Promoting correct and consistent use Condom use is promoted at all GHESKIO clinics, and female and male condoms are readily accessible to clients (both adults and sexually active adolescents). Post-test counselling includes information and motivation to use condoms correctly and consistently. Promoting condoms has increased the contraceptive prevalence rate from 6% up to 24% among the GHESKIO catchment population. Condoms, with or without other contraceptive methods, are the most common family planning method used. The Centre offers services and condoms free of charge. A case study from Haiti Sexually transmitted infections: Assessment and screening Apart from providing free condoms, the first services for sexual and reproductive health to be integrated with VCT in 1991 were diagnosis and treatment of STIs. Now, anyone coming to the GHESKIO Centre is routinely offered screening for syphilis. In addition, anyone with symptoms of an STI, or anyone who is assessed during HIV pre-test counselling to be at high risk of an STI, is offered an appointment the same day with a doctor and counselled and/or treated accordingly. This service has been extended to clients who have been sexually abused or raped. Integrating family planning services: A compelling need In the early 1990s, the need to offer family planning services on-site also became compelling, for two main reasons: • Women living with HIV referred by GHESKIO to family planning clinics were being turned away because of stigma and discrimination as well as lack of competence to meet their special needs. • Using pre-test counselling records as a baseline showed that contraceptive prevalence among people who registered with GHESKIO increased within a period of six months. Condoms, alone or in combination with other contraceptive methods, were offered to women living with HIV,xxii but evidence suggested that a significant number of these women became pregnant, and that most pregnancies were unintended. It became clear that family planning clinics were refusing to take referrals from GHESKIO, fearing that the stigma of AIDS would affect their business. The denial of family planning services to women living with HIV was a clear abuse of women’s reproductive rights, which include the right to freedom from discrimination. At the same time, a vital opportunity to prevent HIV infection in children by preventing unintended pregnancies among women living with HIV was being lost. GHESKIO added family planning to its voluntary counselling and testing services through a pilot programme supported by UNFPA. Four doctors and two nurses received specialist training from Pro Famil, the IPPF Member Association in Haiti. Clinics were subsequently rearranged to provide counselling rooms with the necessary privacy, and protocols were developed for the new programme. From the beginning, the family planning service had a marked effect on encouraging people, especially women, to come for voluntary counselling and testing. Its obvious success led to the training of other staff in family planning as well. Gateways to integration: a case study from Haiti 11 A case study from Haiti Family planning for people living with HIV: Issues about reproductive rights All GHESKIO health workers are now trained to meet the special family planning needs of PLHIV, as well as the routine needs of other clients. Family planning counselling for PLHIV covers a full range of services and includes, for example: • providing information and counselling about reproductive rights, including fertility intentions and options – this includes infertility services, advice on planning a pregnancy for discordant and sero-concordant HIV-positive couples, and contraception • dual protection – the use of condoms alone or in conjunction with other modern contraceptives for optimal protection against both unintended pregnancy and STIs • PMTCT for those who wish to become pregnant and for women who are already pregnant when they consult the clinic • prevention of sexual transmission of HIV to partners. The duty of the family planning counsellors is to inform and educate clients about the services that are available, to help the woman or couple explore their own feelings about childbearing and its implications, and to respect and support them in the choices they make. There is no coercion to avoid pregnancy, whatever a woman’s HIV status. Group discussions are organized, and information, education and communication materials are distributed to all women, encouraging them to return with their partner(s). Sixty per cent of the clients for this service are female and 40% are male. Only 15 to 20% of clients return to the clinic with their partner(s). Generally, more men agree to come back with their female partner than the reverse. GHESKIO is reaching out to address the needs of people who may not have access to sexual and reproductive health services, partly due to stigma: this includes PLHIV, unmarried adolescents, sex workers and men who have sex with men. This brings family planning providers face-to-face with issues of stigma and discrimination – issues that have many implications in HIV/AIDS care and which remain a central focus in the training of all GHESKIO staff. The Centre uses a variety of techniques such as drama and role play to encourage staff to examine their own attitudes and rethink them if necessary to ensure clients’ rights are respected. Face to face with prejudice: One nurse’s story “Family planning counselling for people living with HIV presents many challenges,” says a nurse who works in the clinic. She remembers the specific instance of a young woman who was already on antiretroviral therapy but who had kept her HIV infection secret, even from her husband. The couple wanted to start a family, but the intense fear of disclosure of HIV status and lack of openness between wife and husband made it extremely hard to explore their options. The young woman was referred to the GHESKIO resident psychologist for help. The nurse also tells how she had to confront her own anxiety over HIV/AIDS when starting work in the GHESKIO family planning clinic. In the early days, she was afraid to pick up her own baby when she got home at night in case she had been ‘contaminated’ by her work. “It was very hard,” she says, shaking her head at the memory. She remembers, too, the difficulty she had at first in working with men who have sex with men. During training, all GHESKIO colleagues are required to explore their feelings about HIV/AIDS and to confront their prejudices. The nurse smiles when she recalls being given the part of an HIVpositive woman in a role play where she had to put herself in the HIV-positive woman’s shoes. Having a brother who died of an HIV-related illness also encouraged her to overcome her fears and intolerances. 12 Gateways to integration: a case study from Haiti A case study from Haiti Maternal health services: Issues about childbearing GHESKIO soon realized there was a need to provide maternal health services too, for several reasons: • An annual pregnancy rate of 11% was observed at the HIV clinic regardless of the HIV status of the women. A significant proportion of women living with HIV are pregnant when they first come for voluntary counselling and testing.xxiii • A proportion of women living with HIV who come for reproductive health counselling wish to become pregnant. • Unintended pregnancy remains a significant issue. The majority of women who test positive for HIV do not access family planning services or use contraception. Some of the women who become pregnant do so primarily at their male partner’s request, or because they are afraid to lose their partner. There is a need to empower women to make their own choices. • Pregnant HIV-positive women need services to minimize the risk of HIV transmission to their babies and protect their own health. The PMTCT Unit is part of the GHESKIO Centre, and care is offered by GHESKIO staff (gynaecologists, midwives, social workers and field workers). Babies are also seen at the Centre by a paediatrician. Meeting the needs of