SRH and HIV/AIDS Linkages at Policies, Programmes and Service ...

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Edited byWasim ZamanHairudin Masnin

Table ofContentChapter Titles PagesAcknowledgmentiiIntroductioniii- Review of linkages v (a) - v (b)- Roundtable meeting on linkages vi (a) - vi (j)Case Studies inChapter 1 BANGLADESH 1-40Case Studies inChapter 2 CAMBODIA 41-64Case Studies inChapter 3 NEPAL 65-94Case Studies inChapter 4 PHILIPPINES 95-113ⅰ

AcknowledgementThis publication is a summary of follow-up activities implemented in selected Asiancountries on Linkages of HIV/AIDS and RTI/STIs Prevention with SRHR held duringthe 5th Asia Pacific Conference on Sexual and Reproductive Health and Rights (17-20October 2009) in Beijing. The Symposium was jointly organized by the InternationalCouncil on Management of Population Programmes (ICOMP), the Joint United NationsProgramme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO).We are grateful to Dr Tarannum Dana, Assistant Professor, Department of PopulationSciences, University Of Dhaka, Bangladesh; Mr Somareth Sovannarith, Deputy Director,National Centre for AIDS, Dermatology and STD Control, Cambodia; Professor Dr OfeliaPardo Saniel, Chair, Department of Epidemiology and Biostatistics, College of PublicHealth, UP Manila, Philippines; and Dr Laxmi Narayan Thakur, Freelance Consultant,Nepal for their contributions.We gratefully acknowledge the inputs of: Dr. Nafis Sadik, Special Advisor to the UNSecretary General, and Special Envoy on HIV/AIDS in Asia; Mr J V Prasada Rao, (former)UNAIDS Regional Support Team for Asia and the Pacific; (Dr Michel Mbizvo, Director,WHO Department of Reproductive Health and Research; (Dr Wasim Zaman, ExecutiveDirector, International Council on Management of Population Director (ICOMP); DrWarunee Fongkaew, Associate Professor, Youth Family and Community Development(YFCD), Chiang Mai University; and Ms Mary Frances Ratnam.We would also like to thank the participants who attended the Roundtable Meetingheld in Phnom Penh, Cambodia on 7-8 February 2011.Acknowledgementⅱ

INTRODUCTIONThe 2009 AIDS Epidemic Update Report by the Joint United Nations Programmeon HIV/AIDS (UNAIDS) and the World Health Organization (WHO) shows that theepidemic is stabilizing but at “unacceptably high levels.” Globally, an estimated 33.4million people are living with HIV in 2008, with the annual number of new HIVinfections declining from 3 million in 2001 to 2.7 million in 2008. Although the rateof new HIV infections has declined in several countries, the favourable effect of thistrend is partially offset by the increasing new infections in other countries.The Report of the Commission on AIDS in Asia for 2008 indicates that the percentageof HIV positive women has risen from 19% in 2000 to 24% in 2007. The feminizationof the AIDS epidemic with an increasing rate of HIV prevalence amongst womenand girls is a growing concern. Figures from UNAIDS show that the risk of infectionis increasing for women everywhere and the virus is spreading fastest among youngwomen below the age of 24--women who are at the peak of fertility. In Asia, wherethe virus is spreading rampantly through heterosexual intercourse, infected youngwomen are gaining in number.The extremely high rates of HIV infection amongst women of childbearing age in someparts of the world, particularly with regard to mother-to-child transmission (MTCT) is ofgreat concern. MTCT is by far, one of the largest sources of HIV infection in childrenbelow the age of 15.Despite policy support and operational frameworks, the programmatic actions to linkor integrate reproductive health and HIV/AIDS have lagged behind because of barriersat policy, programme and service delivery and community levels.With support from UNAIDS and WHO, ICOMP has brought together an audience ofkey players from governments, non-governmental organizations (NGOs) and otherstakeholders in Asia-Pacific and Sub-Saharan Africa in a Symposium on Linkages of HIV/AIDS and RTI/STIs Prevention with SRHR held during the 5 th Asia Pacific Conference onSexual and Reproductive Health and Rights (17-20 October 2009). Five sub-themeswithin Track 4 of the conference promote and reinforce the linked approach message,touching on issues that have the highest impact to stem the epidemic in Asia and thePacific.A panel of speakers deliberated on issues and areas that bear the greatest relevanceto support linkages of HIV/AIDS and RTI/STIs prevention with SRHR. The symposiumwas chaired by Dr. Nafis Sadik, Special Advisor to the UN Secretary General, andSpecial Envoy on HIV/AIDS in Asia. The speakers were (i) Mr J V Prasada Rao, UNAIDSRegional Support Team for Asia and the Pacific; (ii) Dr Michel Mbizvo, Director, WHODepartment of Reproductive Health and Research; (iii) Dr Wasim Zaman, ExecutiveIntroductionⅲ

Director, International Council on Management of Population Director (ICOMP); andthe discussant was Dr Warunee Fongkaew, Associate Professor, Youth Family andCommunity Development (YFCD), Chiang Mai University.Symposium 4 focused on gender issues, the role of men particularly due to thefeminisation of HIV/AIDS, increasing concerns on intimate partner transmission,mother-to-child transmission (MTCT) as well as working with young boys and girls inHIV prevention.Given the importance of the issues, the Symposium had attracted a large audience(the venue was fully packed with approximately 400 participants). Among theparticipants were government officials, representatives of UN agencies, representativesof international and national NGOs and a broad cross-section of other conferenceparticipants from Asia and the Pacific, Africa, and Latin America and the Caribbeanwho shared their experiences to support and guide policy and programmes work inAsia and the Pacific.A follow-up to the Symposium and in order to institutionalize the linkages betweenreproductive health and HIV/AIDS at country level, taking into consideration the UNAIDSAction Framework: Addressing Women, Girls, Gender Equality and HIV (UNAIDS ActionFramework), ICOMP conducted the following activities:i. Review of policies, programmes and service delivery to identify the current statusof linkages between reproductive health and HIV/AIDS in Bangladesh, Cambodia,Nepal and Philippines; andii. Roundtable Meeting on Linkages between Sexual and Reproductive Health and HIV/AIDS to review the findings of case studies and develop a framework of action toinstitutionalize reproductive health and HIV/AIDS linkages at all levels.Introductionⅳ

REVIEW OF LINKAGES BETWEEN SEXUAL ANDREPRODUCTIVE HEALTH AND HIV/AIDS IN POLICY,SYSTEMS AND SERVICE DELIVERY IN SELECTED ASIANCOUNTRIESThe study which was conducted in Bangladesh, Cambodia, Nepal and the Philippinesexplores the policy, system and service delivery issues and challenges affecting the bidirectionallinkages of sexual and reproductive health and rights (SRHR) programmes,with policy and programmes for HIV prevention, treatment, care and support. It isintended to identify gaps and ultimately contribute to the development of countryspecificaction plans to forge and strengthen these linkages.The study questions were based on the following:• What is the level and effectiveness of linkages between SRH and HIV related policies,national laws, operational plans and guidelines?• To what extent do systems support effective linkages between SRH and HIV?• To what extent are HIV services integrated into SRH services and SRH servicesintegrated into HIV services?The study used the following methodologies:• Review of SRH and HIV related policies (such as national HIV strategic plan,reproductive health policy, etc), operational plans and guidelines (such as HIVcounseling and testing guide, anti-retroviral treatment protocol, PMTCT guideline,etc);• Interviews with relevant policy makers, head of programme, development partnersand donors. In addition, the study will also interview service providers.All information for this study was collected throughstandard questionnaire adapted from the RapidAssessment Tool for Sexual and ReproductiveHealth and HIV Linkages (IPPF, UNFPA, WHO,UNAIDS, GNP+, ICW and Young Positives). Theobjectives of the Rapid Assessment Tool are toenable countries to assess current national SRH& HIV linkages, identify gaps and contribute to thedevelopment of country-specific action plans. It isbased on a set of principles, including: addressingstructural determinants; focusing on human rightsand gender; promoting a coordinated and coherentresponse; meaningfully involving people living withHIV (PLHIV); fostering community participation;Introductionⅴ (a)

educing stigma and discrimination; and recognizing the centrality of sexuality.Based on a review of literature, key informant interviews and policy and programmeanalyses, this report summarizes major issues to developing linkages and discussespossible strategies and opportunities for engagement and strengthening linkages.There are three major sections of the findings:• Policy – The level and effectiveness of linkages between sexual and reproductivehealth and rights and HIV-related policies, national laws, operational plans andguidelines;• Systems – The extent to which the systems support effective linkages of SRH andHIV with respect to planning, management and administration; staffing, humanresources and capacity development; logistics and supplies; laboratory support; andmonitoring and evaluation; and• Service delivery – The extent to which HIV services are integrated into SRH servicesand likewise, the extent to which SRH services are integrated into HIV services.Four consultants were identified to carry out the review in the selected countries asfollows:• Bangladesh: Ms Tarannum Dana, Assistant Professor, Department of PopulationSciences, University Of Dhaka, Bangladesh• Cambodia: Mr Somareth Sovannarith, Deputy Director, National Centre for AIDS,Dermatology and STD Control, Cambodia• Nepal: Dr Laxmi Narayan Thakur, Freelance Consultant, Nepal• Philippines: Dr Ofelia Pardo Saniel, Chair, Department of Epidemiology andBiostatistics, College of Public Health, UP Manila, the PhilippinesSummary of the FindingsIn general, the study found:• Policy – There is lack of bi-directional linkages between sexual and reproductivehealth and rights and HIV/AIDS in the policies, national laws, operational plans andguidelines.• Systems – Effective linkages of SRH and HIV with respect to planning, managementand administration; staffing, human resources and capacity development; logisticsand supplies; laboratory support; and monitoring and evaluation are limited.• Service delivery – Functional integration of SRH and HIV services has occurred onlyat the primary level service delivery of government and NGOs.Introductionv ⅳ(b)

