Strengthening the Linkages Between Sexual and Reproductive Health and HIV/AIDS
in the World Bank’s Assistance Strategy: A Preliminary Assessment 1
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Strengthening the Linkages Between Sexual and Reproductive Health and HIV/AIDS in the World Bank’s Assistance Strategy:A Preliminary Assessment
Usha Vatsia
World Bank, HNP Unit, Human Development Network
July 8, 2008
Contents
1. Introduction
Rapid literature search
Interviews with Bank staff
Meetings with Interagency Partners
2. The State of SRH and HIV Linkages
International Commitment & Action
Global Funding
Bank Efforts to Date
3. Potential opportunities to engage
External to the Bank
Global Leadership
Interagency Working Group
Within the World Bank
HNP
Global HIV/AIDS Program
The Regions
Annex 1. Rapid Literature Search
Annex 2. Bank SRH-HIV/AIDS Linkages Experience Matrix
Annex 3. Major Organizations Working on SRH-HIV Linkages
Annex 4. FP-HIV Integration Interagency Working Group: Organizations and Experts
Annex 5. Family Planning/HIV Interagency Working Group, October 2008 Meeting
1. Introduction
This World Bank commissioned report (June 2008) is an assessment of the state of SRH and HIV/AIDS linkages with the objective ofproviding preliminary information and recommendations on which to base future Hub efforts on this initiative. Derived from a brief review of recently published and gray literature, key Bank staff interviews, and meetings with interagency partners between May 15 and June 25, 2008, this report summarizes the major findings and potential opportunities for the HNP Unit to strengthen and promote synergies between SRH and HIV/AIDS.
Rapid literature search
A rapid search of literature was conducted using Google Scholar and specific websites, i.e., WHO, for articles published since the 2006 international conference in Addis Ababa, Ethiopia, and documents shared by Bank staff.
60 documents were gathered through this search. Over a third of the documents relate to health systems strengthening and financing, and policy or advocacy, and almost a third relate to meeting the needs of specific demographic groups, i.e., youth, orphans and vulnerable children (OVC), and people living with HIV/AIDS (PLWHA). Thirteen of these documents relate to service integration, and three provide guidance or recommendations to specific organizations on integration. The needs of women and girls were noted to be a cross-cutting theme in many of these documents. The bulk of literature provided by Bank staff relate to HIV/AIDS program experience, two address SRH and HIV integration in strategy documents (HNP and ActAfrica), two are external interagency documents for activities which Bank staff provided technical input, and one report documents SRH/HIV linkages in three countries. The complete list of literature from this search can be found in Annex 1.
Interviews with Bank staff
Background meetings and interviews were conducted with available Bank staff in the Hub, the Global HIV/AIDS Program, and the Regions to gather relevant information for this assignment. Given the brevity of time and staff travel schedules, the interviews conducted in this short period were fewer than ideal. Nevertheless, the interviews conducted were informative. Some of the meetings yielded additional documents for review and are included in Annex 1, though most were not found to relate directly to SRH and HIV linkages. Annex 2 contains a matrix of the Bank’s experience captured in these interviews.
Meetings with Interagency Partners
Meetings were held with partners working on the Family Planning and HIV/AIDS Integration Interagency Working Group (IWG) to gather information on the group’s current agenda, primarily with USAID’s focal points and FHI. These meetings have been vital in gaining access to important information, such as the ongoing Cochrane review on SRH and HIV/AIDS linkages. The scope of the Hub’s rapid literature search, discussed earlier, was adapted as a result of this new information. In addition, HNP became a part of the IWG’s preparatory panels to review current evidence on which it will base its technical recommendations in an upcoming workshop in October described in detail in the next chapter.
2. The State of SRH and HIV Linkages
International Commitment & Action
The international community has evolved in its understanding of SRH and HIV linkages since the 1994 International Conference on Population and Development (ICPD),and in the last two years made a clear statement as the relevance and importance of linking HIV and SRH: for the good of the individuals most impacted—women, girls, and PLWHAS; and for the cost-effectiveness of programs.
In September 1994, the ICPD established that the effective prevention and treatment of sexually transmitted diseases, including HIV, is an integral part of reproductive health services.[1]
Almost ten years later, the Glion Call to Action in May 3-5, 2004[2], and the New York Call to Commitment on June 4, 2004[3] issued policy statements confirming the international community’s commitment to intensifying the linkages between SRH and HIV/AIDS.
In 2005, UNAIDS put forth a policy position paper, “Intensifying HIV Prevention”[4] , which highlighted the urgency to scale up efforts to prevent HIV in order to reverse the epidemic by forging links with other programs and services including SRH since the majority of HIV infections are sexually transmitted or are associated with pregnancy, childbirth, and breastfeeding.[5] Furthermore, the paper identifies some of the same common root causes, i.e., gender inequity, poverty, and social marginalization of the most vulnerable populations and groups. By strengthening links between HIV and SRH programs and services, and by putting special effort into reaching people excluded from access to health and other services, the paper asserts that the result would be more relevant, cost-effective, and impactful programs.