HIV-positive pregnant women, however, presented huge challenges to GHESKIO. Until the late 1990s, the only regimen that was being used to prevent mother-tochild transmission – a course of monotherapy with AZT, including intravenous administration of the drug during childbirth – was not feasible in Haiti where around 80% of women deliver at home, often without any professional care during pregnancy, labour and delivery. GHESKIO did not have the space or capacity to get involved in the delivery of babies. However, service providers in Thailand had been piloting a much simpler regimen with AZT. Though its effects were still not well understood, the Haitian Ministry of Health approved an 18-month trial with funding from UNFPA. This was the first setting in which women would be responsible Protecting women and children from HIV: Global strategies Comprehensive global strategies for preventing HIV infection in women and infants encompass four key elements: 1. Primary prevention of HIV infection in girls and women 2. Prevention of unintended pregnancies in women living with HIV 3. Prevention of transmission from women living with HIV to their infants 4. Provision of care, treatment and support for women living with HIV and their families. xxiv for their antiretroviral prophylaxis and treatment without supervision. In cases where pregnant women living with HIV were at an advanced stage of disease, they received highly active antiretroviral therapy instead of the monotherapy used for prophylaxis. The trial turned out to be a success – women were compliant and were returning to GHESKIO with their child after giving birth to follow up on treatment. The quality of the counselling was vital to this success. The key to expanding services: Innovative nurse-midwife role An idea for spreading responsibilities and easing the workload of doctors is being tested in some PMTCT programmes. Nurse-midwives with specialist training in HIV/AIDS are working under the supervision of GHESKIO gynaecologists to see how many of their duties they are able to handle effectively and safely on their own. If the idea proves a success, specially trained nurse-midwives, backed up by good referral systems, will be the key to expanding maternal health services – considered a priority by the Ministry of Health to address high maternal mortality – despite the chronic shortage of doctors. Such services will be equipped to provide voluntary HIV counselling and testing, and to meet the sexual and reproductive health needs of all women in Haiti, regardless of their HIV status. Gateways to integration: a case study from Haiti 13 A case study from Haiti Financial crises among donors have interrupted funding from time to time, and GHESKIO has had to find support from elsewhere to keep the maternal health services going. Nevertheless, the Centre’s PMTCT programme has succeeded in gradually reducing the rate of vertical HIV transmission from around 30% to 9% among GHESKIO’s clients. The interventions which contribute the most to this decrease are the education sessions (including breastfeeding counselling), the antiretroviral therapy and the formula for infant feeding. Pregnant women who present too late for the education sessions do not have the opportunity to comply and are at higher risk of transmitting the infection. Furthermore, since the start of the maternal health programme, the average number of pregnant women seeking voluntary HIV counselling and testing has risen from around seven per month in 1999 to 120 per month in 2003 – a clear indication that, in a country with frighteningly high maternal and infant death rates, women are keen to have professional care in pregnancy if it is user-friendly. The fact that women living with HIV who attend GHESKIO’s maternal health services have access to longterm antiretroviral therapy (for themselves, their partners and their children if needed) is an added incentive. Women and child centred care: Addressing stigma and fear effectively Mireille,xxv a frail young woman resting a tiny baby on her lap, sits among others who have gathered for group counselling in the PMTCT clinic and tells her story. She tested HIV-positive in 2000 and, like most of the others in the group, fear of stigma and abandonment by her partner has prevented her from disclosing her HIV status to anyone beyond the group. Mireille is raising six children. She is on antiretroviral therapy, and managed to take her pills to prevent HIV infection in her youngest child as secretively as she manages her regular treatment (not all women share their HIV status with their partner(s) or with other family members). It is hard, but she is determined. And she tells inquisitive family and neighbours that she is forced to bottle-feed because of a breast problem. A young woman sitting nearby tells how she managed to hide the fact that she was bottle-feeding by clasping her baby to her bosom beneath a blanket. She had told the woman who delivered her baby that the pills she took regularly were for anaemia. Another tells the group she could not resist the social pressure to breastfeed and has lost a baby to AIDS. It is in dealing with issues like these – directly related to HIV and to stigma – that specialist training is essential for staff working in GHESKIO’s maternal health unit. GHESKIO addresses these issues through its policy of training staff about stigma and discrimination, and how to deal with them, as well as employing PLHIV as counsellors. In addition, procedures are in place to deal with client complaints about stigma and discrimination should any arise. Remedial strategies include staff meetings and further staff training to ensure that counselling to clients is absolutely stigma-free. Counsellors provide knowledge about issues related to HIV/AIDS, reproductive health and sexuality during HIV pre- and post-test counselling which aims to decrease fear and stigmatization and which encourages the client to come back with his or her partner. GHESKIO offers services free of charge to most of the private and public institutions, and gives regular refresher training. There is no legal referral structure in Haiti to deal with cases of stigma and discrimination. 14 Gateways to integration: a case study from Haiti A case study from Haiti Survivors of sexual violence: Skilled specialist services As increasing numbers of women treated for STIs began to report incidents of rape – particularly in times of political turmoil – GHESKIO won support from UNFPA in 2000 to set up a specialist programme for survivors of sexual violence. The wounds inflicted during sexual assault facilitate the transmission of HIV, and 46% of the rapes reported to GHESKIO up to the end of 2004 involved multiple rapists. Moreover, in the poverty-stricken community served by the Centre, HIV prevalence is much higher than the national average. In 1999, for example, it was 30%, six times the national HIV prevalence rate. GHESKIO also collaborates with the Ministry of Women’s Affairs, civil society and various funders on its programme for survivors of sexual violence. The clinic offers antiretroviral drugs for post-exposure prophylaxis (PEP), together with emergency contraception, for rape survivors who arrive within 72 hours of the incident, as well as treatment or prophylaxis for STIs (around 46% of clients for this service present within 72 hours). Until 2003, GHESKIO was the only place where PEP was available, but this service is now offered more widely in VCT centres. A national protocol for providing care to the survivors of rape has been developed. In addition, GHESKIO is part of a roundtable on violence against women which plays a technical role, under the coordination of the Ministry of Women’s Affairs. support group. The number of women who sought treatment and care at GHESKIO following sexual violence increased from around 10 in 2000, when the special programme opened, to well over 250 in 2004. GHESKIO is an important centre for sharing its medical experience and expertise when treating survivors of rape. Women who arrive at GHESKIO too late to prevent possible