ROUNDTABLE MEETING ON LINKAGES BETWEENSEXUAL AND REPRODUCTIVE HEALTH AND HIV/AIDS(7-8 FEBRUARY 2011, PHNOM PENH, CAMBODIA)A Roundtable Meeting on the Linkages between Sexual and Reproductive Health andHIV/AIDS was held from 7-8 February 2011 in Phnom Penh, Cambodia. The purposeof the roundtable meeting was to review the findings of recently conducted countrycase studies and develop a plan of action to institutionalize reproductive health andHIV/AIDS linkages at all levels.The meeting was attended by sixteen participants representing government agencies,international and national non-governmental organisations from Cambodia, Nepal andPhilippines. Participants from Bangladesh had to cancel their participation at a verylast minute due to constraints in obtaining travel document and visa. Governmentofficials from Philippines did not also participate in the roundtable meeting due to priorcommitments.The report will outline highlights from each session in line with the agenda as well aspresent key issues raised during discussions. Key points from country presentation willbe raised as well as the main points from government counterparts when commentswere provided.Session 1: Scaling Up SRHR and HIV/AIDS Linkages towards MDGsThe objective of this session was to appreciate common strategies that can achieveresults on universal access targets and Millennium Development Goals.Mr Hairudin Masnin, Programme Officer of ICOMPThe presentation highlighted the calls for SRHR and HIV linkages through a series of keyinternational commitments including Glion Call to Action (2004), Political Declarationon HIV/AIDS (2006), Maputo Plan of Action (2006) and Guilin Framework (2007).These commitments are expected to intensify the linkages between SRH and HIV/AIDS and recognize the need to consider the sexual and reproductive health andrights (SRHR), needs, and desires of people living with HIV. However, the importantglobal mandates have not translated into the political will needed to accelerate actionand scale up RH/HIV integration in the countries and communities that need it most.At the same time, linkages between RH and HIV at the policy level, which addresshuman rights and other structural issues, lag far behind the need. In particular, whileacknowledging the benefits of RH/ HIV integration, few donors or funding mechanismshave adapted their remits or application processes to proactively attract and resourceprogramme integration and linkages.Introduction ⅵ (a)

Discussions• Linked response strategies are very much related to country’s HIV epidemiologicalstatus, resources, health systems, etc. Linked response also faced challenges,especially in resource poor settings. To overcome these challenges, programmesshould be able to priorities the needs of the population. Every citizen has anequal right to access quality of health, in which can be improved through linkages.Attention should be given to improve access among the vulnerable and marginalizedpopulations.• Question on whether intensifying SRHR and HIV linkages will jeopardize otherhealth programmes such as maternal and child health was raised. This issue canbe minimized if the policy makers and programme planners have a clear vision andcan understand that health is human rights. Linked response will complement otherhealth services.Session 2: Institutional Capacity for HIV/AIDS and SRHR LinkagesThe objective of this session was to present the review on the policies, systems andservice delivery and challenges affecting the bi-directional linkages of SRHR and HIV/AIDSDr Lakshmi Narayan Thakur, Freelance Consultant, NepalNepal has both the national HIV policy (1995) and national HIV strategy (2006-11).Both HIV policy of 1995 and strategy are under the process of revision. Similarly thereis a national SRH strategy (1998) in line with the ICPD programme of action. Thisstrategy was revised in 2006 but the revised strategy which added gender basedviolence could not be endorsed by MOHP. The National RH Strategy (1998) hasidentified HIV as one of the eight components of SRH. Linkages has been made intothe National Safe Motherhood and New borne Health – Long Term Plan (2006-2017)chapters including STI , PMTCT and ART and VCT has been included in the differentnational RH medical standards and protocols. However, there is no systematicapproach to linking SRH and HIV at policy and system level, and national guideline forSRH and HIV linkages at service delivery is also not available.❁ ❁ ❁HIV and SRH programming still remains largely vertical. Thepolicies and strategies, protocols, Medical standards/SOPs,guidelines are developed at different point of time hinderinglinkages between two programmes.❁ ❁ ❁Introduction ⅵ (b)

Mr Roberto M Ador, Executive Director, Family Planning Organization of thePhilippinesLinkages between HIV and SRH have only been recently introduced. HIV-relatedstrategies are now included in the proposed bills on reproductive health. Conversely,reproductive health-related measures are included in HIV strategies. All of these bills callfor the integration of HIV-related services as part of the SRH program. All elements ofRH, including AIDS/HIV, are covered in the bills, which are still pending in for approval.At present, there is no solid strategy for advocacy leading to the integration of SRH andHIV. Bi-directional provisions of RH and HIV/AIDS have yet to be re-oriented; protocolsand guidelines for integration have yet to be developed.❁ ❁ ❁The advocacy efforts to pressure Congress to pass the RHrelatedbills should be further strengthened. There should bemuch broader support from various sectors of the society❁ ❁ ❁Dr Sovannarith Samreth, National Center for HIV/AIDS, Dermatology and STD(NCHADS)There is no separate policy that addresses SRH and HIV/AIDS linkages in Cambodia.Linkages are addressed in the [1] Standard Operating Protocol for Linked Responsefor Prevention, Care and Treatment of HIV/AIDS and SRH; [2] National Guidelines forPMTCT; [3] Joint NCHADS-NCMCH statement on the implementation of PMTCT; and[4] National Policy and Strategy for STI/RTI Prevention and Care. Both SRH and HIVservices are integrated into the public health service delivery in hospitals and healthcenters. Although there is no specific policy on SRH and HIV/AIDS linkages, the linkagesare implemented through coordination mechanism at district level. There is alsocommitment to make birth spacing available for PLHIV and EW at OI/ART service andSTI clinic. In order to ensure effectiveness and efficiency of linked response services,there is a need for staff training, revised training curriculum that include linkages ofSRH and HIV, and materials on linkages.Introduction ⅵ (c)

Model of Linked Response Service Provision in CambodiaDiscussion• The issue of involving most at risk persons (MARPS) and people living with HIV(PLHIV) arose in the discussions. In Nepal, the government officials mentionedthat collaboration with PLHIV is very limited as the role of PLHIV in the planningprocess is unclear. PLHIV organisations are very outspoken and always critical to thegovernment policies and programmes. PLHIV organisations are perceived to bemore interested on the monetary benefits.• Cambodia has established an effective mechanism to address the coordinationissue at all levels, where working groups were established with clear roles andresponsibilities. These coordinating committee and working groups meet regularly.In addition, private sectors and NGOs are required to work together and support thegovernment policies.• In the Philippines, self-organized groups were established at local level. Thesegroups will mobilize support from the provincial and national level governments. Itis important for these groups to start at from bottom and start to pressure the localand national government for better health services.• It is important to involve both the PLHIV and their partners together. The PLHIVgroups can help to improve the provision of services at health facilities and withinthe communities by strengthening their support and link all their activities to healthservices.Introduction ⅵ (d)

Session 3: Health Systems Strengthening for SRHR and HIV/AIDS LinkagesThe objective of this session was to share experiences in improving government anddonor co-ordination to strengthen health system, policies and plansDr Krishna Kumar Rai, Director, National Centre for AIDS and STDs Control,NepalDr Rai described the structural linkages between National Centre for AIDS and STDsControl (NCASC) with other agencies under the Ministry of Health and Population.NCASC is linked with the Department of Health Services, Reproductive HealthDepartment and also the regional, district hospitals and community-based health carefacilities. The linkages with other agencies and facilities have widened the opportunityto integrate SRH and HIV through the PMTCT services. PMTCT is included in thenational medical standard for reproductive health (2009) and also in the SBA trainingpackage. A series of joint workshops were organized to move forward the programalignment with FHD/CHD/NPHL at implementation level.The PMTCT programme, however, face challenges as the health care system in thecountry need to be strengthened to integrate both SRH and HIV within the generalhealth services. It is also important to scale up the PMTCT services across the countryby increasing access to HIV testing and VDRL testing to all women, including MARPs.Guidelines and protocols have been updated to meet the standard. In addition, trainingpackages for different level of health work force as part of health system strengtheningto provide one stop service is under implementation.Model of PMTCT Services in NepalIntroduction ⅵ (e)

