Sexual Reproductive Health and

HIV/AIDS
Linkages
PETER BWALYA COLOURED
CHIMPAMPWE
0966248757
2023 UNZA FOR RM
General objectives
 Introduction to SRH- HIV Linkages
 Importance of SRH – HIV linkage
 Benefits of SHR-HIV Linkage
 Models of SHR service integration: Kiosk, Supermarkets and mail
 SHR linkages with other services
 Adolescent Health
 Family planning
 INTRODUCTION
• Linking HIV/AIDS and sexual and reproductive health
(SRH) programmes has the potential to significantly
curtail the AIDS epidemic.
• Furthermore, it also addresses the unmet need and rights
of women and men living with HIV/AIDS to SRH services.
Well over 75% of HIV infections are acquired sexually, or
through transmission during pregnancy, labour, delivery,
or breastfeeding.
• The presence of sexually transmitted infections (STIs)
other than HIV increases the risk of HIV transmission.
• Aside from these obvious direct associations, many of
the same root causes affecting SRH status also affect
HIV/AIDS.
• Gender inequality, poverty, stigma and discrimination
and marginalization of vulnerable groups affect and
are affected by HIV/AIDS and SRH status
• It reviews tools that link HIV/AIDS with SRH programmes (sexual
health, maternal health, family planning and STI management) and
conversely, that link SRH with HIV/AIDS programmes (prevention,
treatment, care and support).
• The inventory is not intended to be exhaustive, and should be viewed
as a ‘living document’ that will be updated as new tools become
available
key linkages between SRH and HIV/AIDS
programmes consisting of four main
domains:
i. Learn HIV status and access services
ii. Promote safer and healthier sex
iii. Optimize the connection between HIV/AIDS
and STI services
iv. Integrate HIV/AIDS with maternal and infant
health
 Definition of Integration and
Linkages
Integration
• The bi-directional interactions in policy, programmes, services and
advocacy between SRH and HIV. It refers to a broader human rights
based approach, of which service integration is a subset.
Linkages
• Different kinds of SRHR and HIV services or operational programs 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 Integration integrated
services.
Reproductive Health
(WHO definition)
A state of physical, mental, and social well-being
in all matters relating to the reproductive system
at all stages of life
 World Health Organization (WHO)
defines health services integration
• The World Health Organization (WHO) defines health services
integration as services that are managed and delivered in a way that
ensure that people receive a continuum of health promotion, disease
prevention, diagnosis, treatment, disease management, rehabilitation
and palliative care services, at the different levels and sites of care
within the health system, and according to their needs throughout the
course of their lives.
• The above definition summarizes integration as a combination of
definitions 1-5 that emphasize a person-focused, comprehensive,
integrated approach to service delivery
Sexual and reproductive health
and rights (SHRH) and HIV link
• Sexual and reproductive health and rights (SRHR) and
HIV are closely linked – and there are clear
advantages to making connections between them at
policy, programmatic and service delivery levels.
• HIV is primarily sexually transmitted, and is also
associated with pregnancy, birth and breastfeeding.
• People living with HIV need policies, programmes, and
services that support, promote, and advance their specific
SRHR needs.
• Human right violations, gender inequality, harmful cultural
practices and marginalization of underserved individuals
and populations worsen the impact of HIV and lead to
sexual and reproductive ill-health.
• As a result, some populations at risk of or living with HIV
such as women and girls, transgender and gender diverse
people, and indigenous communities are disproportionally
affected and have adverse health outcomes.
Three levels of SRH and HIV
Linkages by MoH
1. Policy level:
• Developing one health policy which addresses issues of SRH and HIV
integration and linkages comprehensively.
• Highlighting gender-based violence (GBV) prevention and
management in all health and related policies.
• Strengthening the monitoring and evaluation (M&E) framework to
include SRH and HIV integration.
• Promoting specific studies to inform policy-makers about the status
of SRH and HIV linkages.
2. Systems level:
• Harmonizing the SRH and HIV planning and management
processes at national level.
• Strengthening coordination among partners and donors
on SRH and HIV.
• Recruiting more health workers.
• Giving special training to all health workers on the
integration and linkages of SRH and HIV services.
• There is also need to strengthen counselling skills among
physicians
• Ensuring follow-up after staff training in facilities to
ensure that staff adhere to recommended guidelines.
• Strengthening M&E structures from the policy to
service delivery levels in order to improve service
quality.
• Undertaking joint monitoring of SRH and HIV
programmes by the Ministry of Health (MoH) and
non-governmental organizations (NGOs).
• Allocating specific budgets for SRH and HIV
integration, including implementation and monitoring
3. Services level:
• Developing an SRH and HIV service integration
strategy.
• Ensuring the availability of protocols and guidelines
for SRH and HIV service integration in facilities.
• The government should ensure that there are
appropriate family planning (FP) referrals for clients
of Catholic Church-run facilities or set up special FP
facilities nearby to enable clients’ access to FP
services.
Importance of SRH and HIV
service integrating
• Higher HIV testing coverage
• More consistent condom use
• Improved quality of care
• Better use of scarce human resources for health
• Reduced HIV-related stigma and discrimination
• Improved coverage, access to and uptake of both SRH and HIV
services for at risk, vulnerable and key populations, including people
living with HIV
BENEFITS OF LINKAGES BETWEEN SRH AND HIV
SERVICES