HIV transmission and/or pregnancy are treated for STIs and psychological trauma. Tremendous shame and stigma are attached to rape in Haiti, so a psychologist skilled at handling sensitive cases and post-traumatic stress works alongside the doctors, nurses and social workers on the team. Each client is assigned a field worker to accompany her through the system to protect her from further trauma and ensure she is fast-tracked through voluntary HIV counselling and testing, other laboratory tests and dispensary, and that she understands all care and treatment that is offered. All clients are encouraged to attend a weekly In general, violence against women, and abandonment or fear of abandonment, can have an impact on HIV status disclosure and access to services. Unfortunately, there is no reliable information or studies available about the relationship between domestic violence, HIV status and access to HIV counselling and testing in Haiti. Gateways to integration: a case study from Haiti 15 A case study from Haiti Sexual and reproductive health services for young people: Building trust By 2000, GHESKIO was seeing increasing numbers of young people aged 10 to 19 years presenting for VCT and other health care. As a result, the centre set up specialist adolescent health services to cater for their needs. The programme developed educational materials, gave specialist training to social workers in counselling young people and set up a support group for clients. and awareness, but it was soon recognized that there was also a need to gather information about individual behaviour, since this was pertinent to their risk of STIs (including HIV) and to identify their special counselling needs. Responses to the expanded questionnaires have revealed, for example, that: Young people are referred to the programme when they come for VCT, and are asked to fill in a questionnaire. This was originally designed to test their knowledge • the young women and girls in GHESKIO’s programme often have sexual partners much older than themselves and little power in these relationships • the great majority of young people attending the clinic have multiple sexual partners • around 44% of young women and girls always have sex without condoms, compared to 19% of boys. In counselling, a non-judgemental attitude is essential to gain the trust of young people, since the great majority who attend the clinic are involved in recreational drug use (over 70%) and other stigmatized or illegal behaviour. Since the special service was introduced, the numbers of young people seeking VCT have escalated. Measures of success: Effect on demand for services It is very hard to measure the impact that integration of services has had on reproductive health and on the AIDS epidemic, especially given the limits in coverage, but the following data give an indication of the effect on demand for services.xxvi • There was a 62-fold increase in the number of clients seeking voluntary HIV counselling and testing between 1985 and 1999 – the period during which sexual and reproductive health services were progressively introduced. • There was a 30-fold increase in the number of pregnant women seeking voluntary counselling and testing at GHESKIO between 1999 and 2004 when the PMTCT programme was introduced. • Of 6,700 new adults seeking voluntary counselling and testing in 1999, 18% received treatment for STIs. • One in five of those who tested HIV-positive that year referred their sex partners for VCT. • In 1999 alone, 19% (1,274) of the 6,700 VCT clients became new contraceptive users, and returned to the Centre for at least three family planning visits. Of these, 16 Gateways to integration: a case study from Haiti 70% (494 men and 408 women) chose to use condoms alone. Thirty per cent (372 women) became users of other modern contraceptives (for example, pills, injectables and spermicides), and half of these also used condoms regularly. • In 1999, 110 HIV-discordant couples were identified and provided with specialized counselling. Of the 85 couples who returned for follow-up testing around 18 months later, no partner had become HIV-positive (25 couples were lost to follow-up). A case study from Haiti Integrated services under one roof: Conclusions and lessons learned Building on the solid foundations of its research programme, the Centre has succeeded in providing a wide range of quality primary health care services free of charge. It has also demonstrated what is possible. However, the Centre in Port au Prince caters for only a tiny proportion of those in need, and GHESKIO – in collaboration with the Ministry of Health and UNFPA, and with support from USAID, the European Union and the Global Fund to fight AIDS, Tuberculosis and Malaria, among other partners – has embarked on a training and expansion programme that aims to establish services based on its model in 27 sites nationwide. As a pioneer of integrated sexual and reproductive health and HIV/AIDS services, GHESKIO has valuable lessons to share from its experience. Stigma and discrimination toward PLHIV are serious handicaps to successful integration of sexual and reproductive health and HIV/AIDS services and require constant, purposeful action to overcome them. In this programme, stigma was a motivating force for integration of services – the fact that PLHIV were experiencing discrimination from mainstream sexual and reproductive health programmes led to the decision to provide sexual and reproductive health services within an HIV programme. This points to the need for sexual and reproductive health programmes to recognize their responsibility toward all people, regardless of their HIV status, and to take active steps to identify and remove discriminatory barriers and create a stigma-free environment. Experience shows, however, that stigma and discrimination continue to be hurdles that must be overcome. Non-judgemental attitudes in service providers are particularly important, and staff should be required during training to confront personal fears and prejudices (especially with regard to HIV/AIDS) and helped to overcome them. Messages challenging stigma and discrimination should be reinforced during staff support and supervision. Providing the opportunity to access other health services at the same time and under the same roof greatly enhances the uptake of HIV counselling and testing. The uptake of HIV counselling and testing is adversely affected by the stigma and fear surrounding infection. Moreover, people are reluctant to be tested if they see no obvious benefit to knowing their status. When voluntary and confidential HIV testing is offered under one roof with other health services, the benefits are clear and attendance increases. Convenience and user friendliness are also vital considerations in encouraging people to attend voluntary counselling and testing and sexual and reproductive health clinics; having related services, including laboratories and dispensaries under one roof, is a huge advantage. Gateways to integration: a case study from Haiti 17 A case study from Haiti Counselling sessions for clients seeking HIV tests are an ideal opportunity to assess their other sexual and reproductive health needs, to counsel for safer sex and to offer them referral for specialist services as necessary. Linking services for HIV counselling and testing and sexual and reproductive health is an effective way of reaching some important target populations – for example men, young people and PLHIV – with sexual and reproductive health care. GHESKIO has developed a questionnaire for VCT clients to be filled in by the counsellor during pre-test counselling that takes a detailed history of the client’s sexual relationships and practices. It includes questions about contraceptive practice, fertility intentions and pregnancy and helps the counsellor with their referrals them to their medical colleagues on-site for other sexual and reproductive health services, if necessary. Sexual and reproductive health tends to be seen as ‘women’s business’, which can inhibit men and young people from attending clinics. But even women, if they are HIV-positive, may be deterred by their status and fear of discrimination from seeking sexual and reproductive health services directly. If there is advocacy for, and automatic access to, family planning and other sexual and reproductive health services on the same site as VCT and other HIV prevention, treatment and care services, many of the practical and psychological barriers to access are removed. GHESKIO had an advantage over many conventional VCT services in that it was set up by doctors, so the non-medical counsellors always had medical back-up for clinical issues, and vice versa. This possibility of referral for specialist medical services was part of the system from the start. Discordant couples who may also be reluctant to attend a sexual and reproductive health clinic are more likely to get the counselling they need to prevent HIV transmission if HIV and SRH services are integrated. 