Dr Naresh Pratap KC, Director, Family Health Division, Ministry of Health andPopulation, NepalFamily Planning has been integrated with maternal and child health since the 3rd FiveYear Plan (1965-70). Currently, there are almost 50,000 female community healthvolunteers, in 97% of rural healthcare facilities to provide primary health care servicesand referrals for family planning and maternal and child health services (WHO, 2008).However, the availability of family planning service, particularly surgical contraceptionservices in several service sites, is low. Although, linkage between family planningand MCH has been effective, to a certain extent, linkages with other services such assafe motherhood, post-abortion and safe abortion care are still lacking. Providers havementioned that integration has overburdened service providers in hospitals, primaryhealth care and among the female community health volunteers.Dr Pratap also highlighted the public-private partnership in health sector in Nepal, whichthe purpose is to increase participation of private sectors/NGOs in safe motherhoodrelated services. These include capacity building for safe motherhood related services,skilled birth attendance training, social mobilization of contraceptives and familyplanning commodities, and collaboration with private healthcare providers to provideComprehensive Essential Obstetric Care (CEOC) services .Lessons learned from the public-private partnership are:• Involving the community during the planning of HF helps in developing ownershipamong the community and easy to make the site functional• Making availability of quality care, free delivery service and providing transportincentive does encourage women to have institutional delivery• Programs at the community to create awareness and making service available in thehealth facility simultaneously will support in improving safe motherhood status• Working in close collaboration and support from EDPs has proven to bring changesin the MNH statusIntroductionⅵ (f)

Model for Public-Private Partnership in Safe Motherhood in NepalSession 4: Improve Access for Special GroupsThe objective of this session was to address unmet needs of special groups such asyoung people, girls and womenDr. Jerker Liljestrand, Program Leader, MNH FP, URC Better Health ServicesDr Lilkestrand started the session by defining the special groups that need both SRHand HIV/AIDS services. These include, among others, sex workers, entertainmentworkers, prisoners, uniform personnel, young people, and drug users.Mr Un Chakery, Communication and Marketing Manager, PSI CambodiaMr Chakery highlighted the condom dual protection programme implemented by PSICambodia targeting entertainment (sex) workers. Through this initiative, condoms weredistributed to entertainment workers through sales teams and United Health Network(UHN). According to a survey conducted by PSI in 2010, 27% of entertainmentworkers had an abortion due to unprotected sex. Thus, there is a need to furtherstrengthen the SRH and HIV/AIDS services to address the problem. In addition, PSIalso provides referral services to entertainment workers to access SRH and HIV/AIDSrelated services.Mr Chea Thy, Technical Advisor, Plan International CambodiaMr Thy describe the three pillars of child rights programming in Cambodia that includesthe practical actions on violations and gaps in provision; strengthening structures andmechanism and constituency building. He further explained the initiatives taken byIntroduction ⅵ (g)

Plan-International Cambodia in SRHR and HIV/AIDS linkages. In order to increaseaccess especially for the children and youth and the most vulnerable population, Plan-International Cambodia is supporting outreach activities and strengthen the referral toSRH services. In addition, Plan-International is also strengthening the capacity of thepeer educators’ network in community to provide SRHR/HIV/AIDS information andwell as training health care providers on Friendly Services.Session 5: Develop Framework for SRH and HIV/AIDS LinkagesIn this session, participants were divided into groups to discuss and develop a frameworkfor SRH and HIV/AIDS linkages. The development of the framework were based onthe review of the existing policies, guidelines representing SA/SE (Nepal, Bangladesh,Philippines, Cambodia and Thailand) in reference to women and girl involvement inthe integration of SRHR and HIV through right based approach.The participants of the regional meeting suggested that:i. Right based approach will be cross cutting involving women and girls in all thestrategies, operational guidelines and protocols.ii. Sensitise the policy makers, programme managers of government, civil society,NGOs and selected beneficiaries on the importance of linkages between SRHand HIV to various approaches such as seminar, forum, workshop and the use ofinformation, education and communication materials.iii. Advocate donors and the government to allocate more resources including humanresources and financial resources to scale-up the provision of linked SRH and HIV/AIDS programmes and servicesiv. Development of Standard Operating Procedures for SRH and HIV/AIDS linkedservices and disseminate the SOPs to relevant stakeholders working in SRH andHIV/AIDS.v. Build capacity of primary healthcare providers in linking SRHR and HIV/AIDS byapplying appropriate curriculum for service providers during pre- and post-servicetrainingvi. Strengthen appropriate referral system within and outside the health facilitiesincluding referral to support groupsvii. Setup appropriate facilities (such as laboratories and counseling room) to supportthe implementation of SRH and HIV/AIDS linkagesviii. Documentation or evaluation of SRH and HIV/AIDS linkages programmeimplementation through operation research to better understand the linkages anddisseminate results for program planning and implementation.ix. Dissemination of best practices through national and international forums andmulti-country study visits involving programme managers and representativesfrom the most-at-risk persons groups.Introduction ⅵ (h)

CONCLUSIONSuccessful linkages between RH and HIV/AIDS programmes and services can only beachieved, if it is supported by commitment at policy level, development of appropriateinstitutional mechanism, coordination and collaboration rather than through attemptsto simply expand and link vertical programmes. Linked response should beinstitutionalised in all policies related to RH, HIV/AIDS, gender and young people.Despite the growing realization among the stakeholders, the need for policy and systemslinking to address SRHR, HIV and AIDS, particularly in the context of the commitmentto universal access to prevention, treatment, care and support, efforts to systematicallylinking SRH and HIV remains limited. This is partly because promoting synergisticapproaches between the SRH and HIV perceived due to the lack of guidance fromthe relevant authorities. More, significantly, existing policy, institutional and financialmanagement contain many barriers linking HIV and SRH programmes.The UN agencies have a key role to play in providing technical support and leadershiprole, despite UNAIDS Intensifying HIV Prevention strategy urges for strong linkageswith SRH. Support to sector wide management processes represents a majoropportunity for developing a comprehensive health sector response to HIV/AIDS, aspart of universal access commitments. HIV/AIDS activities are receiving substantialfunds, which are mainly ‘off budget’ and inflexible.Strategy making processes for HIV and AIDS and SRH are still mainly managed andimplemented separately. This reduces opportunities for developing comprehensivelinking approaches at programming and service delivery levels. National level SRH andHIV/AIDS response is separately administered, funded, and supported by differentdonors and technical agencies.Looking into, the way forward, the entry point could be mobilization of UN agenciesand other key stakeholders to begin the policy dialogue and advocacy for inclusion oflinkage issue in the HIV policy and strategy which are in the process of revision.A mechanism for better coordination and linkage between the two divisions managingSRH and HIV programmes should be initiated through a formal and informal platformsfor joint planning, financing, monitoring and reporting systems for SRH and HIV/AIDS.The pre-service and in-service training curriculum of health service providers (ContinuesMedical Education) when undergoing revision should consider training the serviceproviders on how to deliver integrated SRH and HIV services.A national level standardized package for integration of SRH and HIV services shouldbe developed for the different cadres of health service providers in order to informthem of their roles in the process of providing integrated services and in managingreferrals.Introductionⅵ (i)

8. RecommendationsAt Policy Level• Policy makers and program mangers should be sensitized and advocated for thebenefits of linkage between SRH and HIV service.• Revise national HIV policies to include family planning services for healthy timingand spacing of pregnancies and prevention of unintended pregnancies as part of thestandard of care for HIV services.• Revise RH policies/strategies to include HIV services as part of the standard of carefor RH services.At Programme Level• Donors, UN agencies should provide support for key linkages between RH andHIV/AIDS policies, programs, and services and ensure funding for linkages betweenSRH and HIV/AIDS in current international and national policy statements andprovide support for key linkages between RH and HIV/AIDS policies, programs, andservices.• Donors and decision makers need to ensure their funding and resource allocationare in accord with recommendations for strengthening key linkages between SRHand HIV/AIDS.• Provide more platforms and strengthening mechanisms for collaboration andcoordination within and between government, the nongovernmental sector,development partners, and other stakeholders• Develop and strengthen the capacity of programme managers to link and/orintegrate interventions such as integrate SRH into voluntary counselling and testing(VCT); prevention of mother to child transmission (PMTCT); condom promotion anddistribution for dual purpose; combined SRH and HIV/AIDS messages; etc.At Service Delivery Level• Prepare an integrated package of tools/guidelines for SRH and HIV serviceprovision• Build the capacity of PMTCT, HIV counseling and testing, and HIV care and treatmentservice providers to assess clients’ fertility intentions, offer dual protection counselingand condom promotion, and refer clients to FP services or safe pregnancy services.• Foster sensitivity to the RH needs of PLHIV, thereby reducing stigma and discriminationthrough community outreach workers such as FCHVs and mothers group• Ensure that the space is available for clients comfort and confidentiality.• Address providers concern about workload and encourage staff motivation.Introductionⅵ (j)

INSTITUTIONALCAPACITY FORHIV/AIDS ANDSRHR LINKAGESChapter 1Case Studies inBangladeshTaranum Dana1