Since 2006, there have been two major international consultations to share the evidence on linking SRH and HIV to inform program and policy development in Africa and South Asia. There was also a landmark global consultation on SRH and Rights of PLWHA held in Amsterdam in December 2007 sponsored by EngenderHealth, IPPF, UNAIDS, UNFPA, and WHO. During this meeting, an international group of 65 HIV-positive women, men, young people, and transgender individuals articulated a vision statement to guide advocacy, policy, programs, and funding priorities that respect their basic SRH rights and wishes, emphasizing the need for health systems to do the same.[6]
In 2008, a Family Planning/HIV Interagency Working Group (IWG) has been actively working on building this evidence on integrating three specific service areas with family planning: counseling and testing, preventing mother to child transmission (PMTCT), and, care and treatment. This IWG will convene a workshop this coming October, to be chaired by WHO, where 50 FP and HIV technical experts from donors, NGOs, local governments, and PLWHAs will review what is known about FP/HIV integration, and develop technical recommendations for field programs integrating FP and HIV. To prepare for this meeting, technical expert panels have been formed to review the literature for each of the three intervention areas. The panels will draft technical recommendations to be considered, amended, and finalized at the October meeting. Annex 5 contains more information about this workshop and the literature reviews being conducted by the panels.
The upcoming August 2008 International AIDS Conference in Mexico City has included sessions and workshops which link SRH and HIV, such as addressing challenges for girls and women, in relation to SRH rights, PLWHAs, fertility, and Global Fund proposals, to name a few examples.
Global Funding
The current global health funding climate has led to heightened concerns that HIV/AIDS, and other disease-focused funding is eclipsing funding for other areas of health, including for sexual and reproductive health. As a major donor of HIV/AIDS programs, the USG’s funding limitations, ideologically rather than evidence-based, has crippled the ability of organizations to develop effective and appropriate responses to the epidemic on the ground. These funding patterns have weakened healthcare infrastructure as a whole, as influenced by the movement of workers to better-resourced programs.
At the writing of this report, the proposed US budget is still expansive for HIV/AIDS and malaria initiatives. Counter to that expansion, the US commitment to core programs and services focused on women and children continue to lag without legitimate justification.[7] Uncertainty in the global health funding environment remains, particularly in light of the upcoming US elections, the war-on-terror related commitments, and the troubled US economy.
The one bright light in this scenario appears to be the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) which recently accepted proposals that contain sexual and reproductive health and HIV/AIDS integration services.
Bank Efforts to Date
Efforts to integrate SRH and HIV/AIDS on Bank projects have been limited to date.
In the past year, Africa is the only region (Act Africa) that has been consciously building linkages experience, i.e., in Ethiopia, which it is in the process of finalizing its documentation of lessons learned. Several regions were not interviewed during this brief period (ECA, LAC, SAR), which might have missed integration related activities in those regions.
HNP recently completed documenting three country case studies from Malawi, Niger, and India. In May 2008, HNP joined the Family Planning (FP)/HIV Interagency Working Group (IWG) that is working on building the technical aspects of FP/HIV integration, and is serving on a counseling and testing technical panel which will be used in the October 2008 workshop mentioned earlier in this section.
3. Potential opportunities to engage
External to the Bank
Global Leadership
Given the growth in momentum and international consensus to link SRH and HIV/AIDS, the current funding environment and related complications of current USG policies, this is a critical time for the World Bank to take on a larger leadership role in filling the gaps that emerged in this analysis. In particular, it should consider focusing its efforts on promoting and building the evidence-base for:
- the prevention agenda;
- SRH rights of PLWHA, women, and girls[8];
- health systems strengthening for SRH-HIV integration (from policy level to community level service delivery)
In order to be effective in this global technical leadership role, the Hub would also need to galvanize colleagues in GHAP, including GAMET and ASAP, and in the Regions to develop and contribute to a common agenda to share its experience with the international community.
Interagency Working Group
There are several meetings in the next several months where HNP could continue making a significant contribution to the FP/HIV IWG, including:panels activities to review the literature and draft technical recommendations on FP and counseling and testing integration from July to September in Washington, DC and Mexico City during the International AIDS Conference (IAC);finalizing technical recommendations in October 21-22workshop; and a follow-on donor’s meeting on October 23, the latter two of which will be held in Washington, DC.
HNP might consider continuing to contribute to the IWG in the future to share Bank experience with international partners working on this critical area. A complete list of people and organizations involved in the Family Planning/HIV IWG is contained in Annex 4.