18 Gateways to integration: a case study from Haiti Having multi-skilled staff in the fields of HIV and sexual and reproductive health enhances understanding among colleagues and gives maximum flexibility in organizing clinics. There is much to be gained by requiring specialist staff to broaden their training and share their skills and expertise with their colleagues. This helps to build team spirit, encourages a holistic approach to the provision of care that is a great advantage in broad-based services, and allows staff to take over from or fill in for each other when necessary. A case study from Haiti Some recommendations for health planners and service providers: Potential for scaling up • GHESKIO to consider relaxing the insistence on VCT as prerequisite to access to the wider range of sexual and reproductive health and HIV/AIDS services. There is a sufficient range of sexual and reproductive health and HIV/AIDS services at GHESKIO but it could be argued that it might be more beneficial for clients to have multiple entry points for services, and not be limited to accepting HIV testing as a condition to continued access to other services. VCT as a gateway to other services can be construed as a pressure for clients to undergo testing in order to gain access to the full range of services. • Consider undertaking a quantitative measure on the cost-effectiveness of integration, as this would help evidence-based advocacy at donor level by government and/or civil society. • Scale up client coverage while maintaining quality. GHESKIO coverage is limited, and the challenge is to scale up services. At present, GHESKIO is transferring its experience and expertise to other institutions, working in collaboration with the Government of Haiti and non-governmental organizations. GHESKIO’s capacity to transfer knowledge should be reinforced. • Encourage operations research on the relationship between domestic violence and HIV status and access to HIV counselling and testing in Haiti. • Undertake a study to determine the most effective ways to better mitigate stigma and discrimination. Health care personnel should be given adequate training and supervision, including through values clarification, to eliminate stigma and discrimination against clients in all health care settings. • Evaluate male and female condom acceptability (by men and women), use and impact. • Find better ways to engage men in sexual and reproductive health and HIV/AIDS programmes, since these services are still predominantly used by women. • Support health and HIV education and information of young people, so that they are more fully aware of their needs and rights. • Ensure reproductive health commodity security and increase efforts to alleviate shortages. (When political instability threatened the central warehouse, it had to be moved, which disrupted logistics management). • Continue to assess issues of confidentiality, informed consent and quality of services, especially counselling services, which may be at risk if time pressure due to scaling-up becomes untenable. Partners and supporters: Collaborative alliances Crucial to GHESKIO’s effectiveness and sustainability are the collaborative alliances it has had with research institutes abroad since the beginning, and the diverse network of partnerships it has cultivated locally and internationally over the years. However, lack of collaboration among its many partners and supporters who all have their own agendas, and the often inflexible conditions that come with funds, are regular frustrations. Local partners: Ministry of Health, Haitian Foundation Against Endemic Diseases, Partners in Health, Haitian Medical Association and GRET.xxvii Foreign academic institutions: Cornell, Vanderbilt, Johns Hopkins and Vermont Universities, and Harvard School of Public Health in the USA; Institut Alfred Fournier, Institut Pasteur and Université d’Amiens in France. International agencies: USAID, UNFPA, UNICEF, PAHO, Global Fund to Fight AIDS, TB and Malaria, European Union, US National Institutes of Health, World AIDS Foundation and Fogarty International. Assistance was also provided by the Governments of Canada, France and Japan. • Engage in capacity building on a continuous basis, to offset the shortage of skilled personnel which is exacerbated by poverty, insecurity and political turmoil. • Advocate for the creation of a legal referral system for people affected by stigma and discrimination. Gateways to integration: a case study from Haiti 19 A case study from Haiti Contact details for more information: Groupe Haïtien d’Étude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) Directors: Dr Marie-Marcelle Deschamps and Dr Jean William Pape 33 Blvd Harry Truman BP 164 Port-au-Prince Haiti Phone: + 509-222-0031 + 509-222-2241 Fax: + 509-223-9044 Endnotes i The New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health, UNFPA & UNAIDS, 2004. ii The Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, UNFPA & WHO, 2004. iii Call to Action: Towards an HIV-free and AIDS-free Generation, Prevention of Mother to Child Transmission (PMTCT) High Level Global Partners Forum, Abuja, Nigeria, 2005. xvi Meeting the Sexual and Reproductive Health Needs of People Living with HIV. Guttmacher Institute, UNAIDS, UNFPA, WHO, Engender Health, IPPF, ICW & GNP+, In Brief, 2006 Series, No. 6. Gateways to Integration, UNFPA, IPPF, UNAIDS, WHO, forthcoming. xvii xviii Reproductive Choices and Family Planning for People Living with HIV – Counselling Tool, WHO, 2006. iv Achieving Universal Access to Comprehensive Prevention of Mother-to-Child Transmission Services, High Level PMTCT Global Partners Forum, Johannesburg, South Africa, 2007. xix v xx vi Political Declaration on HIV/AIDS, United Nations General Assembly Special Session on HIV/AIDS. New York, United Nations, 2006. xxi Intensifying HIV Prevention: UNAIDS Policy Position Paper, UNAIDS, 2005. Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages: A Generic Guide, ICW, GNP+, IPPF, UNAIDS, UNFPA, WHO, Young Positives, 2008. Haiti: Country Situation Analysis. UNAIDS, 2007. http://www.unaids.org/en/ CountryResponses/Countries/haiti.asp vii Jean S.S., Pape J.W.; Verdier R-I.; Reed G.W.; Hutto C.; Johnson W.D. & Wright P.F.,The natural history of human immunodeficiency virus 1 infection in Haitian infants. Pediatric Infectious Disease Journal, 1999, Vol 18 Issue 1, pp 58–63. viii xxii Deschamps MM. Impact of MTCT-Plus on PMTCT, and Survival of HIV Positive Pregnant Women and Infants at GHESKIO Center. Poster presentation, XIII International AIDS Conference, Durban, South Africa, 9–14 July 2000. For example see the background paper on the concept of Universal Access prepared for the Technical Meeting for the Development of a Framework for Universal Access to HIV/AIDS Prevention, Treatment and Care in the Health Sector, WHO, Geneva, 2005. Sexual and Reproductive Health and HIV/AIDS: A Framework for Priority Linkages, WHO, UNFPA, UNAIDS & IPPF, 2005. ix Programme of Action adopted at the International Conference on Population and Development, Cairo, 1994. x Resolution adopted by the General Assembly, United Nations Millennium Declaration, New York, 2000. See also Family Health International. Integrating services. Network, 2004,23(3) p8. xi Observation at GHESKIO: of the 496 HIV positive pregnant women who took part in the prevention of mother-to-child transmission pilot programme from 1999 to 2004, N=56 (11%) knew that they were HIV positive, desired pregnancy and became pregnant, and were followed up at the HIV clinic. xxiii xxiv xii WHO, UNFPA, UNAIDS & IPPF, Op. cit. xiii Linking Sexual and Reproductive Health and HIV/AIDS. An annotated inventory. WHO, UNFPA, UNAIDS & IPPF, 2005. xiv Sexual and Reproductive Health of Women Living with HIV/AIDS, Guidelines on care, treatment and support for women living with HIV/AIDS and their children in resourceconstrained settings, UNFPA & WHO, 2006. xv Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health Settings, Stepwise guidelines for programme planners, managers and service providers, UNFPA & IPPF, 2004. 