BANGLADESHCAMBODIANEPALPHILIPPINES2

AbstractBackground: There are a number of healthpolicies and strategies, and guidelines forHIV/AIDS programmes in Bangladesh.These include policies such as the NationalAIDS Policy (1995), the Health, Nutritionand Population Sector Programme (2003-2010), the National HIV/AIDS StrategicPlan (2004-2010), the Adolescents SexualReproductive Health Policy, the NationalHealth Policy (2008), and the draftHealth Nutrition and Population SectorProgramme (2011-2016). The Ministry ofHealth and Family Welfare (MoHFW) hasamong their priorities, issues that includesexual and reproductive health (SRH) andHIV. The Department of Family Planningmanages all SRH services through aprimary health care delivery system all overthe country. The National AIDS and STIsProgramme is the key organisation withinthe MoHFW that manages the NationalAIDS/STD Programme, includingservices such as voluntary counselling andtesting (VCT) and antiretroviral treatment(ART).MethodsThe methodology used for this report wasboth a standard questionnaire for interview,and reviewing secondary materials. Indepthinterviews were carried out amongpolicy makers, heads of programmes,donors and service providers who areexperts in the field of family planning (FP),reproductive health (RH) and HIV. Thesecondary analyses of data was taken fromthe National HIV and Adolescent SexualReproductive Health policy, strategies, andplans, from the recently conducted roundof Behavioural Surveillance Survey (BSS),various other reports on HIV/AIDS andRH, the National Communication Strategyfor Family Planning and ReproductiveHealth, Bangladesh Demographic HealthSurvey 2007 (BDHS) etc. were alsoreferenced. In addition, major NGOsworking in the field of HIV/AIDS werealso consulted.ResultsFindings of this study demonstrate thatthere is no systematic approach to linkingsexual reproductive health (SRH) andHIV at policy and system level. There isno specific strategy for a health systemresponse to HIV and AIDS through alink with other SRH services, althoughSRH and HIV/AIDS are now part ofmainstream health policy. Although boththese issues are jointly addressed togetherthough SRH and HIV programmes, theyare run as separate entities in Bangladesh.GFATM, USAID through FHI, UNFPA,UNAIDS, DFID, World Bank and IPPFare the major funding sources in Bangladesh.However, a large portion of HIV fundingis administered by the government anddevelopment partners, including the GlobalFund.Donors have neither suggested a linkage ofSRH and HIV, possibly because of theirmandate, territorial interests and differentfunding mechanisms.ConclusionThere is an urgent need for a comprehensivepackage in which RH, SRHR, STI, HIVand AIDS issues are addressed with linkages.All government and non-governmentaloffices and the donor community needto have a strong horizontal and verticalcommunication, to achieve the goals.The gaps and challenges need to be addressedat the policy level, with multilateral andbilateral commitment from donors, thegovernment and NGOs, to achieve linkagesbetween SRH and HIV.3

BANGLADESHCAMBODIANEPALPHILIPPINESBackgroundBangladesh is situated in northeasternsouth Asia and covers an areaof 147,570 square kilometres. It isentirely surrounded by India, on thesouth-eastern frontier with Myanmar,and the Bay of Bengal in the south. Itis the world’s largest delta, formed bythree major river systems, the Ganges(Padma), the Brahmaputra ( Jamuna),and the Meghna.Except for the hills in the east and thehighlands in the north, it is largely a low,flat, fertile land, criss-crossed by aboutseven hundred minor rivers, canals, andstreams.Bangladesh is the most denselypopulated country in the world with apopulation of 150 million people anda corresponding population densityof more than 920 persons per squarekilometre. During the first half of thelast century, the population increased by45 per cent (BDHS, 2007). This slowincrease resulted from a combination ofhigh birth rates and high death rates. Inthe second half of the twentieth centurypopulation growth was rapid and thepopulation tripled during this period.The relatively young age structure of thepopulation indicates continued rapidpopulation growth in the future. Sinceindependence in 1971 there have beenlaudable efforts by successive electedgovernments to control the populationgrowth (contraceptive prevalence rate isnow 53 per cent9), a reduction in infantand child mortality rates (IMR of 66per 1000 live births10), and genderparity achieved in primary schoolenrolment (76 per cent and 81 per centnet primary enrolment for girls andboys, respectively11) (BDHS, 2007).According to the Human DevelopmentIndex (HDI) Bangladesh ranks 140thamong nations as presented in the2007-2008 Human DevelopmentReport. The county’s HDI valueis 0.547, placing it in the categoryof medium human developmentcountries. However Bangladesh is stillstruggling to emerge from poverty.The country is ethnically homogenous,except for a small tribal population ofabout 1.2 million. The religion of themajority population is Islam with atraditional context of culture wheremen have dominant roles. Polygamyis common, but sexual relationshipsoutside marriage meets with strongsocial disapproval. However theserelationships are not totally absent andare a threat to exposure to AIDS.Bangladesh is one of the poorestcountries in the world. Nevertheless,the large population (translated intomanpower) is one of the country’sbiggest assets for foreign remittance.International and internal migration foremployment is common, particularlyamongst younger people. Thesemigrations pose a threat to the spreadof HIV, particularly among the low riskpopulation of Bangladesh.Bangladesh has a low-incomeagricultural economy. GDP per capitafor 2008 was US$431, with the percapita GDP growth about 6 per centper annum. The sectoral contributionsto GDP for 2000-2001 were 24.87 percent from agriculture, 26.89 per centfrom industry, and 49.24 per cent fromservices. In the manufacturing sector theready-made garment industry generates4

the highest export earnings. The privatesector is active, and voluntary nonprofitorganisations are highly visible.Infectious diseases still dominate thedisease burden in Bangladesh, as a resultof overpopulation, malnutrition, andpoor hygiene and sanitary conditions.Poverty and illiteracy, compounded bynatural disasters, further complicatethe health situation.MethodologyThe methodology used for this reportwas both a standard questionnaire forinterview and reviewing secondarymaterials. In-depth interviews werecarried out among policy makers, headsof programmes, donors and serviceproviders with experts in the field of FP,RH and HIV.The secondary analyses of data wastaken from the National HIV andAdolescent Sexual ReproductiveHealth policy, strategies, and plans,from the recently conducted round ofBSS.Various other reports on HIV/AIDSand reproductive health, the NationalCommunication Strategy for FamilyPlanning and Reproductive Health,BDHS etc. were also referenced. Inaddition, major NGOs working inthe field of HIV/AIDS were alsoconsulted.Limitations of theAssessmentThe focus of the assessment was toanalyse the linkages of SRHR and HIVand AIDS from the policy, strategy,systems and service delivery perspectives.However the major limitation was toget access to government authoritiesfor in-depth interviews. In the Ministryof Health most officers do not have aclear concept of the programmes. Therewas a clear reluctance on the part ofconcerned GoB officials to share theirideas and views on the subject.Findings1. Policy Environment1.1. Sexual andReproductive HealthProgrammes inBangladeshBangladesh has made remarkablesuccess in family planning (FP) andreproductive health programmes(RHP) over the last two decades.The Population Policy Programmeof the country has evolved through aseries of developmental phases andhas undergone changes in strategy,structure, content and goals. Theremarkable success achieved by theBangladesh Population Programme,despite widespread poverty andunderdevelopment, is a logicalconsequence of the realisation of theconcept of “population and development”adopted in various development plans.The major ingredients attributed tothis successful model exhibited by thePopulation Programme include, amongothers, the following:Sustained political commitmentMaternal and child health-basedstrategyExtensive network of field workersand service centres5

BANGLADESHCAMBODIANEPALPHILIPPINESCommitted field force with womento-womenservicesCafeteria approach to servicesDecentralised service delivery(through satellite clinics and EPIoutreach centres at the grass- rootlevel)Active government–NGOcollaborationAdvocacy with religious and othercommunity leadersPro-active role of the mass mediaInvolvement of womenInter-sectoral collaborationTo overcome multi-dimensional intersectoralproblems and to meet thechallenges according to the spirit of theICPD (Cairo, 1994), the BangladeshGovernment launched the Health andPopulation Sector Program (HPSP) in1998, in consultation with developmentpartners and stakeholders to reformthe health and population sector. Thiswas done through the provision of apackage of essential health care servicesto decrease population growth. TheHPSP envisioned poverty alleviationwith services responsive to clients’ needsespecially those of children, women andthe poor, and achieving quality of carewith adequate service delivery capacityand financial sustainability. Followingthis, the government adopted theBangladesh Population Policy. Itsgoals are to improve the status of FPand MCH including RH services,and to improve the living standard ofthe people of Bangladesh by strikinga desired balance between populationand development in the context of theMDGs and the PRSP.Based on the different policy guidelines,protocols, strategies and action planswere developed for implementationthrough the formal health system.Despite fertility transition and animpressive success of the immunisationcampaign, other health indicators arestill lagging behind. There is still theneed for more investment in the majorcomponents of RH programmes suchas safe motherhood, family planning,maternal nutrition, unsafe abortion,neonatal care, adolescent health care,prevention and control of RTIs / STDs,HIV/AIDS and infertility. The UrbanPrimary Health Care programme(second phase) has included menstrualregulation (MR) in the essential servicedelivery package. This move has beenendorsed by government, that allprogrammes must include this service.SRH services are available through allgovernment and non-governmentalhealth facilities in Bangladesh, butHIV services are available onlythrough selected health institutionsin the country. Many NGOs havespecial programmes and facilities toprovide antenatal care and safe delivery.There are also a number of privatephysicians and an increasing number ofservice sites, especially in urban areas,providing the same service. There isan active social marketing company inBangladesh which sells contraceptivesthrough a network of pharmacies andshops.Bangladesh has a very well designed6

