The importance of linking sexual and reproductive health and HIV

The importance of linking sexual and reproductive health (SRH) and HIV is widely recognized.
The international community agrees that the Millennium Development Goals will not be achieved without
ensuring universal access to SRH and HIV prevention, treatment, care and support. In order to gain a
clearer understanding of the effectiveness, optimal circumstances, and best practices for strengthening
SRH and HIV linkages, a systematic review of the literature was conducted. The findings corroborate the
many benefits gained from linking SRH and HIV policies, systems and services।
Despite diverse settings and clients, the majority of studies
showed improvements in all outcomes measured, and only a
few showed mixed results. Many studies reported an increase
or improvement in:
access to and uptake of services, including HIV testing
health and behavioural outcomes
condom use
HIV and sexually transmitted infection (STI) knowledge
overall quality of service
2) Linking SRH and HIV was considered beneficial and feasible,
especially in family planning (FP) clinics, HIV counselling and
testing centres (C&T), and HIV clinics.
3) Of the 58 studies analysed, more were conducted between
2000–2007 (65%) than 1990–1999 (35%). This trend was
primarily seen in the promising practices; however, this may
be due to publication bias as older, unpublished reports may
no longer be available.
4) There was a slight time trend in directionality of linkages.
Earlier studies were more often SRH programmes adding
HIV services, while later studies were more often HIV
programmes adding SRH services.
5) Preliminary analysis of both cost-effectiveness studies
suggested net savings from HIV/STI prevention integrated
into maternal and child health services.
6) Nearly three quarters (71%) of peer-reviewed studies
evaluated programmes with only one type of linkage. In
contrast, over half (57%) of promising practices evaluated
programmes with five or more linkages, while just 9% had
only one type of linkage. This difference may be due to more
recent programmes linking SRH and HIV services more
comprehensively, or the fact that peer-reviewed studies
were often designed to address narrow research questions.
7) Of the few studies reporting cost outcomes, all were
conducted after 2000. This positive trend may indicate an
intent to scale up linked services.
8) Studies reporting health outcomes were evenly
distributed across time.
9) Interventions which successfully implemented provider
training resulted in improved provider knowledge and
attitudes, leading
to better SRH and HIV service provision.
10) Notably, few or no studies addressed the following:
Linked services targeting men and boys
Gender-based violence (GBV) prevention
Stigma and discrimination
Comprehensive SRH services for PLHIV, including
addressing unintended pregnancies and planning for
safe, desired pregnancies.
11) More attention needs to be paid to commodity security, in
particular contraceptives।
Executive Summary
In 2007, UNESCO commissioned this desk-based review of the global state of sex and HIV education in the formal
education sector in order to inform its possible future work in this area. The review is based on twenty-two key
informant interviews with experts from Africa, Europe and North and South America, together with searches of
published and grey literature obtained from the internet, databases and personal recommendation, as well as
manual searching of key journals. Consistent with the Terms of Reference (Annex 1), the focus of the review is
upon sex, relationships and HIV education programmes within the context of poorer countries, particularly those in
sub-Saharan Africa.
A draft of this review was presented to the UNESCO Global Advisory Group on Sex, Relationships and HIV
Education1 at its fi rst meeting in Paris in December 2007. Members’ comments have been incorporated in this
revised version.
A basic challenge encountered in conducting this review has been the wide range of terms used to describe the
educational activities, methodologies and processes that constitute sex, relationships and HIV education in schools.
For the sake of clarity and simplicity, following consideration by its Global Advisory Group on Sex, Relationships and
HIV Education, UNESCO has decided to use the term sex, relationships and HIV education.
Throughout the world, too few young women and men, including those who are living with HIV, receive anything
approaching adequate preparation for adult sexual life. In many HIV and AIDS curricula, discussion of sex is simply
avoided or else the focus is placed, often exclusively, upon the potential negative consequences of sex. The positive
values of sexual life, such as pleasure and reciprocity, are conspicuous in their absence, despite their healthpromoting
potential.
Schools provide a viable means of reaching large numbers of young people with sex and HIV education in ways that
are replicable and sustainable, and given their number and proximity to students, teachers are best placed to deliver
sex education. Peer educators can also provide useful support. With signifi cantly more children attending primary
than secondary school, it seems appropriate that the subject should be introduced at this level. However, space
needs to be made in already crowded curricula and teachers need to be given the skills, materials and confi dence
to undertake teaching on this topic.
Barriers to the effective implementation of sex, relationships and HIV education in schools include inadequate
resources and community opposition as well as authoritarian and didactic approaches on the part of teachers. In
some settings, pervasive gender bias, sexual coercion and abuse conspire to render school itself a risky environment,
especially for girls. Tackling this issue requires resources and commitment that go beyond the scope of what
is possible within classroom-based sex and HIV education programmes.
Negative outcomes associated with sexual behaviour are the result of both risk (at the personal level) and vulnerability
(the socio-economic and cultural factors that put people at risk in the fi rst place). While sex, relationships
and HIV education can reduce risk, broader action is required over the longer term to tackle underlying issues of
vulnerability.
A range of approaches to sex, relationships and HIV education currently exist. These vary from those that seek to
eliminate risk altogether (‘abstinence-only’ approaches), through to those that seek to reduce risk (for example, by
encouraging delay of sexual debut or condom use) to those (far fewer in number) that seek to reduce vulnerability
by addressing underlying factors that contribute to sexual ill-health, such as poverty and gender inequality, abuse
and violence.
Whatever the approach, it is generally accepted that effective sex education curricula include consideration of facts
and information, interpersonal skills, as well as values and exploration of perceptions of peer norms, attitudes and