20 Gateways to integration: a case study from Haiti Glion Consultation on Strengthening the Linkages between Reproductive Health and HIV/AIDS: Family planning and HIV/AIDS in Women and Children, WHO & UNFPA, 2006. Name has been changed to protect confidentiality. xxv Peck R., Fitzgerald D.W., Liautaud B. et al. The feasibility, demand and effect of integrating primary care services with HIV voluntary counselling and testing. Evaluation of a 15-year experience in Haiti, 1985–2000. Journal of Acquired Immune Deficiency Syndrome, 2003, 33(4) pp 470–475. xxvi GRET is an organization that works to contribute to sustainable, fair development and alleviate poverty and structural inequalities. See www.gret.org xxvii Mireille* tested HIV-positive in 2000 and, like most of the others in the group, fear of stigma and abandonment by her partner has prevented her from disclosing her HIV status to anyone beyond the group. Mireille is raising six children. She is on antiretroviral therapy, and managed to take her pills to prevent HIV infection in her youngest child as secretively as she manages her regular treatment (not all women share their HIV status with their partner(s) or with other family members). It is hard, but she is determined. * Name has been changed to protect confidentiality 

WHO/HIV/2009 • UNFPA/2009 • IPPF-HIV 2009 • UNAIDS 2009 • UCSF 2009 Sexual & Reproductive Health and HIV LInkageS: eVIdence ReVIew and RecommendatIonS The importance of linking sexual and reproductive health (SRH) and HIV is widely recognized. The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to 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. The indings corroborate the many beneits gained from linking SRH and HIV policies, systems and services. key Research Questions Beneits (i) 1. What linkages are currently being evaluated? Bi-directional linkages between SRH and HIV-related policies and programmes can lead to a number of important public health, socioeconomic and individual beneits: 2. What are the outcomes of these linkages? 3. What types of linkages are most effective and in what context? Greater support for dual protection Improved quality of care Decreased duplication of efforts and competition for resources Better understanding and protection of individuals’ rights Improved access to and uptake of key HIV and SRH services 4. What are the current research gaps? Mutually reinforcing complementarities in legal and policy frameworks Better access of people living with HIV (PLHIV) to SRH services tailored to their needs 5. How should policies and programmes be strengthened? Enhanced programme effectiveness and eficiency Reduction in HIV-related stigma and discrimination Better utilization of scarce human resources for health Improved coverage of underserved/ vulnerable/key populations SRH and HIV Linkages matrix Note: Several studies incorporated multiple linkages. As a result, the number of linkages in the matrix exceeds the total number of studies (58). The numbers in each box represent the number of studies that met inclusion criteria, categorized by linkage-type. Matrix sections in grey represent linkage areas not included in inal analysis. Peer-reviewed Studies HIV prevention, education & condoms (a) HIV counselling & testing Element 3 of PMTCT (b) Clinical care for PLHIV Family planning 54 6 2 1 Maternal & child health care 7 GBV prevention & management 4 STI prevention & management 129 Other SRH services 0 Promising Practices 27 9 10 25 5 15 1 9 1 18 12 2 2 (c) 11 2 8 1 1 0 2 4 1 1 4 2 (i) Rapid Assessment Tool for Sexual & Reproductive Health and HIV Linkages: A Generic Guide. GNP+, ICW, IPPF, UNAIDS, UNFPA, WHO and Young Positives, 2008. Psychosocial & other services for PLHIV 6 3 1 4 0 6 1 0 5 1 7 4 1 4 0 (a) Not included in inal analysis are studies integrating HIV prevention, education and condoms with SRH services (column one) as they have been reviewed elsewhere. (b) Comprehensive prevention of mother-to-child transmission (PMTCT) includes the following four elements (from: “A Framework for Priority Linkages”, WHO, UNFPA, IPPF, UNAIDS, 2005): 1. Prevent primary HIV infection among girls and women. 2. Prevent unintended pregnancies among women living with HIV. 3. Reduce mother-to-child transmission through anti-retroviral drug treatment or prophylaxis, safer deliveries and infant feeding counselling. 4. Provide care, treatment and support to women living with HIV and their families. (c) Excluded from review are studies on element 3 of PMTCT not linked to other areas of SRH. methodology Study Inclusion Criteria Linkages are a relatively new approach to increasing universal access to SRH and HIV prevention and care. In order to capture the most recent innovative linkages initiatives, this review was not limited to the standard peer-reviewed and rigorous evaluation studies, but also included “promising practices”. The following inclusion criteria were used: Citations found through database and online searching (n=50,797) Peer-reviewed Studies Published in peer-reviewed journal (19902007) Rigorous evaluation study (pre-post or control group) Citations included in review (n=225) Conducted in any setting ‘Grey’ (non-peer-reviewed) literature (19902007) Conducted in resource limited settings only Vast majority did not meet inclusion criteria Studies evaluating prevention of vertical HIV transmission if only concerned with element 3 (i.e. matrix column 3, row 2), were reviewed elsewhere1,2,3 Citations not retained for analysis (n=167) Promising Practices Some evaluation results reported Citations excluded from review (n=50,570) Citations included in analysis (n=58) Studies evaluating linkages between HIV prevention, education and condoms with SRH services (matrix column 1) were reviewed elsewhere 4,5,6 key Study characteristics Number: 58 studies met the inclusion criteria: 35 peer-reviewed studies and 23 promising practices. Region/Country: 36 Africa, 11 UK or USA, 11 Asia, Eastern Europe, Latin America and the Caribbean. Nearly 80% of the promising practices were based in Africa. Study design rigour: Only six studies used a randomized control design; most used a cross-sectional or pre-post design and/or included a control or comparison group. Setting: Of the 58 studies, 39 fell into one of the following six categories* 1. Antenatal Care Clinics adding HIV services (n=16) 2. HIV Counselling & Testing Centres adding SRH services (n=3) Direction of linkages: 34 studies integrated HIV services into existing SRH programmes 3. Family Planning Clinics adding HIV services (n=6) 4. HIV Clinics adding SRH services (n= 5) 5. Sexually Transmitted Infection Clinics adding HIV services (n=3) 14 studies integrated SRH services into existing HIV programmes 6. Primary Health Care Clinics adding HIV and/or SRH services (n=10) 10 studies integrated HIV and SRH services concurrently Type of integrated service: The majority of studies included HIV testing as part of the integration; fewer studies evaluated integration of other HIV services. Study limitations: Few studies sought to answer a research question speciically about SRH and HIV service integration. Among studies with research questions directly related to integration, none were designed speciically to compare integrated services to the same services offered separately, no studies measured stigma outcomes, and of the few reporting cost outcomes, only two calculated cost-effectiveness. * four studies qualiied for more than one setting 1. Volmink J, Siegfried NL, et al. