HIV Update: Sexually transmitted infections

Sexually transmitted infections

The prevention and management of sexually transmitted infections (STIs) is a fundamental component of sexual and reproductive health, and represents an integral and cost-effective intervention to prevent HIV transmission

Globally, STIs cause considerable mortality and morbidity in both young people, adults and newborns, and have a role in facilitating the transmission of HIV. WHO estimates that each year approximately 500 million new cases of syphilis, gonorrhoea, chlamydia and trichomoniasis occur in men and women between 15 and 49 years of age, and global incidence continues to rise (WHO 2012). While men accounted for over half of all new cases, women often experience more serious complications. Like HIV, key populations are at higher risk of STIs including sex workers, people who use drugs, transgender people, and men who have sex with men (MSM).

While the prevention and management of STIs has long been an integral part of IPPF’s mission, the provision of services for STIs other than HIV have been a lower priority among many IPPF Member Associations (MAs). In 2012, over 50 per cent of all STI-specific services were provided by two MAs, and nine MAs accounted for 75 per cent of these services. Faced with a growing global incidence of syphilis, gonorrhoea, chlamydia and trichomoniasis, however, there is a renewed commitment across the Federation to increasing access to STI prevention, screening, and treatment services. 

As a fundamental component of sexual and reproductive health (SRH), this will not only help address STI symptoms and complications, but represents an integral and cost-effective intervention to prevent HIV transmission. It is known that HIV is transmitted and acquired more easily in the presence of untreated STIs, so effective screening and treatment of STIs, along with the correct and consistent use of condoms, can reduce the risk of HIV transmission. It is also a vital part of the SRH of people living with HIV that STIs are effectively diagnosed and treated.

A number of opportunities to scale up and integrate STI services within existing service delivery programmes have been identified and supported by recent technological advances, including a vaccine to prevent the human papillomavirus (HPV), and rapid, point-of-care testing for syphilis. With commitment and support, a number of simple and cost-effective STI services can be scaled-up, and significantly contribute to increasing service delivery across the Federation. 

Download the full issue of the IPPF HIV Update newsletter: http://www.ippf.org/resource/HIV-Update-35-Sexually-transmitted-infections

Reflections from IPPF

By Anupam Pathni, Programme Officer – HIV and AIDS (IPPF South Asia Regional Office)

The World Health Organization (WHO) regularly releases updated clinical guidelines on the use of antiretroviral (ARV) drugs for adults and adolescents, and for maternal and child health. For the first time ever, WHO undertook a process of developing a set of consolidated guidelines that go beyond incorporating updated clinical guidance (‘what to do’), to include operational (‘how to do’) and programmatic (‘how to decide what to do, where and when’) guidance to help each country make the best decisions on the use of ARVs in their own context.

IPPF was involved as a civil society representative in the operational and service delivery guideline development group (GDG), and participated in the GDG meeting on 6-8 November 2012 in Geneva. Systematic and GRADE reviews of the operational issues being considered were presented. Participants reviewed risk/benefit tables and discussed various recommendations, covering the following topics: community based HIV testing and counselling, task shifting for ART, decentralization of HIV treatment, strategies for improving treatment adherence, integration of ART and HIV in TB treatment settings and vice versa, and integration of ART and HIV care in MNCH and opiate maintenance treatment settings. Based on the deliberations at this meeting and other similar meetings, the guidelines were updated and were launched at the end of June 2013.

These new guidelines have the potential to transform HIV responses in countries and to boost efforts to achieve ‘Universal Access’ targets. Though none of the IPPF Member Associations (MAs) in the South Asia Region are currently providing ART to their clients, all of the MAs play a very important role in supporting the efforts of their national governments in this area. While implementing community HIV testing and counselling strategies, it will be important for MAs to ensure adherence to rights-based principles beyond ensuring linkages with the continuum of care for those who are diagnosed HIV-positive. In tandem with the promotion of community-based HIV testing and counselling, IPPF needs to continue advocating for enabling environments to help treatment adherence, for example by advocating against punitive laws.

Provision of services cannot happen in isolation and needs to be balanced with community mobilization and context-specific demand creation strategies, which is one of the strengths of our MAs. The new WHO guidelines recommend task shifting and decentralization of HIV treatment and our MAs could leverage opportunities under their national programmes to ensure ART provision within their own facilities, or at the community level. A cross-cutting issue that needs to be addressed would be the implementation of efficient referral systems and linkages to support community-based HIV testing and counselling, decentralization, and integration of services.