• Bi-directional linkages between SRH and HIV-related

policies and programmes can lead to a number of important
public health, socio-economic and individual benefits:
• Improved access to and uptake of key HIV and SRH services
• Better access of people living with HIV (PLHIV) to SRH services
tailored to their needs
• Reduction in HIV-related stigma and discrimination
• Improved coverage of underserved/ vulnerable/key populations
BENEFITS OF LINKAGES BETWEEN SRH AND HIV
SERVICES CONT’

• Greater support for dual protection

• Improved quality of care
• Decreased duplication of efforts and competition for
resources
• Better understanding and protection of individuals’
rights
• Mutually reinforcing complementarities in legal and
policy frameworks
• Enhanced programme effectiveness and efficiency
• Better utilization of scarce human resources for health
Models of Integration
1. On-site Model /KIOSK
• a) “One-stop”: Relating to or providing comprehensive services in
one room. In the one-stop model, SRHR and HIV integrated services
are usually offered by one service provider in one room during the
same visit.
• No referral is required in this model
• b) “Supermarket approach”: In this model, integrated SRHR and HIV
services are offered by several service providers at the same facility,
usually located in different rooms during the same visit.
• Facilitated internal-referral is required in this model
2. Off-site Model/MALL
•Integrated SRHR and HIV services: are
offered outside the facility through
facilitated external referral.
3 Mixed Model
• Some services are initiated in one facility, but are provided in
another.
• Or, some services are offered in one facility while others are offered in
a different facility which is a mixture of both the on and off-side
models.
Models of Integration
NURSE (DIFFERENT NURSES
)
PATIENT
A B
. .
INTERNAL REFERRAL
C
.
EXTERNAL REFERRAL
The role of reproductive health
providers in preventing HIV
•These services could provide:
• HIV counselling,
• Testing and
• Condom promotion;
• Information and advice on the management of
sexually transmitted infections; and
• Use of pregnancy prevention as HIV prevention.
Linkage HIV and Adolescents