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev, 2007; Issue 1. 3. Madi BC, Smith N, et al. Interventions for preventing postnatal mother-to-child transmission of HIV. (Protocol) Cochrane Database Syst Rev 2007; Issue 3. 5. Foss AM, Hossain M, Vickerman PT, Watts CH. A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia. Sex Transm Infect 2007; 83(7):510-6. Epub 2007 Oct 11. Review. 2. Wiysonge CS, Shey MS, et al. Vaginal disinfection for preventing mother-to-child transmission of HIV infection. Cochrane Database Syst Rev 2005; Issue 4. 4. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. J Adolesc Health 2007; 40(3):206-17. 6. “Steady, Ready, Go”, Information brief from the Talloires consultation to review the evidence for policies and programmes to achieve the global goals on young people. outcome measures The following outcomes were reported: Peer-reviewed Studies Health Behavioural Knowledge and attitudes Process Stigma Cost (n=5) (n=17) (n=7) (n=18) (n= 0) (n= 0) Promising Practices Health Behavioural Knowledge and attitudes Process Stigma Cost (n=1) (n= 9) (n=7) (n=20) (n= 0) (n= 7) overall Findings 1) programmes with ive or more linkages, while just 9% had only one type of linkage. This difference may be due to more recent programmes linking SRH and HIV services more comprehensively, or the fact that peer-reviewed studies were often designed to address narrow research questions. Despite diverse settings and clients, the majority of studies showed improvements in all outcomes measured, and only a few showed mixed results. Many studies reported an increase or improvement in: access to and uptake of services, including HIV testing health and behavioural outcomes 7) Of the few studies reporting cost outcomes, all were conducted after 2000. This positive trend may indicate an intent to scale up linked services. 8) Studies reporting health outcomes were evenly distributed across time. Interventions which successfully implemented provider training resulted in improved provider knowledge and attitudes, leading to better SRH and HIV service provision. condom use HIV and sexually transmitted infection (STI) knowledge overall quality of service 2) Linking SRH and HIV was considered beneicial and feasible, especially in family planning (FP) clinics, HIV counselling and testing centres (C&T), and HIV clinics. 9) 3) Of the 58 studies analysed, more were conducted between 2000–2007 (65%) than 1990–1999 (35%). This trend was primarily seen in the promising practices; however, this may be due to publication bias as older, unpublished reports may no longer be available. 10) Notably, few or no studies addressed the following: 4) 5) 6) There was a slight time trend in directionality of linkages. Earlier studies were more often SRH programmes adding HIV services, while later studies were more often HIV programmes adding SRH services. Preliminary analysis of both cost-effectiveness studies suggested net savings from HIV/STI prevention integrated into maternal and child health services. Linked services targeting men and boys Gender-based violence (GBV) prevention Stigma and discrimination Comprehensive SRH services for PLHIV, including addressing unintended pregnancies and planning for safe, desired pregnancies. 11) More attention needs to be paid to commodity security, in particular contraceptives. Nearly three quarters (71%) of peer-reviewed studies evaluated programmes with only one type of linkage. In contrast, over half (57%) of promising practices evaluated Factors Promoting or Inhibiting effective Linkages Promoting Factors Inhibiting Factors Positive attitudes and good practices among providers and staff Lack of commitment from stakeholders Ongoing capacity building Non-sustainable funding Involvement of the community and government during planning and implementation Clinics understaffed/low morale/high turnover/inadequate training Simple, easily applied additional services which add no costs to existing services Lack of male partner participation Non-stigmatizing services Male partner inclusion Engagement of key populations Inadequate infrastructure, equipment, and commodities Women not suficiently empowered to make SRH decisions Cultural and literacy issues Adverse social events/domestic violence incidence Poor programme management and supervision Stigma preventing clients from utilizing services Facility-based analysis The following tables summarize indings from a subset of studies grouped by type of facility: 1. Antenatal Care Clinics adding HIV services (n=16) 2. HIV Counselling & Testing Centres adding HIV services (n=3) 3. Family Planning Clinics adding HIV services (n=6) Of the 58 studies, 39 fell into one of these six categories. The remaining 19 studies were conducted in another type of setting or did not clearly specify the setting. Findings are reported and interpreted according to the objectives of the study. For a full list of studies included in each summary, please visit the online document (see page 8 for web addresses). 4. HIV Clinics adding SRH services (n= 5) 5. Sexually Transmitted Infection Clinics adding HIV services (n=3) 6. Primary Health Care Clinics adding HIV and/or SRH services (n=10) antenatal care clinics Studies 9 peer-reviewed studies 7 promising practices Locations Peer-reviewed studies: 2 in USA 1 in Burkina Faso 1 in Zimbabwe 2 in Kenya 1 in China 1 in Zambia 1 in UK Promising practices: 1 in South Africa 1 in United Republic of Tanzania 1 in Ethiopia 1 in Zambia Interventions All interventions integrated some form of HIV counselling C&T into maternal and child health (MCH) services in antenatal care (ANC) settings. C&T in a variety of forms, including in-clinic services; screening for referral to off-site C&T; routine provision of C&T (opt-out); C&T by client request only; C&T performed by clinic providers, trained counselling staff or community volunteers; couples 1 in Dominican Republic 1 in Ukraine 1 in Zimbabwe or individual C&T; individual counselling sessions and group counselling sessions. In many of the interventions, C&T was the only HIV service integrated into routine ANC services. In a few, C&T was performed in conjunction with distribution of nevirapine or offered within an enhanced package of services including care and support for PLHIV. Study Design Peer-reviewed studies: 3 serial cross-sectional 3 cross-sectional 2 non-randomized control trial 1 pre-post Promising practices: 2 serial cross-sectional 1 cross-sectional 4 mixed methods Reported Outcomes Health outcomes: None reported Behavioural outcomes: Condom use, number of sex partners and contraceptive use Knowledge/attitudes outcomes: Male and female condoms, HIV and STI facts Process data /outcomes: Access to HIV testing; availability & uptake of drugs; uptake of HIV testing; provider training; provider knowledge; provider implementation; provider attitudes; quality of services; cost Findings Signiicant increase in condom use among sexually active women, but not men, and among sexually active women living with HIV, but not HIV-negative women. Decrease in number of sex partners among women, but not men. Post-intervention increase in use of a modern method of contraception among mothers. Overall increase in HIV knowledge post-intervention, increases in knowledge of methods to reduce mother-to-child transmission. Increase in HIV tests offered at irst visit, increase in HIV testing coverage, and increased awareness of places offering C&T. Increase in uptake of C&T among all groups directly offered testing, including after a new policy made HIV testing part of routine ANC for all women, and after provider-initiated opt-out testing was implemented, although rates of partners’ testing and counselling did not change