Provision of services related to antiretroviral therapy by IPPF Member Associations

A total of 22 IPPF Member Associations reported providing ART-related services in 2012. In 2012, there was a large increase in the number of services provided, as well as facilitated referrals. This increase was largely due to increased ART service provision in Cambodia, Dominican Republic, Ethiopia, Indonesia, Sierra Leone, Sudan, and Togo; and referrals in India and Tanzania.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy

New WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection

By Dr Lisa Nelson, Medical Officer and Dr Gottfried Hirnschall, Director (HIV/AIDS Department, WHO, Geneva)

On June 30 2013, WHO released updated HIV guidelines on the diagnosis of HIV, the care of people living with HIV and the use of antiretroviral (ARV) drugs for treating and preventing HIV infection.  These guidelines were launched during the 7^th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) held in Kuala Lumpur, Malaysia from 30 June to 3 July 2013.

The document was developed in consultation with country policy makers and programme planners, implementers, researchers, clinicians, and affected communities. These guidelines are novel in several ways by:

1. harmonizing guidance and treatment regimens across populations, as well as along the continuum of care;
2. providing guidance on how to improve service delivery and to make decisions on optimal resource allocation; and
3. consolidating existing and new recommendations into a single document using a public health approach.  

Key data that prompted this update include evidence of the individual and population-level benefit of earlier treatment [1], more effective and simplified treatment approaches, new knowledge on effective service delivery models and new technologies such as point-of-care CD4 testing.

The new clinical recommendations in these guidelines promote early initiation of antiretroviral therapy (ART) at a CD4 threshold of 500 cells/mm3 or less for adults, adolescents and older children. Priority should be given to persons with severe or advanced HIV disease and those with CD4 count of 350 cells/mm3 or less. ART is recommended regardless of CD4 count for certain populations, including people with active tuberculosis (TB) disease who are living with HIV, people with both HIV and hepatitis B virus (HBV) with severe chronic liver disease, HIV-positive partners in serodiscordant couples, pregnant and breastfeeding women and children younger than five years of age. Harmonization of ART regimens for adults, pregnant women and children is recommended whenever possible, with a new, preferred first-line ART regimen of tenofovir/lamivudine or emtricitabine/efavirenz (TDF/XTC/EFV) as a fixed-dose combination tablet once daily. The need to phase out d4T in first-line ART regimens for adults and adolescents is being reinforced. Viral load testing is now recommended as the preferred approach to monitoring ART success and diagnosing treatment failure, complementing clinical and immunological monitoring of people receiving ART.

“These new guidelines have the potential to transform HIV responses in countries and to boost efforts to achieve ‘Universal Access’ targets, towards and beyond 15 million people on antiretroviral therapy in low- and middle-income countries by 2015.” Dr Gottfried Hirnschall 

For pregnant and breastfeeding women and children under age five living with HIV, the routine offer of ART irrespective of CD4 count or clinical stage will improve treatment access.  Current treatment coverage is unacceptably low for these groups.  Simplified approaches such as using a common regimen of TDF/XTC/EFV for all those eligible should also improve uptake.

The guidelines emphasize that ARV drugs should be used within a broad continuum of HIV care.  Additional new recommendations range from community-based HIV testing and counseling, to HIV testing of adolescents, and the use of post-exposure prophylaxis after sexual assault. Summaries and links to existing WHO guidance are provided for HIV testing and counselling, HIV prevention, general care for people living with HIV, the management of common co-infections and other comorbidities, and monitoring and managing drug toxicities.

Data on service delivery models were reviewed and a number of new evidence-based recommendations were developed including a recommendation to initiate ART in maternal and child health and tuberculosis treatment facilities in high burden settings.  ART should also be offered in care settings where opioid substitution therapy (OST) is provided.  Decentralization of services provides an opportunity to offer ART to more people closer to where they live.  Trained non-physician clinicians, midwives and nurses can initiate and maintain first-line ART (task shifting) and supervised community health workers can dispense ART between regular clinical visits.

These guidelines aim to assist countries in decision-making and programme planning, to adapt the recommendations for their epidemic, health systems and resource context.  The document outlines fair, inclusive, transparent and equitable decision-making processes at the country level on the strategic use of ARV drugs.

The implementation of these guidelines will expand the pool of persons eligible for ART and will require additional investments in the near and medium term.  However, modelling clearly demonstrates that earlier treatment initiation will reduce new infections over the medium to long term as HIV transmission is reduced, and will be a major step forward towards reducing the global burden of HIV.