grass-roots based service deliveryinfrastructure available all over thecountry. At national level there is theInstitute of Post Graduate Medicineand Research, the Maternal and ChildHealth Institute (MCHTI), theInstitute of Child & Mother Health(ICMH) and 13 government medicalcollege hospitals. The services offeredare antenatal, prenatal (delivery)including comprehensive EOC servicesand postnatal care for mother andchildcare. At district level, 57 districthospitals provide antenatal and deliverycare including comprehensive EOCservices, postnatal care, EPI and childcare services.There are 90 Mother and ChildWelfare Centres (MCWC) in thecountry situated at the district, Upazilaand Union level, providing antenatalcare, normal delivery services, postnatalcare, EPI, and child healthcare. Outof these 64 MCWCs also providecomprehensive EOC services. Themajor services provided in the 397Upazila health complexes throughoutthe country are antenatal care, normaldelivery, postnatal care, EPI, FP, healtheducation, and child healthcare. Outof these, 40 Upazila Health Complexes(UHCs) also provide comprehensiveEOC services.There are 3,200 Constructed UnionHealth and Family Welfare Centres(UH & FWC) in the country. Theservices provided here are: antenatal(screening for “at risk” pregnanciesand referrals), safe deliveries throughdomiciliary follow up, postnatal care,health education and child care. Thepresent government has plans to stationgraduate doctors in all UH and FWCsin phases.Every month about 30,000 “satelliteclinics” are organised at ward andcommunity levels all over the countryto bring service facilities to the people.These include antenatal care, familyplanning, health education and EPIservices. The services are complementedby approximately 23,000 family welfareassistants and 15,000 health assistantsworking at grass root levels for basichealth and family planning servicedelivery.The SRH situation in Bangladesh canbe easily understood from the tablebelow (table 1) which shows the currentstatistics of key RH indicators.1.2 HIV and AIDSProgramme inBangladeshIn the Asia-Pacific region which hasthe second highest number in the worldof people living with HIV/AIDS,Bangladesh is fortunate to be one ofthe countries where the prevalence rateof HIV infection is low. Since the firstcase of HIV was reported in 1989,about 1,745 cases were reported as of30 th November 2009. The estimatednumber of people living with HIV inBangladesh was about 7,500 in 2007.According to UNAIDS the number ofpeople living with HIV in the countrymay be as high as 12,000 which is withinthe range of ‘low estimate’ by UNICEF’sState of the World’s Children Report2009.Although Bangladesh is still a lowprevalence country for rate of HIV7

1BANGLADESHCAMBODIANEPALPHILIPPINESinfections (less than 1 per cent) anddoes not have a concentrated HIVepidemic, nevertheless it is vulnerableto an expanded HIV epidemic due tothe prevalence of behaviour patternsand risk factors that facilitate the rapidspread of HIV. The recent BehaviouralSurveillance Survey (BSS) dataindicates an increase in risk behaviourssuch as sharing of injecting equipmentand a decline in consistent condomuse, particularly in sexual encountersamong IDUs and female sex workersin the surrounding urban community.The social and sexual interaction hasraised grave concern for the spread ofHIV infection (Bangladesh SerologicalSurveillance Survey 2006).Large Commercial Sex IndustryThere are over 105,000 male and femalesex workers in Bangladesh. Brothelbasedfemale sex workers reportedly seearound 18 clients per week, while streetbased and hotel-based workers see anaverage of 17 and 44 clients per week,respectively.Condom UseThe BSS (2006-2007) 6 th round dataindicates a significant improvement incondom use was recorded (during lastsex with new client) particularly amongbrothel and street-based sex workers.Condom use was 70 per cent forbrothel workers and ranged between51 to 81 per cent among street workers.8

However, condom use was low amonghotel-based sex workers in Dhakaand Chittagong at 40 and 36 per cent,respectively. Hotel-based sex workersare especially vulnerable to HIV asthey have the largest number of clients.Consistent condom use with regularclients is low for all sub-groups.Sexually Transmitted InfectionsSyphilis rates fell among brothel andstreet-based sex workers in Dhaka andamong IDUs in Dhaka and Rajshahibetween 2004 and 2006. Syphilis rates,however, have remained unchangedfor hotel-based sex workers, male sexworkers, and street based workers inChittagong, indicating the presenceof other risky sexual behaviours thatfacilitate the spread of HIV.Needle-sharing amongInjecting Drug UsersThe seventh round of serologicalsurveillance data shows that there is aconcentrated epidemic among IDUs inone neighbourhood of Dhaka with anHIV prevalence of 10.4 per cent. Thislevel of infection among IDUs posesa significant risk as the infection canspread rapidly – and is spreading –within the group, rather than throughtheir sexual partners, and their clients,into the general population. The BSSdata for 2006-2007 indicates thepersistence of unsafe injecting practicesamong IDUs with the majority stillsharing needles and syringes. Anotherconcern is the significant number ofIDUs who sell their blood commercially.Bangladesh continues to rely on thosewho sell their blood to meet part of thetransfusion needs of its people.Lack of KnowledgeData on knowledge and behaviourindicates that only 17 per cent of themost-at-risk populations have correctknowledge about prevention and areaware of the misconceptions - thatHIV/AIDS is spread by coughing orsneezing or through sharing of food andwater with an HIV infected person. A2005 population based survey amongadolescents and young people (aged 15-24 years) indicated that only one out ofthree males in an urban setting and oneout of four in rural areas had correctknowledge of HIV and AIDS. Amongthe general population, data indicatesthat 59 per cent of ever-married womenand 42 per cent of men of age 15-54 were not able to indicate even onemethod to avoid contracting HIV.Migrant WorksMigrant workers are another importantgroup identified as a priority in theBangladesh National Strategic Planfor HIV and AIDS 2005-2010.Approximately 250,000 people leaveBangladesh for employment every year.The risk is that they will get infectedduring their stay abroad and return toBangladesh where they may transmitthe virus to others, especially theirwives who could in turn transmit theinfection to their babies.Subsequent surveillances show that incentral Dhaka, HIV prevalence amongIDUs rose from 1.4 per cent to 7 percent (up to 10.8 per cent in a particularlocality) during the last four years(2005-2009). The level of the epidemicvaries across different geographic areasas well as different population groups.9

BANGLADESHCAMBODIANEPALPHILIPPINESAmong the six districts where HIVcases were identified, Dhaka as thecapital city had the highest at 16.7 percent, Sylhet was second at 15.3 percent and in Chittagong 8.3 per cent.The overall identified cases of HIVthroughout the country are provided inannex 3. The following table (table 2)illustrates the basic indicators of HIVin Bangladesh:1.3 National Response toHIVGovernment: The Government of thePeople’s Republic of Bangladesh remainsfirm in its political commitment tocombat HIV, to maintain Bangladesh’sstatus as a low prevalence country,and to achieve the goal of halting andreversing the spread of HIV by 2015.The Directorate of Health Servicesin the Ministry of Health and FamilyWelfare outlined a National Policy onHIV/AIDS in late 1996. In 1998, asrecommended by the National Policyon HIV and STD, the NationalAIDS/STD Programme (NASP)was established under the DGHS tooversee the HIV/AIDS programmein the country, under the guidanceof the NAC. After the first StrategicPlan was reviewed in 2005, the NACguided the development of the 2ndNational Strategic Plan for HIV/AIDS, 2004-2010 (NSP II), withthe active involvement of a wide bodyof stakeholders, including UNAIDS.The objectives, strategies and prioritiesof this plan are closely aligned withthe National Policy for AIDS and theMillennium Development Goals, andfurther guided by an analysis of theHIV situation and vulnerability factorsin Bangladesh. The main objectives ofNSP II are to:i. Provide support and services forpriority groupsii. Prevent vulnerability to HIVinfectioniii. Promote safe practices in the healthcare systemiv. Provide care and treatment servicesto people living with HIVv. Minimise the impact of the HIV/ADIS epidemicNongovernmentalOrganisations (NGOs):There are more than 400 NGOs whohave been implementing programmes/projects in different parts of the country.These initiatives focus on preventionof sexual transmission among highriskgroups involving mostly femalesex workers, MSM, IDUs, rickshawpullers, and truckers. NGOs are oftenin a better position than the publicsector to reach high-risk groups, suchas sex workers and their clients, andinjecting drug users. Building thecapacity of NGOs, especially the smallones, and combining their reach withthe resources and strategic programmesof the government is an effective way tochange behaviour in high-risk groupsand prevent the spread of the virus tothe general public.DonorsA Global Fund grant for US$40 million(Round 6) to promote prevention ofHIV among adolescents and youngpeople brought together the government10