• Adolescents (10–19 years) and young people (20–24

years) continue to be vulnerable, both socially and
economically, to HIV infection despite efforts to date.
• This is particularly true for adolescents—especially
girls—who live in settings with a generalized HIV
epidemic or who are members of key populations at
higher risk for HIV acquisition or transmission through
sexual transmission and injecting drug use.
• In 2012, there were approximately 2.1 million adolescents
living with HIV
• About one-seventh of all new HIV infections occur during
adolescence
• Access to and uptake of HIV counselling and testing (HTC) by
adolescents is significantly lower than for adults. Survey data
collected from sub-Saharan Africa indicate that only 10% of
young men and 15% of young women (15–24 years) were
aware of their HIV status.
• However, access and coverage vary considerably across
countries and regions.
 HIV testing and counselling for
adolescents
• HIV testing and counselling (HTC) is an essential component of efforts to
achieve universal access to HIV prevention, treatment, care and support.
• Regardless of HIV acquisition route, underutilization of testing and
counselling services results in late diagnosis; increasing uptake of HTC
could lead to earlier diagnosis and more effective care.
• Due to the increasing availability of ART and prevention interventions,
early diagnosis can reduce transmission and improve health outcomes,
thereby decreasing HIV incidence and HIV-related morbidity and
mortality.
• HTC for adolescents, as for adults, offers many important benefits.
• Adolescents who learn that they have been diagnosed
with HIV are more likely to obtain emotional support
and practice preventive behaviours to reduce the risk
of transmitting HIV to others, and more likely to
obtain HIV treatment and care, assuming these
services are available to them.
• Early access to care can help them to feel better and
to live longer, than if they present for care when their
disease is already at an advanced stage.
• Access to HTC is also important for adolescents who do not
have HIV to reinforce prevention messages and facilitate
access to prevention services and commodities.
• Recent data from South Africa suggest that adolescents who
had taken a test had a lower incidence of HIV over time
compared with those who had not
• HTC is also an essential component of the package of care
included in voluntary medical male circumcision (VMMC)
programmes for HIV prevention that are being scaled up in
14 priority countries in sub-Saharan Africa—in which
adolescents are a key target group
 HIV treatment and care for
adolescents living with HIV
Modes of transmission
• Adolescents can acquire HIV infection in two ways—through vertical or
horizontal transmission.
Vertical (mother-to-child) transmission
• Adolescents living with HIV include long-term
survivors of vertical transmission, some who are on
treatment, as well as slow progressors (not on
treatment).
• Some of these adolescents are receiving care having
been followed through PMTCT programmes. However,
a significant proportion has not been diagnosed due
to loss to follow-up (LTFU) or poor coverage of PMTCT
programmes
Horizontal transmission
• Horizontal transmission occurs in two ways:
• Sexual transmission
• Sexual activity begins during adolescence in most parts of the world,
although age and conditions vary greatly. Risks for acquisition of HIV
include sex without safe condom use, early coerced sex and sexual
exploitation involving coercion and sometimes violence.
• Parenteral transmission
• Non-sexual transmission among adolescents can involve injecting drug
use (IDU), traditional practices (e.g. female genital mutilation (FGM),
scarification with shared razor blades and traditional treatments
requiring cutting of the skin) and certain medical procedures such as
unsafe surgical procedures, injections and blood transfusions.
 Factors that make adolescents vulnerable to
HIV infection
• There are social and contextual factors that make adolescents
vulnerable to HIV infection through horizontal transmission.
• These factors include:
• age and sex,
• gender,
• social and cultural norms and
• value systems about sexual activity,
• location (where the adolescent lives, learns and earns),
• economic and
• educational status and
• sexual orientation.
• Adolescents who are particularly vulnerable include those
from key populations as well as orphans, migrants and
refugees, prisoners and other groups that are socially
marginalized and discriminated against, and adolescents
affected by humanitarian crises.
• Conflict, displacement and food insecurity all can heighten
risk.
• The HIV epidemic itself also increases vulnerability; for
example, adolescents orphaned by AIDS can be more
vulnerable to HIV if their circumstances lead them to engage
in sex with older and/or concurrent partners for economic or
emotional support
REASONS AS TO WHY HIV IS
HIGH ON YOUNG PEOPLE
• Young people have sex -Sexual activity begins in adolescence for the
majority of people
• Young people lack information- the vast majority of young people
have no idea how HIV/AIDS is transmitted or how to protect
themselves from the disease.
• Girls are very vulnerable - older men are having sex with young girls.
Difficulty for girls to afford school fees and some seek sugar daddy for
school fee or sex workers. Some men wants sex with virgins for
various reasons
• Many young people are at especially high risk - Those young
people who are forced to live on the social and economic
margins of society have even less access to information, skills,
services and support than young people normally do
• Young people who inject drugs
• Adolescents who are sexually violated
• Young males having sex with males
• Children and youth on the street
• Young people in the sex trade- Clients often target younger
adolescents because they believe that children do not carry HIV.
Adolescents who are sexually exploited also have virtually no
negotiating power to ask for safe sex from their exploiters
Family planning
• In parts of east and southern Africa, approximately
60% of new HIV infections are among women and girls
of all ages.
• In this region adolescent girls and young women (ages
15–24) account for one quarter of new infections,
even though they constitute only 10% of the