The full guidelines and accompanying annexes are available at: http://www.who.int/hiv/pub/guidelines/arv2013/download/en/index.html

References

1.     Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 2011, 365:493–505.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy

HIV Update: Antiretroviral therapy

Antiretroviral therapy

By Lucy Stackpool-Moore (IPPF)

A record 10 million people living with HIV now have access to antiretroviral therapy but now is not the time to become complacent

The latest scientific results were presented by the leading thinkers and scientists at the 7^th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2013) in Kuala Lumpur at the end of June. At this conference, the World Health Organization (WHO) released new international guidelines on the use of antiretroviral (ARV)drugs to inspire more and better access to treatment for people around the world.

The new guidelines call for increased access to ARVs for many people – earlier initiation of treatment for people living with HIV (by increasing the recommended CD4 count to 500 cells/mm3), treatment for life for pregnant mothers living with HIV and any infants born with HIV, and provide operational guidance for programmers and planners to adopt the guidelines. These recommendations are ambitious in a time when pediatric treatment remains unacceptably low and funding to guarantee access to treatment risks being inadequate and unsustainable. Complacency, or so-called ‘AIDS fatigue’, and fears of global financial hardship are all factors that may jeopardize the success of the uptake of the new WHO guidelines. Strong leadership is critical within such a moment in time.

Enhanced access to treatment will not be the panacea for meeting all needs, but it is a good start. It can catalyze a great deal through enhancing comprehensive prevention efforts, ensuring lifesaving and health promoting treatment, and reducing the likelihood of HIV transmission. But even with enhanced access, stigma remains; as do many of the structural determinants that fuel HIV and render people vulnerable to ill-health. New challenges will also emerge in terms of treatment adherence for more people and potential risks of increased drug resistance.

Colleagues from across IPPF have recently responded to a question about the need for an exceptional response to HIV. The responses overwhelmingly affirmed that such a response is still necessary – to consolidate hard-won gains of the last 30 years, to innovate and catalyze strengthening in health systems, to protect human rights of the most marginalized people around the world (who are often also the most vulnerable to HIV), and to continue to tackle wider structural determinants of health. As one colleague said, quite simply, “stigma still remains as a great obstacle in many senses: cultural, and political. People that need treatment, don´t have it yet.”

Visionary leadership for HIV is as critical now as ever before. People matter, and every person’s life is important. Now and for the foreseeable future, HIV is part of life – as is living with HIV – for individuals, families, communities, societies and countries around the world.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-Antiretroviral-therapy

Spotlight on HIV and Family Planning: After the Summit

By Julia Bunting, Director, Programme and Technical Division (IPPF Central Office)

The year 2012 saw the reinvigoration of a loud and visible global movement committed to achieving universal access to family planning, as part of a commitment to comprehensive sexual and reproductive health (SRH) services that put the rights and needs of clients at the very centre. This groundswell was catalyzed at the London Summit on Family Planning held in July 2012, which built on the foundations laid down by family planning pioneers more than half a century ago. The Summit called for political commitments, backed by increased resources, to enable an additional 120 million women and girls in the world’s poorest countries to access contraceptive information, services and supplies by 2020.

At the Summit, IPPF made an unprecedented commitment to treble the number of SRH services provided annually by our Member Associations – from a 2010 baseline of 89 million services. By offering a comprehensive and integrated package of rights-based services through the existing network of 64,000 clinics and community-based service delivery points, we estimate that our efforts will prevent 46.4 million unintended pregnancies and 12.4 million unsafe abortions by 2020. We also estimate that 54,000 deaths of some women and girls will also be averted during this period. In this renewed focus on family planning, as in all of our work, we will maintain a particular focus on services for poor and vulnerable women, men and young people.

At the Summit, IPPF also committed to develop a compendium of indicators on linkages between HIV and SRH including family planning, maternal and child health. A greater focus on integration, particularly of HIV and family planning services, provides an unparalleled opportunity to expand access to a wide range of SRH services. The rationale is indisputable: the majority of cases of HIV transmission are sexual or are associated with pregnancy, childbirth and breastfeeding; the risk of HIV transmission and acquisition can be increased by the presence of certain sexually transmitted infections (STIs); and HIV continues to be the leading cause of death among women of reproductive age.

It is vital that all women and girls have access to a full range of sexual and reproductive health options, including HIV services, family planning, contraceptive choices, and access to safe abortion services. Women living with HIV, who continue to face barriers accessing both family planning and programmes that prevent HIV transmission from mother to child, must remain at the centre of attention. Prioritizing the integration of family planning and HIV services will greatly contribute to achieving the sexual and reproductive health and rights for all.