2and Save the Children, USA, and isbeing implemented through NGOs.An FHI/USAID-supported project(US$13 million, 2005-2008) focuseson selected interventions for somehigh-risk groups and the expansion ofVCT services. Big Lottery Fund is alsoproviding HIV programmes throughCARE Bangladesh.There are three major HIV preventionprojects operating in Bangladeshfocussing only on young people, sexworkers, injecting drug users, MSMand mobile populations like transportworkers and rickshaw pullers. Not all ofthe groups have been identified as beingat risk. While it is well understood thatraising awareness of HIV in the at-riskpopulation is important, improvementin knowledge needs to be linked withbehaviour change. It is not yet certainthat this is happening.Currently there are three major HIVprogrammes being implemented inBangladesh (UNGASS 2010):a. The HIV/AIDS TargetedIntervention (HATI) 2008-2009supported by the World Bankfinanced the Health, Nutritionand Population Sector Programme(HNPSP). HATI focuses onintervention packages for six highrisk groups: IDUs, sex workers -brothel based, street based, andhotel and residence based, - clientsof sex workers, MSMs, MSWs andhijra.b. The Bangladesh AIDSProgramme (BAP) 2005-2009:This programme is funded by USAIDwith about US$14 million and isimplemented through a team comprisingFHI, Social Marketing Company(SMC), John Snow Inc Bangladesh ( JSI11

BANGLADESHCAMBODIANEPALPHILIPPINESBangladesh) and Masjid Council forCommunity Advancement (MACCA)The programme has the supportof 18 implementing agencies andnumerous collaborating partners. TheBAP focused on providing preventionservices among MARPs. As a followup to the BAP, Modhumita, (a newcooperative agreement with USAID)started in October 2009 with aboutUS$13 million and will continue till2013. The programme’s overarchingobjective is to support an effective HIVprevention strategy through improvedprevention, care, and treatment servicesfor MARPs, and a strengthenednational response.c. Global Fund to FightAIDS, Tuberculosis andMalaria (GFATM) supportedprogrammes:There are three programmes fundedby GFATM Round 2 (March2004-November 2009). Round 2is a grant project for prevention ofHIV among youth and adolescentsamounting to US$19.7 million,managed by Save the Children USA.Round 6 of the GFATM grant (US$40million) aims to limit the spread andimpact of HIV in the country byproviding prevention services amongMARPs, and improving the capacityto deliver high quality interventions.The government of Bangladesh is theprincipal recipient for both the grants.1.4 National Policy andGuidelines for SRHR andHIV/AIDS LinkagesThere is only one national policydeveloped for adolescent sexualreproductive health and rights.However, no policy has been developedfor SRHR in general. The SRH strategyplan has not been revised since it wasdeveloped.All RH issues are broadly highlightedin the National Health Policy, HNASPand also in the Population Policy. RHprogrammes include safe motherhood,family planning, maternal nutrition,unsafe abortion, neonatal care,emergency obstetric care, adolescenthealth care, infertility, and preventionand control of RTIs / STDs, and HIV.The programmes are directly managedby the DGFP, in cooperation withnational and international NGOs.In Bangladesh women require specialattention in HIV interventions dueto their social, economic and politicalstatus. Women are four times more likelyto contract HIV than men. Howeverwomen’s lower social and culturalstatus causes them to have less access toeducation, employment opportunitiesand health care, including opportunitiesfor HIV tests, counselling and medicalcare. Women are often subjected to earlymarriage, sexual abuse and violence inintimate and marital relationships. Anincreasing number of women are forcedto sell their bodies as the only way tosurvive and provide for their children.Men who buy sex from women areoften reluctant to use condoms.Women have little negotiating power.Even within their marriages, they mayhave unprotected sex with their spouseswho might be engaging in one or morehigh-risk behaviours, and be exposed toHIV.12

Many important national guidelines,manuals and strategy documents weredeveloped in recent years for SRHand HIV (see annex 4). While thecoverage of HIV prevention activitieswas limited during the first part of thisdecade, the national HIV programmewas progressively scaled up in its qualityand coverage.Outcomes from the HATI project in2008 revealed that more than 110,000clients received services and informationfrom the 146 drop-in-centres and4,195 were referred to VCT serviceproviders. In 2008, a total of 849,200people attended education sessions onHIV/AIDS. During the course of itsimplementation, the project reachedover 3.4 million people with sucheducation sessions.By the end of 2008, 37,275 patients hadreceived STI services. In the previousthree years (2005-2007), a total of139,780 people benefited from STIservices. Among the targeted groups,some behaviour change was observedover the four year (2005-2008) period.More sex workers are capable ofconvincing their clients to use condoms– 44 per cent of male and 67 per centof female sex workers used a condomwith their last client. There has beenan increase in the overall demand forcondoms among all target groups, andmore people at risk received VCTsupport. In addition, the attitude ofcommunities towards street-based sexworkers and HIV/AIDS has changedpositively and harassment by lawenforcing agencies has reduced. 34 percent of IDUs used sterile equipment attheir last injection.Despite being a low HIV prevalencecountry, the HIV epidemic receivedhigh priority in the health sector ofBangladesh. The focus has been on theneed for prevention programmes, withina broader framework that addresses theneed for treatment, care and support ofPLHIV. After extensive consultationand involvement of ministries, NGOs,the private sector and the affectedcommunity, the Second NationalStrategic Plan for HIV-AIDS, 2004-2010 was adopted, with a strong focuson its first strategic objective: to providesupport and services for priority groups(those with the highest HIV prevalenceand risk).The four other objectives are: 1) toprevent vulnerability to HIV infection;2) promote safe practices in the healthcare system; 3) provide care andtreatment services to PLHIV; and 4)minimise the impact of the epidemic.Subsequently, in order to address gapsand to elaborate further on the SecondNational Strategic Plan, NASP, withthe assistance of UNAIDS, developedthe ‘National AIDS Monitoring andEvaluation Framework and OperationalPlan’ covering 2006 to 2010.NASP has recently started a projecton PMTCT with UNICEF and is theonly linkage programme between SRHand HIV. Other than that NASP hasdeveloped several national guidelines,manuals and policies/strategies onspecific intervention areas (see annex:4).The NASP has taken the initiativeto revise and update the NationalStrategic Plan for HIV/AIDS. Therevision address issues such as gender13

BANGLADESHCAMBODIANEPALPHILIPPINESinequality, low level of engagementof men in responses to HIV relatedprogrammes, and HIV-related stigmaand discrimination. Legislations andpolicies, social and community attitudestowards key populations (e.g. MSM,SWs, IDUs, sexual minorities, migrants,refugees, displaced populations, youngpeople) are also addressed in the recentrevision.The National Youth Friendly HealthSurvey standard has been approvedand endorsed by the government underthe GFATM funded HIV/AIDSprogramme. Training manuals and thenational curriculum have also beenrevised.The National Standard OperatingProcedures (SOP) for IDUs, SWIsand PLHIV has been finalised by Savethe Children USA, and endorsed andpublished by the Government. TheseSOPs are now being applied to providethe respective services by NGOs andGoB funded programmes. There areseveral guidelines to assist doctorsand all persons providing services toPLHIV. However, there are no specificguidelines on SRH for women livingwith HIV.In Bangladesh, condoms are available formarried couples. The government has apolicy for procurement of condoms ona CYP (couple year protection) basis.CYP is the amount of contraceptionnecessary to protect one couple for oneyear [i.e. 100 male or female condoms,14 cycles of oral contraceptives, 0.5CycleBeads, 100 vaginal foaming tablets,.285 intrauterine devices, 4 injectables(3-month dose), 6 injectables (2-monthdose) or 12 injectables (1-month dose),0.1 voluntary sterilisations, 0.285implants and 13 doses of emergencycontraception].CYP is calculated by multiplying thequantity of each method distributedto clients by a conversion factor, toyield an estimate of the duration ofcontraceptive protection providedper unit of that method. The CYPsfor each method are then summed upfor all methods to obtain a total CYPfigure. CYP conversion factors arebased on how a method is used, failurerates, wastage and how many unitsof the method are typically neededto provide one year of contraceptiveprotection for a couple. The calculationtakes into account that some methods,like condoms and oral contraceptives,for example, may be used incorrectlyand then discarded, or that IUDs andimplants may be removed before theirlife span is realised. (See Annex 5 fordetails)Male condoms are distributed freeof charge to persons who seek healthservices in the local health centres;female condoms are only available insome pilot areas. The GFATM fundedHIV/AIDS programme has developeda strategy for young peoples’ access tocondoms, aimed at protection againstunintended pregnancy and STIs,including HIV. The strategy is awaitingGoB approval.There is no national guideline forroutine testing for HIV and syphilisamong pregnant women, although allhealth service sectors have facilitiesfor HIV testing. In Bangladesh thereis no legal age for HIV testing, neitheris it compulsory. Testing is done14

