Bridging An Inexplicable Divide: Integrating Reproductive Health Services and the Global HIV/AIDS Response

This article is part of a series on global AIDS issues to be published by RH Reality Check throughout December. Other articles in the series can be found by searching "global AIDS 2009" on RH Reality Check.

Imagine two projects in a sub-Saharan African country, both supported by the U.S. government. One of them is a network of private health clinics that has helped meet the significant need for family planning. The other is a highly successful network of 20 voluntary HIV counseling and testing centers that test thousands of people each year. Now imagine the family planning clinics referring patients to the HIV counseling and testing centers, and vice versa.

And what we have is a new generation of centers that integrate family planning and HIV/AIDS by having a family planning doctor actually working in the HIV counseling and testing centers. The same organization would then train family planning providers to offer HIV counseling and testing in other countries. Although such integration makes perfect sense from a public health point of view, the sad truth is that such coordination is all too rare.

As we marked World AIDS Day 2009, the HIV and AIDS epidemic is still running ahead of our efforts to stop it. Millions of those in need are now receiving antiretroviral treatment, and a new UNAIDS report indicates a decline in new infections in some populations. Yet if we are to make a real impact on reversing the course of the pandemic, we must address the complex challenges that people – especially women and youth – face in their daily lives.

Unfortunately, we are not fully addressing these challenges in large part because of inexplicable policies that have hindered full integration of HIV/AIDS and reproductive health programs. The U.S. response on the global stage has been lagging in part because of stagnant funding levels for family planning and in part because of barriers to RH-HIV integration.

The bipartisan U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), launched by President Bush in 2003, is rightly hailed for its successes as an emergency plan with an initial focus on getting AIDS treatment to millions who need it around the world. The 2008 law reauthorizing PEPFAR puts a greater emphasis than in the past on preventing new HIV cases through a comprehensive set of interventions, but it falls short of explicitly stating family planning as a key component in the effort to prevent new infections.  This omission directly affects the development of country operating plans and the flexibility of HIV prevention funding intended to meet the greatest needs.

Another barrier is the anti-prostitution pledge – a requirement that organizations receiving U.S. funds publicly state their opposition to prostitution in order to continue their work fighting HIV/AIDS. The Department of Justice in July temporarily withdrew its appeal of a court injunction prohibiting enforcement of the pledge – a welcome action that should be accompanied by clear guidelines upholding the free speech rights of organizations.

There are further signs of hope. In his first week in office, President Barack Obama rescinded the Global Gag Rule, which now needs legislative action to permanently put it to rest. The Obama administration also has sent clear signals to coordinate and integrate all of the U.S. government’s global health programs through the Global Health Initiative (GHI). Robust funding for both PEPFAR and reproductive health and family planning programs will be keys to the GHI’s success.

U.S. actions to improve policies on RH-HIV integration will immediately result in better prevention programs, but we also must face up to the laws and policies of other countries that interfere with effective HIV/AIDS programs by further entrenching stigma, violating human rights and driving vulnerable populations away from HIV-related services. Harsh criminal penalties on groups at higher risk for HIV infection – such as men who have sex with men and sex workers – are human rights violations and must be viewed as such.

Fifteen years ago at the International Conference on Population and Development (ICPD), 179 U.N. member states committed countries to provide universal reproductive health care by 2015. World Health Organization guidelines also clearly state that reproductive health services are critical to effective HIV prevention strategies. Despite these proclamations, we have seen backtracking in the availability and use of condoms, the adoption of safe sex behaviors, and the ability of women and girls to negotiate safer sex. It is time for policymakers across the spectrum to unite behind evidenced-base interventions that promote integration of HIV/AIDS and reproductive health program.

In the coming year, we need to move forward to ensure that:

• The global community through the U.N. and other forums clearly speaks out against laws and policies that further stigma and violate rights of people living with and affected by HIV and AIDS
• Family planning and gender considerations are integral aspects of the program guidance PEPFAR managers send to and use in the field.
• The Global Health Initiative is robustly funded and has clear mandates on RH-HIV integration.
• Congress and the Obama Administration permanently put to rest the Anti-Prostitution pledge and Global Gag Rule.

Until we have a safe and effective vaccine, integrating sexual and reproductive health services remains one of the strongest – and as yet underutilized – tools to prevent further HIV infection.