population and are three times more likely to acquire
HIV infection than male peers their own age
• At the same time, as many as one quarter of adolescent girls
and young women in sub-Saharan Africa use modern
contraception, and contraceptive prevalence is even higher
in high HIV burden countries such as Lesotho (59.2%),
Zimbabwe (50.7%) and Kenya (36.8%) (3).
• While family planning (FP) service coverage needs to expand
to reduce unmet need, current FP service coverage in high
HIV burden countries suggests that FP services may be an
important venue for reaching adolescent girls and young
women with HIV testing and linkages to prevention and
treatment for those at high ongoing risk.
• Concrete action is required, particularly in these regions, to expand
coverage of services for FP, HIV testing and linkage to HIV
prevention and treatment for women and adolescent girls.
• Where HIV burden is high, family planning clients should be
routinely offered HIV testing and HIV prevention options in addition
to a choice of contraceptive methods
• Integrated FP and HIV testing services (HTS) can be implemented
through a variety of provider-delivered and self-testing modalities.
• In particular, HIV self-testing (HIVST) is emerging as a convenient,
effective and feasible way to integrate HIV testing into FP services in
health facilities, pharmacies and communities.
 Key definitions
• Family planning
• Family planning (FP) enables individuals and couples to
plan for and attain their desired number of children and
to space and time births, achieved through use of
contraceptive methods.
• The term “FP services” encompasses all services that
deliver contraceptives and infertility treatment, including
contraception for adolescent girls and young women.
• HIV testing services
• The term HIV testing services (HTS) encompasses a range of
services that should be provided together with HIV testing.
• These include brief pre-test information; post-test counselling;
voluntary provider-assisted referral (index testing); linkage to
appropriate HIV prevention, care and treatment services and
other clinical and support services; and coordination with
laboratory services to support quality assurance.
• HTS may be delivered by providers, through self-testing and
through partner-delivered approaches in health facilities and
community settings.
•HIV self-testing
•HIV self-testing (HIVST) is a testing modality
where a person collects their own specimen
(oral fluid or blood) and then performs an
HIV test and interprets the result, often in a
private setting, either alone or with
someone they trust.
CONTRACEPTIVE CHOICES FOR
WOMEN AT HIGH RISK OF HIV
• All contraceptive methods, with the exception of spermicides
containing nonoxynol-9, are safe for people at high risk of HIV
acquisition.
• This includes both hormonal methods (combined estrogen and
progestogen or progestogen-only) and nonhormonal methods.
• WHO recommends that, in high HIV burden settings, testing for HIV
be made available for all women at FP services.
• Integrating HIV testing into FP services presents an opportunity to
reach both women with undiagnosed HIV and link them to ART and
to link women at high risk of HIV to prevention services and options
 MODELS FOR INTEGRATING HTS
INTO FP SERVICES
1. Health facility-based FP and HIV testing
• In health facilities HTS can be offered routinely to FP clients through
provider-delivered or self-testing options.
• HIV self-testing (HIVST) kits can be offered in waiting rooms for FP
clients to test on-site or take home. Clients who use HIVST on-site may
discuss results as well as prevention, diagnosis, treatment, partner
services and linkage options with their FP provider.
• Clients may take HIVST kits home to share with partners
• Provider-delivered HIV tests are offered to FP clients by providers during
FP consultations. Clients who are tested for HIV by an FP provider on-site
may discuss results, as well as prevention, diagnosis, treatment, partner
services and linkage options
2. Community-based FP and HIV testing
• Community-based FP and HTS can be delivered through provider-
delivered or HIVST options.
• Where FP outreach and community-based HIV testing services are
already underway in parallel, partnerships between programmes to
co-deliver FP and HIV testing could improve efficiency and optimize
resource use.
• Regardless of testing modality, linkage to prevention, treatment and
partner services can be offered to all clients.
3. Retail-based FP and HIVST distribution
• HIVST kits can be distributed by pharmacists or in vending machines
to clients who are picking up contraception.
• Women receiving HIVST kits can be offered information and support
through virtual interventions including helplines, chat-bots and
linkage services.
4. Virtual interventions to support access to FP and HIV
testing
• Virtual interventions including websites, apps, chat-bots and
social networks that can be used to:
• Link users to facility-based services for FP and HIVST
• Link users to community or retail-based FP services and HIVST
• Deliver informative and motivational messages and linkage
support
• Order mail delivery of HIVST or self-sampling kits.
• Virtual tools such as smartphone apps and websites may be used to
connect users to contraceptives and HIVST, especially among
populations not adequately reached by existing services, such as
adolescent girls and young women, or as part of focused outreach to
members of key populations
5. Secondary distribution:
• FP clients can pick up HIVST kits to share with partners
• At health-facility and in community-based settings, FP clients can
receive HIVST kits to share with partners.
• Information, support and linkages can be delivered through virtual
interventions including help lines and chat-bots.
Populations at high risk of HIV
• While risk varies by local context and individual circumstances, the
following are examples of women who are at high risk of HIV
infection:
i. Young women (15–24 years) in sub-saharan africa
ii. Young women who sell sex
iii. Female sex workers
iv. Women who inject drugs
v. HIV-negative women with a partner living with HIV
vi. Women who have experienced sexual violence
vii. Transgender men (female-to-male) with childbearing reproductive organs
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