voluntarily, among project participantsparticularly the at-risk population.SRH documentation does not includeissues of HIV apart from some specialprogrammes for special groups ofpeople. CARE Bangladesh has createdpositive but not significant change forMSMs, SWs, IDUs and PLHIV. Thereis a need for more policy support fortheir right to health services, especiallyHIV services, and the reduction ofviolence.Within the broader HIV operationalplan, there are explicit activities toimprove access, coverage and qualityof SRH services to the generalpopulation, and target populations(e.g. MSM, SWs, IDUs, young peopleand PLHIV). At present the GoB isplanning to mainstream HIV, STI,and SRH services within all healthservices.The SOP makes clear reference toconfidentiality and disclosure for HIVrelatedservices. Confidentiality ismaintained for every case. Priority fordisclosure is at the total discretion of theclient. Some respondents reported thecontinued existence of discriminationwith regard to testing and support todisadvantaged groups (e.g. children,orphans, street children, and women),although the consent for HIV testingof adolescents is mentioned in thestrategy.In the National Youth Friendly HealthSurvey standard, training manuals andnational curriculum address the issuesrelated to HIV for minors and youth.Married, unmarried and minors haveaccess to VCT centres that are beingrun by different NGOs in the country,which helps to create opportunitiesfor knowledge disbursement amongthe MARP. “Youth Friendly HealthServices” and “Access to Condoms forYoung People in Bangladesh” in a senseis a stand-alone initiative. However theGoB may include it in the NationalHealth Policy or even in the NationalOperational plan.There are strong legislative and policyframeworks for effective action on bothHIV and SRH, and the promotion andprotection of sexual and reproductiverights. Laws related to issues thathave implications for HIV, AIDSand SRH (e.g. gender-based violenceand sexual coercion, discrimination,early marriage, widow inheritance)help officials to monitor human rightsviolations of MARPs. Civil societies,media, activists and professionalsregularly collect and share cases relatedto human rights violations. Networksof PLHIV and other groups (MARPs)also publish such cases regularly intheir newsletters, in an effort to movetowards a rights-based approach andensure equity of services. Nevertheless,the criminalisation of some riskbehaviours associated with HIVtransmission (sex work, illicit druguse) is impeding the implementation ofother HIV-supportive policies. Furthercoordination with law enforcementagencies and the criminal justice system,with strong support and commitmentfrom the highest levels of government,is still needed.Majority of respondents both from GOsand NGOs said that documentationshows that there are bi-directionallinkages between SRH and HIV15

BANGLADESHCAMBODIANEPALPHILIPPINESprogrammes. For example the HIV/AIDS programme in Bangladesh ispart of the HNPSP, PRSP and alsoappears in the ARHR policy paper.However the HIV/AIDS policy doesnot include issues of SRH. At theimplementation level, there are no bidirectionallinkages among the twoprogrammes. The FP programme that isrunning in the country does not includeVCT, PMTCT, and HIV programmes.However the VCT programmes carriedout by NGOs include FP issues.Respondents from the NGO sector saythat HIV/AIDS is usually mentionedwhen providing reproductive healthcareservices. However there is no linkagebetween the two programmes. Theministry of health reports that HIVprogrammes have been given priority inthe National Health Policy. However,national programmes on SRH do notinclude HIV prevention treatment,care and support issues such as VCTand HIV treatment, although SRHservices include BCC on HIV.All respondents agreed that the linkageis very weak and is vaguely designedbecause the strategies and policies weredeveloped at different points of time.As a result, linkage between policiesand programmes was not possible.Respondents from the NGO sectorsaid that both the programmes arerunning vertically because of the specificmandates of the organisations anddonors. The MoHFW is responsiblefor the overall policy, the DGFP isresponsible for the planning andimplementing of SRH programmes,and the DGHS is responsible for healthservices. The NASP was developedunder the DGHA to act as the focalpoint for developing all HIV/AIDSpolicy strategies and implementationof the programmes. Some respondentswere of the opinion that there aregaps between the two organisationsproviding support in SRH and HIV/AIDS in the country. Findings alsorevealed that none of the departmentswere concerned with linking SRH andHIV.1.5 Budget Funding andBudgetary SupportThe government has mobilised loansand grants from development partners,including the World Bank, GFATM,UN agencies, and other multilateraland bilateral donors, to supportinterventions to prevent and treatHIV among particularly vulnerablepopulations.ANational AIDS Spending Assessment(NASA) has yet to be carried out in thecountry. Much of the funding for HIVin Bangladesh comes from internationaldonors. Programmes under HNPSP /HIV are mainly funded by the WorldBank, the ADB and the GoB poolfunding. Table 3 below shows majorfunding sources and projects during theyears of the current national strategy.Tables 5A and 5B show the totalamount spent for the six major strategiccomponents of the programme.Spending for advocacy and technicalsupport was much higher than othercategories. Government financing forthe programme was less in comparisonto international not-for-profit sources,mainly international non-governmentalorganisations. Different financingsources have specific functional focus,16

ut all sources have consistently spenthighest on prevention, care and support.Spending on programme managementand administration needs careful andcautious interpretation; a detailedbreakdown of expenditure is necessaryto be able to draw conclusions. As thefinancing of national response is heavilyreliant on international funding, so is themanagement of funds. In other words,a large proportion of available fundsis managed (or spent) by or throughmultilateral agencies and INGOs.2. Systems2.1 PartnershipsIn Bangladesh partner organisationson SRHR related issues are mainlyfrom Sweden, working closely withthose from the Netherlands (EKN),DFID, WHO, and UNFPA. Swedensupports the sector programme inhealth where donors give their supportto the government via the World Bank.An example is the Urban PrimaryHealthcare Programme (UPHCPH)which is supported by Sweden via ADB,together with DFID and UNFPA.Development partners have beenplaying a significant role in theprevention and control of HIV inBangladesh, building the capacity ofgovernment to plan, design, implementand monitor the national HIVprogramme. Development partners arefrom multilateral bodies such as UNagencies, bilateral donors, internationalNGOs, and national and internationalresearch organisations such as IEDCRand ICDDR,B respectively. Theexisting HIV interventions are mainlysupported by USAID (through FHI),GFATM (through Save the Children-317

45.A5.BBANGLADESHCAMBODIANEPALPHILIPPINES18

USA) and the World Bank ledconsortium through HNPSP.The Bangladesh HIV/AIDSprogramme has been receivingfunding from three major sources.In response to the HIV/AIDSsituation, the HIV/AIDS PreventionProject (HAPP) was conceived andapproved in December 2000 by theGoB, the International DevelopmentAssociation (IDA) and DFID. Theproject was implemented during2004-2007 with management supportfrom UNICEF, WHO and UNFPA.The UNICEF Bangladesh CountryOffice facilitated implementation oftargeted interventions for the most atrisk populations, through procuringNGO services. The implementation ofthe HAPP programme was seriouslyaffected with repeated fundingdisruption, which caused high staffturnover and undermined capacitydevelopment interventions. TheHAPP project ended in December2007 and the HIV and AIDS TargetedInterventions (HATI) were initiatedunder HNPSP through an agreementwith MOHFW and UNICEF. HATIwas designed utilising lessons learnedfrom HAPP as the country’s largestintervention for high risk populations.The HATI ended in June 2009. Asa continuation of HATI, the HIV/AIDS intervention services (HAIS)was initiated for an initial durationof six months, from December 2009,under HNPSP.Global FundThe Global Fund to Fight AIDS, TBand Malaria (GFATM) is one of themajor sources of funding for HIV andAIDS programmes in Bangladesh.The country has received three grantsfrom GFATM in HIV/AIDS throughRound 2, Round 6 and the RCCgrant. The total budget was US$130million for six years. Save the ChildrenUSA has been providing leadership inHIV/AIDS programmes since 2004,funded by the Global Fund Nationalprogramme. The goals of each roundwere different.Round 2 (2004-2009) total amount ofUS$20 million to be spent in HIV/AIDS programmes in the country.The main aim during this phase wasto prevent HIV/AIDS among youngpeople in Bangladesh through thefollowing activities:Information campaignYouth friendly health services andlife skills educationInstitutionalisation of HIV/AIDSin education and trainingAdvocacy and sensitisation withparents, religious leaders and policymakersGenerating evidence for policies andprogrammesRound 6 (2007-2012) total amountreceived US$40 million. The main aimin this phase is HIV prevention andcontrol for the target population andvulnerable young people through thefollowing activities:Targeted interventions with IDUs,FWsCare and support for PLHIV19

BANGLADESHCAMBODIANEPALPHILIPPINESWork place intervention in garmentfactoriesScaling up prevention strategies foryoung peopleCapacity building at national anddistrict levels, implementation andstrategic partnershipsM&E and generating evidenceRCC Programme (2009-2015) totalamount received US$91 million. Themain aim in this phase is to consolidateHIV prevention through the followingactivities:Scaling up prevention strategies foryoung people- media campaigns,advocacy, teacher training, generatinginformation.Provide Cotimoxazole at no chargeConduct ART lab investigations toassess clinical stage and to monitordisease progression of PLHIVEnsure hospital care throughInfection Diseases Hospital (IDH)Intervention; efforts at nationaland district level with IDUs, FWs,MSM; implementation and strategicpartnerships.M&E and evidence generationfor supporting programmes andpoliciesUNICEFUNICEF has played a significant rolein maintaining the low HIV prevalencestatus of Bangladesh through itsmanagement of the HIV/AIDSPrevention Project (HAPP) from 2004to 2007 and the HIV/AIDS TargetedInterventions (HATI) project fromJanuary 2008 until it was handed overto the government in 2009. UNICEFmanages the procurement of NGOservices to implement preventionactivities among the most at-riskpopulations – injecting drug users,sex workers, mobile populations, menwho have sex with men, and clients ofsex workers. Services were providedthrough 146 drop-in centres (DICs) in44 districts of Bangladesh. In the DICs,major activities include: medical carefor STIs, management of other healthproblems, rest and recreation facilities,crisis care shelter, peer education,counselling and health education,referral services, outreach services. Theproject has also been working to:Increase condom use (more than 6.6million condoms were distributedto the target group between Januaryand September 2008)Increase care for those with STIs(37,275 received services fromDICs)Decrease needle and syringe sharingamong drug users (more than 2million syringes and 1.3 millionextra needles were distributed).Under the HAPP project, a ‘PeerEducator’s Guidebook’ and a ‘SupervisorGuideline for Peer Education’ weredeveloped to encourage peer educationprogrammes. Training sessions wereconducted to equip implementingNGOs with adequate skills andknowledge for STI management,peer education and outreach work,advocacy and management. Through20

