Investing in sexual and reproductive health and rights of women and girls to reach HIV and UHC goals
Authors: Manjulaa Narasimhan, Yogan Pillay, Patricia J García, Pascale Allotey, Robin Gorna, Alice Welbourn, Michelle Remme, Ian Askew, Anders Nordström, Bernard Haufiku
Journal: The Lancet Global Health (2018)

Each year, 200 million women have an unmet need for modern contraception, more than 45 million women receive inadequate or no antenatal care, 1 million women and girls acquire HIV, and 25 million abortions are unsafe.1Every Woman Every ChildThe global strategy for women's, children's and adolescents' health (2016–2030). Every Woman Every Child, New York2015http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdfDate accessed: June 6, 2018Google Scholar, 2UNAIDSFact sheet: latest global and regional statistics on the status of the AIDS epidemic.http://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdfDate: Nov 20, 2017Date accessed: June 11, 2018Google Scholar These numbers illustrate huge gaps in access to basic sexual and reproductive health services, posing serious challenges to achieving universal health coverage (UHC) by 2030. These gaps in access are heightened by reduced financing for international development, and highlight the importance and urgency of strengthening linkages between HIV and sexual and reproductive health and rights (SRHR) programmes. The Guttmacher–Lancet Commission3Starrs AM Ezeh AC Barker G et al.Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission.Lancet. 2018; 391: 2642-2692Summary Full Text Full Text PDF PubMed Scopus (319) Google Scholar on SRHR highlights the need for all women and girls to be able to access an integrated package of SRHR interventions, which includes HIV prevention, treatment, and care. Although this integrated approach has been promoted for two decades and was the cornerstone of national AIDS responses in the 1980s, the progress since then to move national health systems from vertical programmes to more integrated HIV and SRHR policies, financing, and service delivery, has been insufficient.4Warren CE Hopkins J Narasimhan M Collins L Askew I Mayhew SH Health systems and the SDGs: lessons from a joint HIV and sexual and reproductive health and rights response.Health Policy Plan. 2017; 32: iv102-iv107Crossref PubMed Scopus (14) Google Scholar Supporting countries to implement strategies that enable UHC, including sustainable approaches to advance universal access to integrated sexual and reproductive health and HIV services, must be a priority for the global health community. Three key strategies are required to address multiple SRHR and HIV needs, improve access to essential health services, and ensure financial protection so no woman or girl is left behind. The first key strategy involves engaging, empowering, and building individual, community, and collective capacities among women and girls. These capacities must build upon the knowledge and lived experiences of women and girls,5WHOConsolidated guideline on sexual and reproductive health and rights of women living with HIV. World Health Organization, 2017http://apps.who.int/iris/bitstream/handle/10665/254885/9789241549998-eng.pdf;jsessionid=AB427306E0F41CB95A52F4CE0F531F9F?sequence=1Date accessed: June 5, 2018Google Scholar and should include initiatives to promote, support, and safeguard community engagement. To design and implement both effective and acceptable sexual and reproductive health interventions, community norms arising from women's lived realities and expressed priorities need to be understood. Patriarchal norms that prevent good sexual and reproductive health—such as non-consensual, age-disparate sexual relationships, violence against women, and disregard for women's rights—need to be addressed. Woman-centred interventions are possible through education and empowerment, to equalise power dynamics in intimate, family, community, and health-care relationships.6Jewkes R What works evidence review: social norms and violence against women and girls. What Works to Prevent Violence.https://static1.squarespace.com/static/5656cae6e4b00f188f3228ee/t/59e44dfa29f187ab4cdbd147/1508134401059/Social+norms+Evidence+Brief_2+Oct.pdfGoogle Scholar WHO recommends the provision of evidence-based interventions on self-efficacy, and empowerment for maximising and fulfilling the SRHR of women and girls, including women living with HIV, in all their diversity.5WHOConsolidated guideline on sexual and reproductive health and rights of women living with HIV. World Health Organization, 2017http://apps.who.int/iris/bitstream/handle/10665/254885/9789241549998-eng.pdf;jsessionid=AB427306E0F41CB95A52F4CE0F531F9F?sequence=1Date accessed: June 5, 2018Google Scholar These interventions are crucial to reduce stigma, disrespect, violence, and lack of safety faced by many women and girls within and outside the health-care sector.1Every Woman Every ChildThe global strategy for women's, children's and adolescents' health (2016–2030). Every Woman Every Child, New York2015http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdfDate accessed: June 6, 2018Google Scholar The second key strategy involves securing accountable leadership, governance, and financing from governments and international agencies. Annually, 100 million people face extreme poverty due to health-care costs.7WHOUNAIDSUNFPAUNICEFUN WomenThe World Bank GroupSurvive, thrive, transform. Global strategy for women's, children's and adolescents' health: 2018 report on progress towards 2030 targets.http://www.everywomaneverychild.org/wp-content/uploads/2018/05/EWECGSMonitoringReport2018.pdfDate accessed: June 11, 2018Google Scholar Although the share of out-of-pocket expenditures has been decreasing overall, households remain the main source of funding for reproductive, maternal, neonatal, and child health, and pay for about half of these expenditures in some low-income and middle-income countries.7WHOUNAIDSUNFPAUNICEFUN WomenThe World Bank GroupSurvive, thrive, transform. Global strategy for women's, children's and adolescents' health: 2018 report on progress towards 2030 targets.http://www.everywomaneverychild.org/wp-content/uploads/2018/05/EWECGSMonitoringReport2018.pdfDate accessed: June 11, 2018Google Scholar, 8Lie GS Soucat AL Basu S Financing women's, children's, and adolescents' health.BMJ. 