References listed in the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

Spoilt for choice

By Nienke Blauw, Advocacy Officer UAFC Joint Programme (Rutgers WPF, The Netherlands) and Saku Mapa, HIV Officer: Prevention, Treatment and Care (IPPF Central Office)

Like male condoms, female condoms (FCs) provide protection against unintended pregnancy and most sexually transmitted infections (STIs), including HIV. However, unlike their male counterparts, female condoms remain a relatively unknown and underfunded dual protection method. For a long time, the success of the product has been affected by a combination of frequent stock-outs, skepticism, myths and prejudices, high prices, and lack of variety.

In 2008, the Universal Access to Female Condoms (UAFC) Joint Programme was formed by four organizations (Netherlands Ministry of Foreign Affairs, I+solutions, Rutgers WPF and Oxfam Novib) to address the bottlenecks around availability and access to female condoms. As part of its holistic approach (combination of advocacy, large scale female condom programming, and manufacturing support and regulatory issues), UAFC commissioned a clinical study in China and South Africa to compare the functional performance of and preferences for three new female condom designs (Cupid, Women’s Condom and VA w.o.w.) compared to a ‘control’ design, called Female Condom 2 (FC2).  In each country, around 300 people took part in the study who were primarily urban women aged 18-45 who were either novice or experienced users of female condoms.       

"The female condom is gaining ground as it should do, I myself used throughout my life six different methods for family planning and protection, not even counting abstinence, this shows that variety is key." Marijke Wijnroks, Director for Social Development / HIV and SRHR ambassador for the Netherlands

The primary goal of the study was to look into the device functioning (clinical and non-clinical breakage, total breakage, slippage, misdirection, and invagination), while the study also looked into safety and acceptability. It was found, both in China and South Africa, that most women preferred the Women’s Condom. Overall, the study concluded that the three new condoms are non-inferior to the FCS, and recommended them as worthwhile products to add to the market alongside the FC2 (report available here).

The data gathered during this study will be used to secure regulatory approvals for the female condoms, including UNFPA/WHO prequalification. The Cupid female condom, as well as its manufacturer Cupid Ltd, was the first to fulfill all requirements and was prequalified by UNFPA/WHO in July 2012, thereby introducing more variety to the  female condom market.

At a recent meeting in The Hague, The Netherlands, some experts spoke out in support of this development as an important step in the right direction as variety of designs will increase competition leading to lower prices for procurers and eventually also for users, thus providing better access and more choice.

For more information about the UAFC Joint Programme visit: www.condoms4all.org.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

Integrating postnatal care, family planning, and HIV services

By Dr James Kimani, Senior Analyst (Population Council, Nairobi, Kenya)

Addressing the postpartum needs of new mothers, including new mothers who are living with HIV, and new mothers living in settings with a high HIV prevalence, is a neglected area of care throughout sub-Saharan Africa and other resource-limited settings. Few developing countries have mechanisms in place to ensure that mothers and their newborns are assessed early and monitored during the initial six-week postpartum period.

Some of the challenges include lack of clearly defined standards, including the content and timing of both postpartum and postnatal services, and a discontinuity of services limiting linkages to other key postpartum services for new mothers, including family planning and HIV care services for women living with HIV.

According to the World Health Organization, over 60 per cent of maternal deaths occur within the first 48 hours after childbirth [2], while newborn morbidity and mortality, including postnatal transmission of HIV to infants, are more likely to happen soon after birth [3, 4]. In high HIV prevalence settings, there is also evidence that women living with HIV are at 1.5–2 times greater risk of maternal mortality than women who are HIV-negative [5]. Providing adequate and effective services to meet the needs of mothers and their infants during this postpartum period can substantially reduce maternal and infant morbidity and mortality.

It is often assumed that women who deliver in a facility will have received adequate care prior to discharge and do not need further attention until the six-week consultation. Women giving birth at home are least likely to receive any care, especially within the first two days, when they are most susceptible to postpartum hemorrhage and hypertensive disorders [6].

However, our research has supported other studies that have found that regardless of where a woman gives birth, she is unlikely to receive the comprehensive care she needs. Two critical issues need further attention – the first, to promote family planning and prevent future unintended pregnancies, and the second, to prevent vertical transmission of HIV during the postpartum period.

To promote family planning, research has shown that during the extended postpartum period (12 months after birth), women may want to delay or avoid future pregnancies, but do not have access to a modern contraceptive method. A review of data from Demographic and Health Surveys (DHS) in 27 developing countries found that 67 per cent of women who gave birth within the previous year had an unmet need for family planning [7]. Although unmet need for family planning during the postpartum period is widespread among all women, evidence from recent studies has shown that substantial proportions of women living with HIV also have an unmet need. Studies in Zambia and Kenya found that 39 per cent and 65 per cent of postpartum women living with HIV reported that they were not using any contraceptive method with their regular sexual partner [8].