signiicantly. Increase in the availability of antiretroviral (ARV) drugs for women living with HIV but no change in rates of uptake of single-dose nevirapine among women living with HIV after implementation of opt-out testing in one study. Post-intervention increase in health workers trained in HIV counselling and other topics. Increase in provider knowledge about HIV post-intervention, increase in providers identifying exclusive breastfeeding as one of the ways to reduce mother-to-child transmission. Increases in proportion of irst-visit clients receiving HIVrelated information or services and proportion of observed client–health worker interactions which included a discussion about mother-to-child transmission and infant feeding choices. Higher rates of thorough and appropriate counselling experiences reported by clients post-intervention. Improvements in provider attitudes toward provision of HIV services and attitudes about PLHIV. No difference in client satisfaction with consultation between those who did and did not receive routine C&T. Clients reported more favourable views of counsellors’ performance during counselling sessions if counsellors had been exposed to a prevention of mother-to-child transmission (PMTCT) training. Cost for promoting timely initiation of breastfeeding was lower than that of other intervention components (i.e., HIV education, voluntary counselling and testing (VCT) uptake, delivery in ANCs, exclusive breastfeeding) yet showed the most signiicant improvements. VCT uptake showed the lowest rate of increase, and was the most costly behaviour to change. HIV counselling and testing centres Studies 1 peer-reviewed study 2 promising practices Locations Peer-reviewed studies: 1 in Haiti Promising practices: 2 in Kenya Interventions VCT clinic that progressively integrated a variety of SRH and primary health care services, including tuberculosis services, STI management, FP services, nutritional support for families affected by HIV, prenatal services for pregnant women living with HIV (including PMTCT), post-rape services (including counselling, emergency contraceptives, and post-exposure prophylaxis [PEP]) and PEP for health care-workers. VCT providers trained in FP counselling and methods. Study Design Peer-reviewed studies: 1 serial cross-sectional Promising practices: 1 cross-sectional 1 pre-post Reported Outcomes Health outcomes: None reported Behavioural outcomes: HIV testing, FP use, condom use Knowledge/attitudes outcomes: Providers’ knowledge of and attitudes toward FP methods Process data /outcomes: Availability of guidelines, policies and supplies; client-provider discussions about FP and fertility; referrals, client satisfaction and cost; preferred timing of FP in VCT The number of clients being tested for HIV increased dramatically. After adding FP, there was no change in observed quality of VCT. Percentage of VCT clients who chose a FP method increased. Cost per VCT provider trained in FP was US$672. VCT providers’ knowledge and attitudes toward FP improved. In timing of FP counselling during VCT, providers preferred pre-test counselling and clients preferred post-test counselling. Findings Trained providers were more likely to engage in FP discussions with VCT clients. Family Planning clinics Studies No peer-reviewed studies 6 promising practices Locations Peer-reviewed studies: None Promising practices: 1 in Kenya 1 in Nepal 1 in South Africa Interventions Existing FP clinics integrating C&T services or C&T as part of a package of new STI services offered. 1 in Dominican Republic 1 in Uganda 1 in United Republic of Tanzania Integration of C&T into FP services comparing direct provision of C&T services versus referral for testing. Existing FP clinic integrating C&T and provision of ARV drugs. Study Design Peer-reviewed studies: None Promising practices: 1 participatory appraisal approach 3 cross-sectional 1 serial cross-sectional 1 mixed methods Reported Outcomes Health outcomes: None reported Behavioural outcomes: Condom use Knowledge/attitudes outcomes: HIV and STI knowledge Process data /outcomes: Availability of ARV drugs and HIV testing; availability of equipment and materials; providers’ knowledge and attitudes & use of skills; providers’ training; quality of services; uptake of FP materials and ARV drugs; uptake of HIV testing; cost Findings Integration of HIV services into FP services is feasible and improves outcomes. Two studies reported absolute cost data but no costeffectiveness data or comparisons across models. Integration did not increase waiting times or decrease quality of FP services. Conducted in resource-limited settings only. One study comparing direct provision of C&T versus referral found that both versions should be considered. HIV clinics Studies 5 peer-reviewed studies No promising practices Locations Peer-reviewed studies: 2 in UK 2 in USA 1 in Thailand Promising practices: None Interventions HIV clinic offering women living with HIV screening for STIs, contraceptives, pre-conception counselling, and cervical cytology. MCH programme started within an HIV clinic to improve clinic attendance. The programme involved a number of woman and child friendly aspects, such as private waiting areas and examination rooms for women and children, more female providers, free onsite child care, and transportation. With the goal of increasing safe sex practices, adults with HIV received safe sex messages that either emphasized the beneits or costs of their decisions. The study included a control group. A sexual health clinic was started for clients with HIV to increase uptake of STI screening. Women living with HIV were offered STI screening, and those who consented received an exam, screening for skin ulcers, and STI testing. STI treatment and condoms were free. Study Design Peer-reviewed studies: 2 serial cross-sectional 1 cross-sectional 1 randomized trial 1 non-randomized control trial Promising practices: None Reported Outcomes Health outcomes: None reported Behavioural outcomes: Unprotected sex and condom use Knowledge/attitudes outcomes: None reported Process data/outcomes: Availability of STI screening; uptake of cervical cytology; uptake of scheduled HIV visits; uptake of STI screening; uptake of Hepatitis B screening; quality of services Findings Unprotected sex either decreased or remained the same compared to control depending on the speciic intervention and the subpopulation under study. Use of condoms decreased among clients with HIV in one study (interpreted by the authors as a success, as their goal was to increase uptake of more reliable forms of contraception, although this outcome was not measured). Offer of STI screening increased: annual STI screening and STI screening at irst visit were higher among intervention than control. Uptake of screening for Hepatitis B was similar between intervention and control. Uptake of cervical cytology increased from pre- to postintervention and was higher among intervention than control. The number of women living with HIV attending at least 75% of their scheduled HIV visits was greater among the intervention than the control. Client reporting showed that physicians talked about safer sex at half or more of clinic visits, an increase from baseline values. Sexually transmitted Infection clinics Studies 3 peer-reviewed studies No promising practices Locations Peer-reviewed studies: 1 in India 1 in USA 1 in Thailand Promising practices: None Interventions HIV C&T offered to STI clinic clients. Women living with HIV at an infectious disease clinic and an STI clinic offered STI screening and treatment, as needed. Study Design Peer-reviewed studies: 1 retrospective cohort 1 cross-sectional 1 time series Promising practices: None Reported Outcomes Health outcomes: Gonorrhoea incidence Behavioural outcomes: Condom use Knowledge/attitude outcomes: HIV transmission and prevention knowledge Process data /outcomes: None reported Findings Post-test rates of gonorrhoea re-infection were consistently lower than pre-test rates. Two of three studies reported positive behavioural outcomes. After the