2015; 351: h4267Crossref PubMed Scopus (5) Google Scholar High health-care need in socioeconomically disadvantaged women and girls is often inversely related to their access to financial resources. Thus, public financing of integrated SRH and HIV services is vital so that they are accessible at the point of delivery.1Every Woman Every ChildThe global strategy for women's, children's and adolescents' health (2016–2030). Every Woman Every Child, New York2015http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdfDate accessed: June 6, 2018Google Scholar It is entirely feasible to use national and global financing mechanisms to reorient existing, vertical health systems and services to implement comprehensive, integrated, user-centred SRHR and HIV programmes.1Every Woman Every ChildThe global strategy for women's, children's and adolescents' health (2016–2030). Every Woman Every Child, New York2015http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdfDate accessed: June 6, 2018Google Scholar, 4Warren CE Hopkins J Narasimhan M Collins L Askew I Mayhew SH Health systems and the SDGs: lessons from a joint HIV and sexual and reproductive health and rights response.Health Policy Plan. 2017; 32: iv102-iv107Crossref PubMed Scopus (14) Google Scholar To date, fragmented evaluation and minimal accountability of integrated SRHR and HIV approaches have resulted in scarce evidence on the health, economic, and social benefits arising from these linkages.4Warren CE Hopkins J Narasimhan M Collins L Askew I Mayhew SH Health systems and the SDGs: lessons from a joint HIV and sexual and reproductive health and rights response.Health Policy Plan. 2017; 32: iv102-iv107Crossref PubMed Scopus (14) Google Scholar Investments are needed in implementation research, particularly to understand and inform the scaling up of evidence-informed, multisectoral approaches that have proven effective in small-scale pilots. This research can assist in the implementation of health service delivery that promotes and supports principles of gender equality, human rights, and woman-centred care. The final key strategy involves coordination of coherent actions within and across sectors. Integration of HIV interventions within existing sexual and reproductive health services can improve both access and efficiency for family planning and maternal and newborn care, and within education, social development, and community welfare sectors.9Kennedy CE Spaulding AB Brickley D et al.Linking sexual and reproductive health and HIV interventions: a systematic review.J Int AIDS Soc. 2010; 13: 26Crossref PubMed Scopus (89) Google Scholar For example, HIV testing services could be provided together with contraceptives, intimate partner violence screening, and cervical cancer screening services.6Jewkes R What works evidence review: social norms and violence against women and girls. What Works to Prevent Violence.https://static1.squarespace.com/static/5656cae6e4b00f188f3228ee/t/59e44dfa29f187ab4cdbd147/1508134401059/Social+norms+Evidence+Brief_2+Oct.pdfGoogle Scholar, 9Kennedy CE Spaulding AB Brickley D et al.Linking sexual and reproductive health and HIV interventions: a systematic review.J Int AIDS Soc. 2010; 13: 26Crossref PubMed Scopus (89) Google Scholar, 10Haberlen SA Narasimhan M Beres LK Kennedy CE Integration of family planning services into HIV care and treatment services: a systematic review.Stud Fam Plann. 2017; 48: 153-177Crossref PubMed Scopus (43) Google Scholar Policy decisions are needed in all the sectors listed here, to fulfil the rights of women and girls to voluntary, confidential, and informed choices about their bodily autonomy (appendix). These policy decisions will require approaches based on gender and human rights for successful implementation, and should consider personal autonomy in decision making, informed consent, respect of privacy and confidentiality, freedom from violence, abuse, and coercive practices, and meaningful engagement with women and girls living with and vulnerable to HIV. Advancing UHC through integration of SRHR and HIV links the strategies of the Sustainable Development Goals and the specific focus on leaving no one behind. The aim is to ensure that the lives, health, rights, and wellbeing of women and girls are improved. Now is the time to redefine the development agenda for the next 10 years. This Comment is based on discussions at the Wilton Park Consultation "The importance of sexual and reproductive health and rights (SRHR) to reach HIV fast-track goals and Universal Health Coverage for women and girls" on Oct 25–27, 2017. The participants at the Consultation include Adenike Esiet, David Wilson, Rob Yates, Michalina Drejza, Martha Brady, Jillian Gideon, Jeanette Afounde, Matt Jackson, Montasser Kamal, Mukesh Kapila, Carmen Barroso, Nithya Mani, Dayo Adeyanju, Izeduwa Derex-Briggs, Tyler Crone, Elly Leemhuis, Sofia Gruskin, Kathleen Costigan, Miles Kemplay, Mike Mbizvo, Rosemary Ellis, Yuhsin Huang, Maureen Kangere, Rachael Hinton, Alankar Malviya, Jon Hopkins, Divya Bajpai, Christopher Castle, Siobhan Malone, Sten Vermund, and Charles Chauvel. We declare no competing interests. We thank the participants in the Consultation for sharing their time and expertise. Special thanks also to Tim Sladden for providing feedback. Financial support for the consultation from the Special Programme for Human Reproduction funded by the United Nations Development Programme, United Nations Population Fund, UNICEF, WHO, and World Bank is gratefully acknowledged. The contents are the responsibility of the authors and do not necessarily reflect the views of the World Health Organization. Download .pdf (.7 MB) Help with pdf files Supplementary appendix Time to realise our sexual and reproductive health and rightsAs women living with HIV who were involved in a global values and preferences survey on the sexual and reproductive health and rights (SRHR) priorities of women living with HIV, we welcome the Comment by Manjulaa Narasimhan and colleagues.1 Our survey, Building a Safe House on Firm Ground (2015),2 commissioned by WHO, was led and designed by a diverse group of women living with HIV to inform the WHO 2017 Consolidated Guideline on the SRHR of women living with HIV.3 Our survey aligns with the key points highlighted in the Comment. Full-Text PDF Open Access