Linking Sexual & Reproductive Health
and HIV:
Evidence Review and Recommendations
Lucy Almers, Debbie Bain Brickley, Gail Kennedy, Laura
Packel, Joy Mirjahangir, Alicen Spaulding, Caitlin Kennedy,
Michael Mbizvo, Lynn Collins, Kevin Osborne
SRH & HIV Linkages
Agenda
Political Commitment
Priority Framework
Evidence Review
Rapid Assessment Tool
Indicators
Objectives
 The international community agrees that the Millennium
Development Goals will not be achieved without ensuring
universal access to sexual & reproductive health (SRH)
and HIV prevention, treatment, care and support
 In order to gain a clearer understanding of the
effectiveness, optimal circumstances, and best practices
for strengthening SRH and HIV linkages, a systematic
review of the literature was conducted
Potential Benefits
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Improved access to and uptake of key HIV and SRH services
Better access of PLHIV to SRH services tailored to their needs
Reduction in HIV-related stigma and discrimination
Improved coverage of underserved/vulnerable/key populations
Greater support for dual protection
Improved quality of care
Decreased duplication of efforts and competition for resources
Better understanding and protection of individual rights
Mutually reinforcing complementarities in legal and policy
frameworks
Enhanced programme effectiveness and efficiency
Better utilization of scarce human resources for health
Key Research Questions
 What linkages are currently being evaluated?
 What are the outcomes of these linkages?
 What types of linkages are most effective and in what
context?
 What are the current research gaps?
 How should policies and programmes be strengthened?
Definitions

Linkages - The bi-directional synergies in policy,
programmes, services and advocacy between sexual
and reproductive health and HIV. It 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.
Methods
 Systematic review
— Comprehensive online search of scientific databases, program
websites, and consultation with experts
— Systematic methods used for screening, data extraction, and
quality assessment of studies
 Inclusion criteria
Peer-reviewed studies
— Published in peer-reviewed
journal (1990-2007)
— Rigorous evaluation study
(pre-post or control group)
— Conducted in any setting
Promising practices
— ‘Grey’ (non-peer-reviewed)
literature (1990-2007)
— Must report some
evaluation results
— Conducted in resourcelimited settings only
Citations identified
through search
strategy
(n=50,797)
Results
Citations excluded from review (n=50,570)
• Did not meet inclusion criteria
• Interventions with element 3 of PMTCT (matrix column
3, row 2) were reviewed elsewhere (see full report)
Citations included
in review
(n=225)
Citations not retained for analysis (n=167)
• Interventions linking HIV prevention, education
and condoms with SRH services (matrix
column 1) were reviewed elsewhere (see full report)
Citations included in
analysis
(n=58)
SRH-HIV Linkages Matrix
Key Study Characteristics

58 studies included in analysis
— 35 peer-reviewed studies
— 23 promising practices

6 of 58 studies used a randomized control design

Region
— 36 Africa (80% of promising practices were in Africa)
— 11 United Kingdom and United States of America
— 11 Asia, Eastern Europe, Latin America and the Caribbean

Direction of linkages
— 34 studies integrated HIV into existing SRH services (earlier studies)
— 14 studies integrated SRH into existing HIV services (later studies)
— 10 studies integrated HIV and SRH services concurrently
Key Outcomes
 Health
— HIV incidence: 2 studies, average rigour = 4
 1 positive effect, 1 no effect
— STI incidence: 2 studies, average rigour = 6.5
 Both positive effect
 Behavioural
— Condom use: 13 studies, average rigour = 3.8
 8 positive effect, 3 mixed effect, 2 no effect
— Contraceptive use (other than condoms): 6 studies, average
rigour = 3.3
 4 positive effect, 2 mixed effect
Key Outcomes
 Process
— Uptake of HIV testing: 12 studies, average rigour = 2.2
 All positive effect
— Quality of services: 7 studies, average rigour = 2.7
 5 positive effect, 2 no effect
 Other
— Stigma: 0 studies
— Cost: 7 studies, average rigour = 1.6
 5 studies presented costing data only (absolute cost per unit)
 2 studies presented cost-effectiveness; Both suggested net savings
from HIV/STI prevention integrated into MCH services
Promoting and Inhibiting Factors
 Promoting
— Stakeholder involvement
— Capacity building
— Positive staff attitudes and non-stigmatizing services
— Engagement of key populations
 Inhibiting
— Lack of sustainable funding and stakeholder commitment
— Staff shortages, high turnover or inadequate training
— Poor programme management and supervision
— Inadequate infrastructure, equipment, and commodity supply
— Client barriers to service utilization, including low literacy, lack of
male partner involvement, stigma, and lack of women’s
empowerment to make SRH decisions
Overall Findings

The majority of studies showed improvements in all outcomes
measured
— A few mixed results
— Very few negative findings

Linking SRH and HIV services was considered beneficial and
feasible, especially in:
— Family planning clinics
— HIV counselling and testing centres
— HIV clinics

Promising practices tended to evaluate more recent and more
comprehensive programmes
— 71% of peer-reviewed studies reported only one type of linkage
— 57% of promising practices reported five or more linkages, while just 9%
had only one type of linkage
Gaps
 Inadequately studied interventions
—
—
—
—
Linked services targeting men and boys
Gender-based violence prevention and management
Stigma and discrimination
Comprehensive SRH services for people living with HIV, including
addressing unintended pregnancies and planning for safe pregnancies, if
desired
 Infrequently used study designs & research questions
— Research questions that specifically address SRH and HIV service
integration
— Study designs that compare integrated services to the same services
offered separately
 Insufficiently reported outcomes
—
—
—
—
Health
Stigma reduction
Cost-effectiveness
Trends in access to services
Strengths and Limitations
 Strengths
— Broad scope of review
— Systematic methodology
 Limitations
— Difficult to synthesize data due to heterogeneity in:
 Interventions
 Populations
 Research questions/objectives
 Study designs/rigour
 Measured outcomes
— May not have captured all promising practices
3 of 15 Key Recommendations

Policy makers: Advocate and support SRH and HIV
linkages at the policy, systems and service levels since
they are demonstrated to improve outcomes

Programme managers: Strengthen linked SRH and HIV
responses in both directions and rigorously monitor and
evaluate integrated programmes during all phases of
implementation

Researchers: Direct rigourous research towards areas
of integration that are currently understudied, evaluate
key outcomes, and disseminate findings
2008 Linking SRH & HIV works
Cochrane Evidence
Review:
• increases access to
and uptake of services
• improves health and
behavioural outcomes,
including condom use
• increases knowledge
of HIV and other STIs
• improves quality of
services
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More information about linkages is
available from:
 www.igh.org/linkages
 www.unaids.org
 www.unfpa.org
 www.ippf.org
 www.who.int/reproductive-health/
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Evidence Review and Recommendations