Within the World Bank
HNP
HNP may consider actively engagingall relevant teams within the Hub to ensure that the SRH-HIV/AIDS Linkages initiative is appropriately incorporated into current and future Hub activities, such as the health systems strengthening study. By the same token, it may explore how the initiative might be added into other PopRH projects to maximize the results of each work program.
Hub colleagues could be invited to attend presentations SRH and HIV integration, such as the August 20, 2008 meeting planned with FHI, to gain a better understanding of the importance of this area to the Hub’s work and to the progress made in international commitments in the HIV and SRH community.
Global HIV/AIDS Program
Before starting any integration work together, HNPmight need to orient GHAP colleagues on SRH and its relationship to HIV/AIDS, and GHAP might be asked to brief the Hub on current related issues from its perspective. Doing so will help both teams better understand the rationale and benefits of integration.
As mentioned in the last Chapter, there is no apparent conscious effort to integrate SRH into HIV/AIDS programs. Nonetheless, when presented with the opportunity, there was expressed interest in GHAP in collaborating on cost-effectiveness studies and in developing practical tools.
Another potential area to partner is with the Global AIDS Monitoring and Evaluation Team (GAMET), which works closely with UNAIDS and other global partners such as other UN agencies, bilateral donors, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, is the identification, development, and testing of integration measures or indicators.
To facilitate related knowledge sharing and product development in the Bank, the Hub could form an Intraagency (World Bank) SRH/HIV/AIDS Linkages Working Group that could be formed as a sub-group of the PRH Thematic Group, to engage and build awareness on the importance of integrating SRH and HIV with GHAP and the Regions. This IWG could be initiated in partnership with GHAP to create a technical balance to the proposed working group. The SRH and HIV focal points could be invited to participate in this IWG and plan joint activities based on shared goals.
HNPmight facilitate GHAP’s invitation to the FP/HIV/AIDS Integration Interagency Working Group (IWG) based on its expressed interest in joining this activity.
The Regions
All but one of the regions interviewed report having no experience with integrated programs in their countries.
Africa is the only region (Act Africa) that has linkages experience, i.e., in Ethiopia, which it is in the process of finalizing its lessons learned; HNP could follow up to request a copy of this report and attend briefings on it, if any are planned. Although there was no need for technical assistance expressed at the time, the region might be asked if they have any needs that became more apparent as a result of their lessons learned from Ethiopia. ActAfrica is likely to develop knowledge products in the coming year, which might be an area for collaboration. It also plans to start attending the interagency working groups on integration, which it attended in the past. HNP is already collaborating with ActAfrica in inviting FHI to share lessons learned from its recently conducted five-country assessment in a meeting planned for August 20ththis year.
East Asia and Pacific (EASHD) region assisted in developing a small communications piece for a SRH and HIV education project for the transport sector in China, and conducted a biobehavioral study in Papua, Indonesia. They have plans to conduct a behavioral survey in PNG. Although the region did not have any current technical assistance needs, it may in a couple of years to follow up to the work in Papua.
Middle East & North Africa (MENA) region has a possibility to develop an integrated health and HIV/AIDS program in Djibouti where there might be an opportunity to provide technical assistance. This region has no other current needs, but is more open to SRH than HIV due to the conservative nature of the societies in the countries in works with.
Most regions seemed not to completely understand SRH and how it might be integrated into HIV/AIDS. The Regions could be invited to join the PRH Thematic Group, which will be re-activated, to develop a common agenda on integration, i.e., building the technical knowledge within the Bank, share experience, and create practical tools.
Annex 1. Rapid Literature Search
- Adair, T, Desire for Children and Unmet Need for Contraception among HIV-Positive Women in Lesotho, DHS Working Papers, Macro International, Inc., March 2007.
- Askew, I, Berer, M, The Contribution of Sexual and Reproductive Health Services to the Fight against HIV/AIDS: A Review, Reproductive Health Matters 2003; 11 (22):51-73.
- Bates, N, Policy Updates: Significant Changes Expected for Global Health Programs Funding in FY 2007, Global Health Link, August-September 2006 Issue 140.
- Bearinger, LH, Sieving, RE, Ferguson, J, Sharma, V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential, The Lancet, Vol. 369, April 7, 2007.
- Bell, E, Mthembu, P, O’Sullivan, S, Moody, K. Sexual and Reproductive Health Services and HIV Testing: Perspectives and Experiences of Women and Men Living with HIV and AIDS, Reproductive Health Matters, 2007.
- Bell E; Perchal P,Sexual and reproductive health for HIV-positive women and adolescent girls: manual for trainers and programme managers, New York, New York, EngenderHealth, 2006. [235] p.
- Daly, M.