To prevent vertical transmission of HIV, there is evidence that even if counseling and information on family planning is available within programmes for the prevention of mother-to-child transmission of HIV (PMTCT), this does not necessarily translate into the initiation of contraception [9].

Evidence has shown that providing a continuum of care from antenatal, delivery, postnatal services and beyond results in improved maternal and neonatal health outcomes [10-12].  For example, in Swaziland, integration of PMTCT into postnatal care led to considerable improvements in follow-up visits during the first three days postpartum, a significant increase in the proportion of postpartum women and their partners who got tested for HIV, an increase in the proportion of women and infants who received HIV treatment and care, and significant improvements in the proportion of mothers practicing exclusive breastfeeding [11].

However, there is still a paucity of evidence from southern and eastern Africa (where HIV prevalence is highest) focused on measuring the benefits of integrated HIV and sexual and reproductive health services, particularly, postnatal care services.

As part of the Integra Initiative, our study in Kenya has contributed to filling this gap and aimed to build the evidence base by assessing the effect of integrating HIV and postnatal care services on the uptake of provider-initiated HIV testing and counseling and family planning services among women attending postnatal care in public health facilities. Preliminary results indicate that an integrated delivery approach of postnatal services is beneficial in increasing the uptake of HIV testing and family planning services among postpartum women, including the uptake of long-term family planning methods. However, there are important gaps in the uptake of these services based on facility-type and socio-demographic characteristics. This has important implications in addressing the sexual and reproductive health and HIV needs of women, including prevention of unintended pregnancies.

References listed in the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

HIV Update: Family planning and HIV integration

From words to action

By Lucy Stackpool-Moore (IPPF)

One of the many things that the response to HIV has shown the world over the last 30 years, is that communities can stand up, demand access to better quality services, defend their sexual and reproductive rights, and ultimately make a difference to policies and programmes. The growing movement for women, girls and their partners to demand sexual and reproductive health and rights, including family planning, can learn from these successes.

One of the key messages from the session on sexual and reproductive health (SRH) and HIV linkages at the London Summit on Family Planning Summit in July 2012 was that: “family planning needs to take a holistic approach to women’s health including their direct engagement in the prioritization of what is needed, what works and what is the appropriate method mix." (full session report) To be effective, this ‘holistic approach’ needs to engage communities not only as clients and end-users of services alone, but also as active participants in demanding the range and quality of services that meet their needs.

Internationally, different ‘communities’ have been speaking out to galvanize attention, energy and action on family planning and HIV integration. This past month has seen action on the commitments made during the Summit and a renewed focus on the potential health and economic benefits of integrating HIV and family planning services.

From the research community, the results from the five-year Integra operations research Initiative - launched at the UK Houses of Parliament - indicated that integrating SRH and HIV services can reduce unmet need for family planning, especially for women living with HIV. Several of the study components showed an unmet need for SRH services among women living with HIV, and suggest that integrated services can help realize their fertility intentions and meet their contraceptive needs. New technologies, such as different varieties of the female condom, have also been developed and evaluated that could contribute to the range and accessibility of family planning methods.

From the donor community, building on the London Family Planning Summit it was announced that the UK government will provide additional support for Malawi’s HIV response as well as support for wider healthcare – an additional £21 million pounds was provided specifically for family planning and HIV. In Malawi, this was welcomed as direct action following on from their first national family planning conference (held in May 2012) and owes much to sustained political leadership on maternal and child health by President Joyce Banda.

From our IPPF community, we remain committed to scaling up family planning and HIV service delivery particularly for poor and vulnerable women, men and young people. We also celebrate the vast contribution that Kevin Osborne has made to the HIV community - within IPPF and beyond - through his vision and leadership over the last 10 years.

Different communities are speaking out and demanding action. All of us – clients, providers, managers, advocates and ambassadors defending sexual rights – need to make sure that we listen and continue to drive the actions (and not only the words in declarations of commitments) forward.

Download the full issue of the IPPF HIV Update newsletter: http://ippf.org/resource/HIV-Update-April

HIV in the workplace

By Dieneke ter Huurne, HIV Officer (IPPF Central Office)

HIV is a workplace issue. According to the International Labour Organization, nine out of every ten people living with HIV will go to work each day (available here). Unfortunately, stigma and discrimination remain a reality in many workplace settings. To counter this, it is imperative that we adopt, institutionalize and internalize HIV workplace policies and programmes across the Federation.  Such policies and programmes serve to sensitize, inform and educate our staff and volunteers about HIV and AIDS. They also act as a way of challenging, and ultimately reducing, instances and acts of discrimination towards those living with or affected by HIV. 

