The ABCs of SRH
As a gender and HIV activist, getting the opportunity to attend the 26th UNAIDS Programme Coordinating Board (PCB) meeting in Geneva, Switzerland, as a female youth observer was very important for me.
Coming from Zimbabwe where HIV infection leans more towards women than men, I am always aware of the need for women and girl’s empowerment against oppressive gender norms if my nation is to ever overcome the epidemic which still stands towering above us at over 14% prevalence.
Prior to the two-day PCB meeting, and as part of the programme, I attended a thematic session on integrating sexual and reproductive health (SRH) and HIV services.
Quite honestly, I had never really thought of the intricacies of linking Sexual Reproductive Health (SRH) and HIV services, although I had always known about the importance of providing HIV testing and treatment services within antenatal care for pregnant women and girls.
At the thematic session, however, I learnt just how far back we are falling on this.
As Gottfried Hirnschall of the World Health Organization (WHO) shared, HIV is currently contributing to 19.2% of global maternal deaths in the 15-44 year age group. And TB is contributing a further 6.4%.
Imagine that.
TB and HIV – both manageable diseases, when early detection and treatment are available – are accounting for a quarter of the deaths of all pregnant women in the world.
And with southern Africa, my region of the world, being the area most affected by HIV, that means that even more women here are dying needlessly. National HIV statistics from all over the region consistently show that HIV prevalence among pregnant women who attend antenatal clinics is usually much higher than overall national figures.
It was therefore heartening to hear about some of the good work being done in the region to begin to address the urgent need for stronger integration of services.
Dudu Simelane of the Family Life Association of Swaziland gave a perspective from her country of the successes and opportunities for integration.
Her organisation is working with various development partners to provide youth-friendly SRH and HIV services that integrate interventions such as screening for STIs and TB, HIV tests, pap smears for cervical cancer, pre-and post abortion care, male circumcision, ART and the promotion of condoms for dual protection (that is, using condoms not only to prevent contracting HIV but also to prevent unwanted pregnancies).
What’s good about such sites is that they provide a broad range of services under one roof. And ultimately, this cuts down on a woman’s use of usually scarce resources such as money and time. So instead of spending two amounts of bus fare to first get to an HIV testing centre and then to the STI clinic where she’s been referred, a woman only spends one amount to get all the services she needs. This also saves her time for travel, which is also often a very practical barrier to a woman being able to access services.
But perhaps even more importantly, such integration helps to reduce stigma. As a visitor to one of the Swazi sites noted, “It’s not like other clinics where I have to go to the ART wing. I go to the same dispensary as everyone else to get my medicine.”
That sort of set-up does a world of good to fight stigma and discrimination. I have heard ghastly stories in Zimbabwe about how people who visit the opportunistic infections clinics of hospitals are set apart from other people receiving services and labeled imi vanhu veHIV (you people with HIV). Such treatment has serious influence on whether a person will continue to come to collect their medicine every month and can actually lead them to stop taking drugs completely, thereby building up drug resistances and damaging the immune system.
If you think stigma doesn’t kill, think again.
As Sofia Gruskin of the Harvard School of Public Health reminded us, one of the main obstacles to integration is stigma and discrimination. And sadly, this is usually perpetuated by the very workers in the health sector. Gruskin cited examples of the prejudice of healthcare workers in many parts of the world who refuse to offer contraceptives and STI services to unmarried women (who in the eyes of the workers should not be having sex in the first place). And on the flip side of the coin, there are health workers who will not give a married woman contraceptives in the belief that she should be having as many children as possible.
In its most extreme manifestation, stigma and discrimination has seen healthcare workers sterilisng HIV positive women, after childbirth, to ensure that they do not have the option to have any more children.
Also, what’s been found at the sites in Swaziland is that there has been increased male involvement through the provision of male circumcision (MC) as an entry point. Studies have already shown that MC has high efficacy rates of around 60% when it comes to HIV prevention (if practised with correct and consistent condom use) and providing it in such a setting seems like a good way of ensuring that men don’t shy away from being seen with their partners at sites which they would ordinarily think of as places for women.
Morolake Odetoyinbo of Nigeria’s Positive Action for Treatment Access pointed out how culture and socialisation leads to the detachment of men from SRH issues by always teaching girls about SRH and not doing the same for boys. In many African cultures, it is acknowledged that a woman’s virginity is the greatest prize that she can ever give a man. And also, it is commonly emphasised that her role within sexual intercourse is solely to please her man. To this effect, women in some Zimbabwean cultures are instructed to pull on their vaginal labia from an early age so that these lips protrude. Apparently, this has an effect on sensation and stimulation for a man during sex.
But nothing is without its challenges. As Simelane pointed out, healthcare providers can become overwhelmed by demand for the integrated services, seeing more patients than usual. Also, there tends to be increased client waiting time due to provision of HIV counselling and testing which is a time-consuming process.
For such service integration to be successful, there is need for a range of competencies, including capacity building as well as the fostering of strong partnerships with national and international organisations that may be able to provide staff on secondment or funds towards integration.
And a word of warning.
Integration doesn’t necessarily mean cost saving. In order to be effective, it requires a lot of investment and patience. It takes time to change perceptions and attitudes. Donors need to be aware of this and should not expect radical results within a short amount of time.
And you can’t put all expectations of success on the donor’s shoulders either.
A comprehensive country response to SRH and HIV integration will require the cooperation of civil society, government and the private sector with overall leadership and coordination by the national AIDS authority. National HIV plans will need to be better linked with national SRH plans. Funding streams will need to stop supporting vertical structures.
So how can all of this work in the real world?
The most important thing is for healthcare workers to stop moralising and stigmatising patients. Rigorous training and monitoring is required. Journalists and the media should be mobilised to write articles on the matter so that the general public can know when they are receiving sub-standard services. A healthcare worker’s role is to provide quality service – and not an opinion.
Secondly, I believe that current upscale of MC in Africa provides an immense opportunity for SRH and HIV integration. Rather than set up stand alone MC sites that drain resources in terms of infrastructural development and staff recruitment, let’s look at integrating them into pre-existing sites. Also, when we finally develop an effective HIV-preventing microbicide, this must be accessible in terms of cost, as well as available as part of a holistic range of sexual and reproductive health services. In other words, I should be able to get my microbicides at my local clinic, and not at some high-tech lab.
And let’s make sure that everyone who needs to get HIV services can do so. Antenatal care coverage in Africa is still too low. In fact, some women still don’t know about it. Let’s take the information and the services to the people and build the capacity of community-based initiatives.
But most importantly, let’s remember that sexual and reproductive health rights are human rights. No, they aren’t a passing fad or the latest NGO buzz. When implemented, they represent human lives saved and money well spent.