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

Jeffrey Sturchio

Integrating reproductive and sexual health services with HIV prevention is essential to ending the AIDS epidemic. Yet US policies continue to hamper effective strategies.

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

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.

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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

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


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