As an employer of more than 30,000 staff around the world, and working in collaboration with more than one million volunteers, IPPF has a collective responsibility to provide a supportive and non-discriminatory work environment for all. In 2010, IPPF’s Governing Council adopted a revised HIV policy, which includes our commitment to addressing HIV in the workplace. We have institutionalised this commitment by making it a requirement for accredited Member Associations to have an HIV workplace policy. By 2011, more than 83 per cent of all Member Associations had a written HIV workplace policy; up from 56 per cent in 2009.

IPPF also actively encourages people living with HIV to work and volunteer in Member Associations and across the Secretariat. In order to support people living with HIV working in the Federation, IPPF+ was launched to ensure IPPF is recognized as an organization that not only responds to HIV issues in the communities in which we work, but also as an employer that has grappled with the workplace effects of this epidemic.

The challenge now is to bring these policies and initiatives to life and internalize HIV workplace programmes across all our offices and branches. Three key strategies to do this are included in the box below. IPPF has also developed a training guide to support staff at IPPF Regional Offices and Member Associations with planning and facilitating HIV workplace trainings. It will become available in English, French, Spanish and Arabic early in 2013 – so keep an eye out for it! 

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HIV and the politics of fear

By Matthew Weait, Professor of Law and Policy (Birkbeck College, University of London, United Kingdom)

For the past decade or so I have been privileged to participate in, and contribute to, national and international policy initiatives concerned with the criminalization of HIV transmission, exposure and non-disclosure. The people involved in this work, paid and unpaid, have been tireless in their efforts to draw the attention of those with legislative power to the negative impact that punitive responses to people living with HIV, and to those in key populations, has had and continues to have on prevention efforts and on reducing HIV-related stigma and discrimination. They could not, I think, have done more. 

Yet punitive responses remain – a stubborn stain that refuse to be shifted (except for a few notable exceptions). Why is this so? Why, in an era in which effective treatment (where it is accessible and available) means that people living with HIV with an early diagnosis have a similar life expectancy to those without HIV, should people be so afraid of infection that they want to punish and imprison? And why is this even more apparent in countries where that treatment is indeed accessible and available (North America, Australasia and Europe)? It seems to me that the answer lies in an increasingly obsessive focus on the value of security and in a perversion of that value during the last twenty years.

There was a time when we accepted that our bodies were fragile, porous, weak – open to disease and infection. To be human was to be a much more vulnerable organism, more susceptible during accidents, childbirth, and illness. As biological, medical, and pharmaceutical sciences have developed, as we have come increasingly to believe that we are able to regulate, manage and master the pathological agents that threaten our physiological integrity. 

It is thus completely explicable that HIV – despite being a manageable, if serious, chronic illness – should be stigmatized to the point of criminalization. Explicable because it is a reminder – an embodied reminder – that we are mortal; that the fantasy we entertain about our bodies is merely that – a fantasy.  Any threat to this – including the person who fails to let us know that they are a potential source of infection, and the person whose virus might (but doesn’t) escape – is, quite literally, intolerable. 

HIV is an environmental fact. It coexists with humans. The humans in whom it is embodied suffer criminalization, stigma, and discrimination not because of HIV itself – it’s a virus (!) – but because HIV confounds us, challenges us, frightens us, forces us to acknowledge what being human really means. And these negative effects of HIV can, and will, only be eradicated (for as long as there is neither vaccine nor cure) if we learn from the experience and practice of those who have organized so hard to counter them: if we (re)learn the value of, and progressive political opportunities that come from, working together and with a certain degree of humility in the face of nature. 

If there is one legacy from HIV that we might wish to remember, I hope that it is the reaffirmation of what can be achieved – for ourselves and for others – through a politics that acknowledges the value of community rather than one that thrives on the fear of difference.

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HIV Update: Rights in Action

By Kevin Osborne (IPPF)

Since the beginning of the epidemic, HIV has been at the crossroads of science, rights and moral values. All too often human-rights, tolerance, and acceptance are seen as ‘nice-to-haves’ but not ‘must haves’ as part of national and international responses to HIV. Yet studies have shown that failure to respect human rights undermines the return on investment. There is a financial as well as moral imperative to ensure that the efforts, attention and hard-earned currency invested in responding to HIV are as effective as possible.

