Services on Demand
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Print version ISSN 0042-9686
Bull World Health Organ vol.87 n.11 Genebra Nov. 2009
Michel Sidibé; Kent Buse*
Joint United Nations Programme on HIV/AIDS, 20 avenue Appia, 1211 Geneva 27, Switzerland
Recent increases in resources for achieving the goal of universal access to HIV prevention, treatment, care and support have given renewed impetus to the longer-standing political commitment for achieving targets in sexual and reproductive health and rights. As a result, we see increasing optimism that progress on these interdependent goals can be achieved - particularly if they are tackled together.
The AIDS response has been remarkably successful in transforming a deafening demand for inclusive policy processes and evidence-informed, rights-based programmes into tangible achievements measured in lives saved and dignity restored. The most visible manifestations of these achievements are the more than 4 million people presently on antiretroviral treatment and the tremendous advances in overcoming the stigma and discrimination faced by people who inject drugs, men who have sex with men, and sex workers and their clients.
It is encouraging to see evidence that well designed AIDS responses can and do strengthen health systems.1 Nonetheless, evidence also confirms that greater and more systematic efforts must be made to take AIDS responses out of isolation to support wider health, development and human rights agendas.
Fostering improved linkages is also critical to the AIDS response. Despite treatment successes, we will not turn the tide on the epidemic, which sees five new people infected with HIV for every two individuals starting treatment, unless prevention is intensified. This can be achieved in part through service integration, which achieves more cost-effective resource allocation and responds to peoples' desires for a seamless and comprehensive continuum of care.
There are several linkages between HIV and sexual and reproductive health responses. Services to virtually eliminate mother-to-child HIV transmission provide an ideal platform to deliver the entire recommended minimum package of antenatal, maternal, child health and reproductive health services. This would ensure that pregnant women are not only offered HIV screening, but that they and their partners are also offered services to prevent HIV and other sexually transmitted infections, unwanted pregnancies and sexual violence.
Calls for integration are not new. The global community reached consensus on the need to provide holistic sexual and reproductive health services as far back as 1994 with the Programme of Action of the International Conference on Population and Development. The need has been further reaffirmed in important global declarations since then - notably the United Nations Political Declaration on HIV/AIDS of 2006.
Increased integration is intuitively appealing and enjoys a great deal of scientific support for the benefits it can deliver.2 These include increasing coverage, and thereby access, at lower cost as well as improving quality of care and acceptability for often stigmatized conditions. WHO, the United Nations Population Fund, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and other partners have supported countries to increase service integration within national programmes.3
It is no coincidence, therefore, that many of UNAIDS current corporate priorities, including to reduce sexual transmission of HIV, stop violence against women and girls, remove punitive laws and promote human rights, and empower youth, provide strategic entry points to strengthen linkages between HIV and sexual and reproductive health responses, as Gillespie et al. (866-870), Steen et al. (858-865) and Fransen (877-879) demonstrate in this theme issue.
However, as Dickinson et al. (846-851) argue, exploiting linkages has too often been the exception rather than the rule. Integration has been held back by several factors. For example, parallel funding streams for disease-specific programmes have not provided incentives for operational integration but are perceived as being more tightly controlled financially than integrated services.4 Vertical programmes may develop technical guidance and lists of essential drugs that are condition specific and pay little attention to related areas in sexual and reproductive health and rights. Professional and cultural rivalries often present further barriers.
Accomplishing integration of HIV and sexual and reproductive health programmes demands an honest recognition of the political, not just the operational, barriers, and the willingness of donors, international agencies and programme managers to address actively the political blockages and change the way that they themselves do business.5
Yet successful integration also depends on demand from below. In renewing primary health care, more emphasis needs to be placed on family-centred services and communities - ensuring greater accountability and voice.
Civil society, the driving force behind the AIDS response, has shaken up global health. Its support is crucial to foster integration of HIV and sexual and reproductive health and rights programmes. Given political commitment, the moment is right to take the AIDS response out of isolation. We see signs of such commitment in the International Health Partnership, in President Obama's Global Health Initiative, in the new Partnership Frameworks of the United States President's Emergency Plan for AIDS Relief, and in the joint approach of the Global Fund to Fight AIDS, Tuberculosis and Malaria, The World Bank and the GAVI Alliance to supporting sustainable and cost-effective health systems.
The time has come to unite the forces of the global AIDS movement with other constituencies to ensure that people have universal access to integrated and comprehensive prevention, treatment, care and support that is rights-based, equitable and effective.
Available at: http://www.who.int/bulletin/volumes/87/11/09-071621/en/index.html [ Links ]
1. World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. Lancet 2009;373:2137-69. PMID:19541040 doi:10.1016/S0140-6736(09)60919-3 [ Links ]
2. Sexual & reproductive health and HIV. Linkages: evidence review and recommendations. Geneva/New York/London/San Francisco: World Health Organization/Joint United Nations Programme on HIV/AIDS/United Nations Population Fund/International Planned Parenthood Federation/University of California San Francisco; 2008. Available from: http://www.who.int/reproductivehealth/publications/linkages/srh_hiv_linkages_evidence/en/index.html [accessed on 9 October 2009] [ Links ].
3. Sexual and reproductive health and HIV/AIDS: a framework for priority linkages. Geneva: World Health Organization/United Nations Population Fund/International Planned Parenthood Federation/Joint United Nations Programme on HIV/AIDS; 2005. Available from: http://www.who.int/reproductive-health/stis/framework.html [accessed on 9 October 2009] [ Links ].
4. Oliveira-Cruz V, Kurowski C, Mills A. Delivery of priority health services: searching for synergies within the vertical versus horizontal debate. J Int Dev 2003;15:67-86. doi:10.1002/jid.966 [ Links ]
5. Buse K, Martin-Hilber A, Widyantoro N, Hawkes SJ. Management of the politics of evidence-based sexual and reproductive health policy. Lancet 2006;368:2101-3. PMID:17161732 doi:10.1016/S0140-6736(06)69837-1 [ Links ]