Linking sexual and reproductive health and HIV interventions: a systematic review

Kennedy et al. Journal of the International AIDS Society 2010, 13:26 http://www.jiasociety.org/content/13/1/26 RESEARCH Open Access Linking sexual and reproductive health and HIV interventions: a systematic review Caitlin E Kennedy1*, Alicen B Spaulding2, Deborah Bain Brickley3, Lucy Almers3, Joy Mirjahangir3, Laura Packel3, Gail E Kennedy3, Michael Mbizvo4, Lynn Collins5, Kevin Osborne6 Abstract Background: The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to both sexual and reproductive health (SRH) services and HIV/AIDS prevention, treatment, care and support. Recently, there has been increasing awareness and discussion of the possible benefits of linkages between SRH and HIV programmes at the policy, systems and service delivery levels. However, the evidence for the efficacy of these linkages has not been systematically assessed. Methods: We conducted a systematic review of the evidence for interventions linking SRH and HIV. Structured methods were employed for searching, screening and data extraction. Studies from 1990 to 2007 reporting prepost or multi-arm evaluation data from SRH-HIV linkage interventions were included. Study design rigour was scored on a nine-point scale. Unpublished programme reports were gathered as “promising practices”. Results: Of more than 50,000 citations identified, 185 studies were included in the review and 35 were analyzed. These studies had heterogeneous interventions, populations, objectives, study designs, rigour and measured outcomes. SRH-HIV linkage interventions were generally considered beneficial and feasible. The majority of studies showed improvements in all outcomes measured. While there were some mixed results, there were very few negative findings. Generally, positive effects were shown for key outcomes, including HIV incidence, sexually transmitted infection incidence, condom use, contraceptive use, uptake of HIV testing and quality of services. Promising practices (n = 23) tended to evaluate more recent and more comprehensive programmes. Factors promoting effective linkages included stakeholder involvement, capacity building, positive staff attitudes, nonstigmatizing services, and engagement of key populations. Conclusions: Existing evidence provides support for linkages, although significant gaps in the literature remain. Policy makers, programme managers and researchers should continue to advocate for, support, implement and rigorously evaluate SRH and HIV linkages at the policy, systems and service levels. Background The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to both sexual and reproductive health (SRH) services and HIV prevention, treatment, care and support [1]. Recently, there has been increasing awareness and discussion of the possible benefits of linkages between SRH and HIV programmes at the policy, systems and service delivery levels [2-5]. * Correspondence: 1 Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, USA Linkages between SRH and HIV-related policies and programmes may lead to a number of important public health, societal and health systems benefits [2]. Linkages are expected to improve coverage, access to and uptake of both SRH and HIV services for vulnerable and key populations (where HIV risk and vulnerability converge), including people living with HIV (PLHIV) [2]. Linking SRH and HIV interventions may lead to a reduction in HIV-related stigma and discrimination [2] by integrating HIV with other SRH services. Linkages may enhance programme effectiveness and efficiency [2] as redundancies in vertical programmes are eliminated and clients’ multiple needs are addressed in one setting [3]. © 2010 Kennedy et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kennedy et al. Journal of the International AIDS Society 2010, 13:26 http://www.jiasociety.org/content/13/1/26 These potential efficiencies and cost savings are particularly important in the context of a maturing global response to HIV that focuses less on emergency measures and more on ensuring long-term sustainability and integration of HIV programmes with other programmes and health systems. Linkages may improve access to family planning and other key SRH services for PLHIV, thereby reducing perinatal transmission with a costeffective component of prevention of mother to child transmission (PMTCT) [6,7] and ensuring access by PLHIV to SRH services tailored to their needs [8]. The international community has issued statements calling for commitment and action to increase linkages as a result of these and other expected benefits [4,5]. However, prior to this study, the evidence that linkages actually result in these benefits had not been systematically examined. Evidence for the benefits of SRH and HIV linkages is crucial to sound funding, programmatic and policy decisions. There have been several compilations of articles and reports related to SRH and HIV linkages. These include an inventory of documents and tools related to SRHHIV linkages [9] and a continuously updated website compiling full-text documents, tools, news reports and other resources [10]. Despite these resources, evidence in support of linkages has not been rigorously evaluated. This study presents the first systematic review and analysis of interventions linking SRH and HIV. Methods A supplementary file with a more detailed description of methods, including the list of search terms, is available online [11]. Definitions Linkages can occur at multiple levels. In order to capture all of these levels, the following definition of linkages was used: “the bi-directional synergies in policy, programmes, services and advocacy between SRH and HIV” [12]. To be included in the review, studies had to meet this definition by evaluating a linkage between an SRH intervention and an HIV intervention. HIV interventions were classified into five categories: (1) HIV prevention, education, and condoms; (2) HIV testing; (3) element 3 of PMTCT (prevention of vertical HIV transmission from a mother to her infant) [13]; (4) clinical care for PLHIV; and (5) psychosocial and other services for PLHIV. Interventions related to injection drug use would generally fall under categories 1 or 5. SRH interventions were also classified into five categories: (1) family planning; (2) maternal and child health care; (3) gender-based violence prevention and management; (4) sexually transmitted infection (STI) prevention and management; and (5) management of other SRH Page 2 of 10 issues, such as gynaecologic cancers, obstetric fistula and menopau (...truncated)