There is an unconscionable economic, human and social cost of inaction on human rights. In my home country South Africa, a study by the Harvard School of Public Health found that the political inaction during the AIDS denialism of Thabo Mbeki’s government equated to 365,000 premature deaths. This included 330,000 South Africans who died for lack of treatment and the 35,000 babies who perished because of ineffective, incomplete or absent efforts to prevent the transmission of HIV from their mothers. In total, the economists found this was at least 3.8 million years of life, lost.

On a global scale, a recent study has also quantified the cost of inaction. A new investment framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for the prevention of HIV transmission.  The framework differentiates between (i) basic programme activities that aim to directly reduce HIV transmission, morbidity, and mortality; (ii) activities that are necessary to support the effectiveness and efficiency of these programmes (critical enablers); and (iii) investments in other sectors that can have a positive effect on HIV outcomes (synergies with development sectors). Human rights, tolerance and social inclusion are core principles at the heart of creating such an enabling environment. Scaling up and implementing   the new investment framework, would avert 12.2 million new HIV infections and 7.4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches.

The significance of human rights in the response to HIV has been integral from the very beginning. Due to the link between HIV and traditionally sensitive issues, the epidemic has brought into the open differing values and attitudes related to human sexuality and behaviour. As the spotlight shines away from HIV and specific sources of funding are opened up to incorporate other diseases and health systems strengthening, there is a risk that addressing these rights could falter. With an ever-increasing focus on numbers and scales (which are both important) it is imperative that rights – which are often difficult to quantify – are not jeopardized, forgotten, or simply taken for granted.

For IPPF, putting rights into action by upholding the sexual rights of all and addressing HIV-related stigma are key priorities for our work. Practical measures such as ensuring that our workplace is a stigma-free environment and providing stigma-free services in all of our clinics, go a long way in maintaining a rights-based approach in everything we do.

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Integrating services to increase men’s uptake of services

By Joelle Mak, Research Fellow (London School of Hygiene and Tropical Medicine, United Kingdom)

It is well documented that men’s use of health services in general, and sexual and reproductive health (SRH) services in particular, is much lower compared to women’s. Despite recognizing the need for male involvement in SRH, men are still engaged predominantly to improve women’s health rather than their own health and results in very little increase in men’s uptake of SRH services [3,4].

One approach that may work better is to integrate different health services. Integration of services allows clients to receive more services in a single visit. Variations of integration models mean that some services are provided by the same health care worker, or in the same consulting room or at the same facility. In general, integration of services is expected to produce benefits for both clients and service providers through improvements in the quality, uptake and efficiency of services [5,6].

Reviews synthesizing the evidence-base of SRH and HIV service integration identified studies primarily from low-income settings and found largely positive results across various outcome indicators including: increases in uptake of HIV testing, reduction in STI incidence, increases in condom use and improvements in quality of care [7-10], although a lack of vigorous evaluation and analysis that accounts for confounders reduces the possibility to draw firm conclusions. Many evaluations focus on female-orientated facilities or departments, such as family planning, ante or post-natal care, or maternal and child care which have little relevance for men. A consistent finding in different settings was that of substantial missed opportunities by service providers to address other SRH issues when clients present to clinics.

As part of the Integra Initiative (www.integrainitiative.org), different models of service delivery for integrated SRH and HIV services are being evaluated. Two rounds of cross-sectional household surveys have been conducted in Kenya and Swaziland. These will be analyzed to explore changes in service uptake among men and women as well as changes in the levels of demand for integrated services. It is anticipated that these findings will contribute to our limited knowledge about whether integrated services can improve men’s and women’s uptake of SRH services.

The potential to enhance male involvement in HIV services - an example from Swaziland

By Joshua Kikuvi, Fieldwork Coordinator, Swaziland (Integra Initiative)

At one of the Integra Initiative sites in Swaziland (King Sobhuza II Public Health Unit), there exists the potential of increasing men’s access to HIV services in a high HIV prevalence setting. The facility is located on the outskirts of an urban industrial zone, and offers both maternal and child health (MCH) services as well as dental, STI and dermatological services. All clients presenting themselves for any of these services are asked to state their HIV status (if known). Regardless of their status, basic HIV and STI counselling is offered to all clients before referral to the ART department for more comprehensive counselling (and testing, if the client consents).

Although the facility caters predominantly to women and children, there is a huge potential to use these services to create linkages that strengthen integration of HIV services with other curative and preventive services. These can be creatively tailored to promote male involvement in say, family planning and couples testing in such service packages as antenatal care, prevention of mother to child transmission and antiretroviral treatment, so that when women use these services, they also encourage their partners to seek healthcare. These baby steps towards integration of HIV and other services could improve men’s access to sexual reproductive health and HIV services.