intervention, clients reported less frequent visits to sex workers and more consistent use of condoms. Primary Health care Studies 5 peer-reviewed studies 5 promising practices Locations Peer-reviewed studies: 1 in Kenya 1 in United Republic of Tanzania 1 in Zimbabwe 1 in Zambia 1 in USA Promising practices: 4 in Kenya 1 in Brazil Interventions Integrating HIV and STI services and HIV and FP counselling and services, providing contraceptives to PLHIV, and building the capacity of health care staff and health facilities to provide integrated services. Integrating HIV, STI and FP services into services offered at a primary health care clinic at a border-crossing truck stop, district level primary health care facilities, a post-abortion care facility, a well-child/acute care paediatric clinic, an adolescent health clinic, a governmental hospital and primary health care clinic, and a mobile clinic. Study Design Peer-reviewed studies: 1 randomized control trial 1 pre-post 1 prospective cohort 1 cross-sectional 1 serial cross-sectional Promising practices: 3 cross-sectional 1 serial cross-sectional 1 participatory appraisal Reported Outcomes Health outcomes: HIV incidence Behavioural outcomes: Contraceptive use, condom use, number of sexual partners Knowledge/attitude outcomes: None reported Process data /outcomes: Access to HIV testing; access to other services; availability of drugs; availability of FP methods and information, education, communication (IEC) materials; provider training; provider implementation; uptake of HIV testing, drugs, condoms, FP methods, IEC materials, other services; quality of services; cost. Findings No signiicant effect of integrating HIV testing on HIV incidence among males and females, although impact on HIV incidence is only likely to be shown after long term observation. Receiving VCT increased condom use, dual contraceptive methods, and receipt of a positive HIV test generally resulted in fewer sexual partners and higher levels of condom use. Improved access to VCT and increased HIV C&T uptake, especially if point-of-care tests were offered, but mixed results for postpartum C&T. High rates of uptake for other services, such as HIV education. High rates of attendance at ANC and well-baby visits, increased uptake of post-abortion services. Increased number of pregnant women who learned their HIV status at irst ANC visit, and increased uptake of nevirapine among women living with HIV, but not among women living with HIV who received a postnatal follow up visit. Inconsistent availability and uptake of supplies. Availability of IEC materials decreased post-integration in one study; uptake was low in some settings but high in others. FP methods restricted to only some facilities. Training of providers was inadequate on a range of topics. Provider implementation and quality of services showed mixed results. Cost of delivering integrated services was reported but not translated into cost-effectiveness. 15 key Recommendations Policy makers Programme managers Researchers 1. Advocate and support SRH and HIV linkages at the policy, systems and service levels since they are demonstrated to improve outcomes. 6. Strengthen linked SRH and HIV responses in both directions through: c) Health provider training 11. Design rigorous studies to evaluate integrated SRH and HIV services, particularly comparative assessments of integrated delivery of services versus non-integrated delivery of the same services. d) Client education involvement 12. Evaluate key outcomes, such as: 2. Develop, adopt, modify and strengthen relevant policies, HIV and SRH strategic plans and coordination mechanisms to foster effective linkages. 3. Create a supportive policy environment to ensure the implementation of a collective human rights and gender-sensitive approach to SRH and HIV linkages. a) Stakeholder commitment b) Human resources and planning e) Quality of services a) Health f) Infrastructure b) Stigma reduction g) Supply management (including commodity security) c) Cost-effectiveness d) Trends in access to services 4. Advocate for additional funding of rigorous research to address important outcomes, such as health, cost, and stigma of integrated services as well as novel approaches to integration. 7. Through the development of robust indicators, rigorously monitor and evaluate integrated programmes during all phases of implementation to improve current and future programmes. 5. Act on commitments made through regular assessments of national responses to SRH and HIV linkages. 8. Ensure that key HIV services (including VCT; PMTCT; and antiretroviral therapy (ART)) are integrated with other SRH services. 9. Ensure that key SRH services (such as FP, including preconception planning; maternal and child health; prevention and management of GBV; and STI management) are integrated with other HIV services. 10. Advocate, support and facilitate operations research to demonstrate that linking SRH and HIV can act as a modality of stigma reduction. 13. Direct research towards areas of integration that are currently understudied, notably integrating SRH services with HIV services for PLHIV, including clinical and psychosocial care, contraception and pre-conception planning if pregnancy is desired, gender-based violence reduction and linked services for men and boys. 14. Foster community participation in research to ensure that all research on linkages has relevant outcomes for clients. 15. Ensure strengthened collaboration between the SRH and HIV research communities through the development of a collective linkages research agenda. acronyms and deinitions AIDS acquired immunodeiciency syndrome ANC antenatal care ART antiretroviral therapy ARV antiretroviral C&T counselling and testing FP family planning GBV gender-based violence GNP+ The Global Network of People Living with HIV/AIDS HIV human immunodeiciency virus ICW International Community of Women Living with HIV/AIDS IEC information, education, communication IPPF International Planned Parenthood Federation MCH maternal and child health PEP post-exposure prophylaxis PLHIV people living with HIV PMTCT prevention of mother-to-child transmission SRH sexual and reproductive health STI sexually transmitted infection UCSF University of California San Francisco UK United Kingdom UNAIDS The Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund USA United States of America VCT voluntary counselling and testing WHO World Health Organization Linkages: The bi-directional synergies in policy, programmes, services and advocacy between sexual and reproductive health and HIV. Refers to a broader human rights based approach, of which service integration is a subset. Integration: Different kinds of sexual and reproductive health and HIV services or operational programmes that can be joined together to ensure and perhaps maximize collective outcomes. This would include referrals from one service to another, for example. It is based on the need to offer comprehensive services. ........................................................................................................................................................................................................................................................................................ This document is a preliminary overview of indings. For more information about the methodology and programme-speciic indings, as well as a complete list of references, please refer to the full report available on the websites below. International Planned Parenthood Federation 4 Newhams Row, London SE1 3UZ Tel +44 (0)20 7939 8200 Fax +44 (0)20 7939 8300 Email info@ippf.org www.ippf.org Published in September 2009 UCSF UCSF Global Health Sciences 50 Beale Street Suite 1200 San Francisco, CA 94143 www.igh.org/linkages UNAIDS Avenue Appia 20 1211 Geneva 27 Switzerland Tel +41 22 791 3666 Fax +41 22 791 4187 www.unaids.org UNFPA 220 East 42nd Street, New York NY 10017, USA Tel +1 212 297 5000 www.unfpa.org WHO Avenue Appia 20 1211 Geneva 27 Switzerland Tel + 41 22 791 2111 Fax + 41 22 791 4806 www.who.int/ reproductive-health