References listed in the full issue of the IPPF HIV Update newsletter: http://www.ippf.org/resource/HIV-Update-Engaging-men-and-boys

Perceptions of positive parenting

By Jon Hopkins, HIV Officer (IPPF Central Office)

“If I was an HIV negative father, my worries on my own self or on my life and my medicines would have been less. It can happen with any disease, but the stigma attached with HIV deepens the impact and stresses you out. The worry for the future of your children increases multi-fold. It increases one’s responsibilities multi-fold too” Father living with HIV, India 

In 2011, IPPF supported qualitative research in nine countries to document the perspectives and experiences of young people living with HIV accessing standalone or integrated sexual and reproductive health (SRH) and HIV services. Young people living with HIV were interviewed in each country including young men and women under the age of 30 some of whom were men who have sex with men (MSM), sex workers, transgender people and migrant workers.

Further analysis has been done on the results of the survey in Sudan, Mexico and India. Interesting gender differences can be seen in the perceptions of parenthood among young people living with HIV, with a greater concern that HIV status affected parenting choices more for men than women. In all three countries, a majority of respondents felt that being HIV-positive affected a man’s role as a father. The reasons given were that men had a greater sense of responsibility towards their children as their primary role was providing social and financial security and this was affected by being HIV-positive (see figure 1).

The importance of male involvement can be clearly seen in these findings. Young men and young women living with HIV see the importance of male involvement when considering their own parenting choices. This shows that attention, support and services need to focus not only on the sexual and reproductive health and choices of young women, but also on men and their dreams and desires of fatherhood. 

Download the full issue of the IPPF HIV Update newsletter: http://www.ippf.org/resource/HIV-Update-Engaging-men-and-boys

Masculinity as a barrier to SRH and HIV services

By Hayley Thomson, Research and Policy Officer (Sonke Gender Justice Network, South Africa)

As HIV testing and treatment services become more widely available across the world, it is becoming apparent that fewer men than women are accessing them. For example, in South Africa, according to 2010-2011 data, men represented only 30 per cent of those who tested during a national, and widely publicized, HIV counselling and testing campaign. Despite this, very few efforts are made to specifically target men to increase their uptake of testing and treatment services. Some policymakers and service providers may feel that the only barrier to men accessing services is men themselves, and that it is more important to focus energy on providing services to women. While it is obviously necessary to ensure services are available to women, it is unhelpful to assume that there is nothing that can be done to encourage men to access testing and treatment services. We should also not overlook the fact that men’s access to HIV and SRH services benefits women. 

Men are shown from a young age that clinics and hospitals are female spaces – staffed by women and attended by women. From the onset of menstruation women are encouraged to prioritize their health, attend annual check-ups, go for pap smears, and so on. It is acceptable for girls and women to discuss such female health issues with their mothers and other female relatives and friends.  What do we do to encourage men and boys to prioritize their health?

To be considered a man, men are also taught from a young age that they need to be strong and in control. As South African President Jacob Zuma recently expressed in an interview when discussing his childhood, "You could not afford to be a coward or they would tell you that you have to cook like a girl, instead of eating the food that is cooked by the girls". Any behaviour that does not conform to this hegemonic notion of masculinity runs the risk of being labelled as unmanly, feminine, or even ‘gay’. Within our social hierarchy men have more power than women, but heterosexual men have more power than homosexual men, therefore in order to be accepted as a ‘real’ man, boys are conditioned to realize that any behaviour that could elicit the label of being ‘gay’ should be avoided. Going for medical check-ups, getting tested or seeking treatment, just doesn’t fit in with this masculine ideal – it seems weak, it involves asking for help, making oneself vulnerable, and therefore could be viewed as womanly. It is clear that men’s uptake of HIV and SRH services are a far more complex issue than a question of individual choice.

There is much that needs to, and can, be done to enable and encourage men to access SRH and HIV services. Interventions focussing on these issues have been shown to effectively increase men’s support for their partner’s SRH and improve the health of men, women and children. Sonke Gender Justice Network, along with their partners and other CSOs, worked hard to ensure that South Africa’s National Strategic Plan on HIV, STIs and TB 2012-2016 acknowledged the need to address men’s health-seeking behaviour and masculine gender norms [Available here]. Sonke, along with their MenEngage partners, also conduct policy advocacy work to address this issue throughout the region.

Download the full issue of the IPPF HIV Update newsletter: http://www.ippf.org/resource/HIV-Update-Engaging-men-and-boys