the Prevention of Parent to ChildTransmission (PPTCT) programmein Bangladesh, UNICEF is pilotinginterventions in three selected healthcare facilities (one is currently operating,two to begin in 2009). The facilitiesprovide anti-retroviral prophylaxis,treatment and support for HIVpositive pregnant women and theirfamilies. Comprehensive VoluntaryCounselling and Testing (VCT), careand support are provided for infectedchildren and pregnant women. A leafletabout PPTCT has been developed andwill be distributed to relevant serviceproviders in contact with the most atrisk, to support PPTCT counsellingand ensure referral to PPTCT pilotfacilities.UNICEF is also increasing itsemphasis on community support, careand services for orphans and vulnerablechildren, in the Chittagong Hill Tractsand urban poor communities.UNICEF supported the developmentof the National CommunicationStrategy for HIV 2005- 2010, thenational PPTCT guidelines and otherkey documents. UNICEF’s south Asianfemale character, Meena, has also beenused in the region to raise awarenessabout HIV and AIDS. In the first yearof the PPTCT pilot project, VCTservices were provided to 59 pregnantwomen out of whom five who wereHIV positive received the necessarytreatment and care.Other UN agenciesTo address the national priority ofprevention and protection against theHIV epidemic, the United NationsDevelopment Agreement Framework(UNDAF), 2006-10 aimed to achieve‘increased ability of the countryto understand and respond to theHIV epidemic.’ Accordingly countryprogramme action plans of the UNagencies in Bangladesh focused on thefollowing three broad interventionareas during 2008-09, in line with theNational Strategic Plan (NSP) forHIV/AIDS 2006-2010:A comprehensive national responseis in placePeople are able to protect themselvesfrom HIV infection.Continued advocacy on AIDSUSAIDThe other major source of fundingfor HIV/AIDS programmes inBangladesh has been from USAID,with FHI Bangladesh as the MSAwhich started to support interventionsin 2000 for people most vulnerable toHIV. FHI Bangladesh supports a widevariety of community– based and faithbasednon-governmental organisations.The USAID funding also addressedthe national surveillance system andbehaviour change communication toreduce risk and vulnerability to HIV(including condom promotion amonghigh-risk populations), improvingmanagement of sexually transmittedinfections (STIs), and building capacityof government and NGO partners toplan, implement, and monitor HIV/AIDS interventions. Over time, FHIBangladesh expanded its activities toinclude training of health providersin syndromic management of STIs,21

BANGLADESHCAMBODIANEPALPHILIPPINESand the establishment of voluntaryHIV Counselling and Testing (VCT)centres. FHI continues its programmeand its current phase will end in 2012.In addition to the targeted interventionsbeing implemented in the country asmentioned above, the German Agencyfor Technical Cooperation (GTZ) hasbeen working at four city corporations:Chittagong, Rajshahi, Khulna, andSylhet with the aim to improveprevention, counselling, diagnosis andtreatment for HIV/AIDS and STIservices through its multidisciplinaryHIV/AIDS programme. TheAsian Development Bank has beencontributing towards HIV preventionintegrated into urban primary healthcare including VCT from 2006-2010.World BankThe World Bank supports thegovernment’s two-pronged strategy:first, increasing advocacy, prevention,and treatment of HIV/ AIDS withinthe government’s existing healthprogrammes, and second, scaling upinterventions among high-risk groups.The HIV/AIDS Prevention Project(HAPP 2000–2007) jointly financedby the Bank and DFID providedUS$27 million to support the scalingup of interventions among groupsat high risk in a rapid and focusedmanner, while strengthening overallprogramme management. With theclosure of the project, HIV/AIDSinterventions are being integratedinto the government of Bangladeshandmulti-donor-supported Health,Nutrition, and Population SectorProgrammes (HNPSP). HNPSPis a sector-wide programme with atotal cost of US$4.3 billion whichincludes the Bank’s contribution ofUS$300 million and a multi-donortrust fund of approximately US$460million. For the period 2008–2011,a total of US$27.9 million has beenallocated for HIV/AIDS interventionsincluding prevention activities amonghigh-risk groups, communication andadvocacy, treatment and care, impactmitigation, capacity building of NASP,and safe blood transfusion. Increasedcoordination among the three mainfunding sources –HNPSP, GFATM,and USAID – is underway.NGOs working with the community forseveral years have a better understandingof community issues that help thembridge the gaps between service andcommunity. This understandingof community issues often allowsNGOs to advocate for their rights. Allcategories of NGOs are major providersof services for both SRH and HIVprogrammes. Therefore NGOs playan important role in HIV responses,in community based mobilisation,prevention and care services, and inreaching key groups, such as MSM,and sex workers, IDUs and migrantworkers. MARPs representatives ortheir networks are regularly involvedin all activities ranging from policydevelopment, proposal writing andimplementation, and monitoring of theimplementation.MARP and vulnerable communityledAshar Alo Society, Mukto Akashand Bandhu are some of the leadingorganisations in the country workingwith vulnerable groups and PLHIV.They play a crucial role in improving22

access to services for their constituencymembers as well as contributing tothe planning and policy developmentprocesses. They are also active inadvocacy at various levels to ensureaccess to ART and other services.The group has been successful inmany advocacy outcomes and hascontributed to accessing ART as wellas ensuring ART adherence. This groupis also active in positive prevention andensuring the rights of infected/affectedchildren and women.2.2 Planning Managementand AdministrationAll respondent were of the opinion thatSRH and HIV programmes run by thegovernment and NGOs do not haveany linkages. However respondentsagreed that SRH or HIV is alwaysspoken about as one and this has nowbecome part of the mainstream healthsector. The lack of linkage of SRHand HIV programmes is due to it notbeing included in the project objectives;neither do donors request for them tobe overlapped. The other issue that wasidentified was the lack of an integratedbudget. Monitoring and coordinationof activities were also weak.2.3 Human Resources andCapacity DevelopmentThe recruitment and retention of healthprofessionals, doctors and nursing staff,particularly in the remote district levelsis a problem that needs to be addressed.Although there is a National TrainingCurricula this does not include issueson HIV and SRH. At the same time,trainers themselves are not skilledenough despite having well documentedtraining materials prepared by variousNGOs for the government. Thereis a shortage of learning equipmentand material; transport facilities formonitoring and supervision of fieldtraining are lacking. There is inadequateopportunity and capacity for needsbasedin-service training on HIV/AIDS. Training needs have not beenidentified for different categories ofservice providers, and inadequate inservicetraining opportunities. Clinicalservices related to ART, HIV TC,PMTCT, OI and STI are impactedby:Challenges related to deploymentand retention of health professionalsin the rural areasFrequent transfer of governmenthealth workers leading to a need forconstant trainingInability to retain health workers inthe NGO sector due to unfavourablepay scalesLack of supportive supervisionwithin the health systemSupervision of NGO-deliveredservices not linked to the governmentsystem.Almost all respondents felt that thereis an urgent need for orientation andtraining on linkage and integrationbetween SRH and HIV, stigma anddiscrimination, and counselling.Training is also required on proposalwriting, advocacy, VCT counselling,RH protocols and laboratory standardoperating procedures (SOPs). At thesame time the target group for thesetrainings should cover all levels that23

BANGLADESHCAMBODIANEPALPHILIPPINESplay a role in these fields such as policymakers, GoB officials, and serviceproviders. Capacity building on SRHand HIV should incorporate avoidanceof stigma and discrimination, gendersensitivity, and confidentiality onreproductive rights and choices.There are separate training manualsfor pre-service and in-service training;curricula for secondary education andteacher training have incorporatedsafer sex, sexual health stigma, sexualviolence, condoms and reproductiverights.2.4 Logistics/SuppliesMajority of respondents thoughtthat the two track system of logisticmanagement restricts the proper use ofbudget and is not cost effective. SRHlogistics and supplies are procuredand supplied through DGFP and byUNFPA SMC and FPAB, also viaother NGOs that provide RH services.On the other hand HIV supplies areprocured from SMC and UNFPA,supplied through NCASC. Hencethere is a two track system of supplychain for drugs and test kits and othercommodities. USAID, through FHIprovides support for the nationallogistics supply of HIV commodities.2.5 Laboratory SupportThe laboratory facilities are inadequateto serve the needs for SRH and HIVservices in the country, especially inthe rural areas, being highly dependenton the level of facilities. Respondentsagreed that good quality, comprehensivelaboratory services are only availablein Dhaka and Chittagong. Accordingto respondents there is a lack ofdiagnostic capacity, and unsatisfactoryinfrastructure. There is a shortage ofequipment and re-agents, and an absenceof mainstreaming for the procurementand supply of HIV commodities. Addedto this is the shortage of competentlaboratory staff, and laboratorieslack bench manuals/handbooks inlocal languages. Compounding theseproblems are the inadequate in-servicetraining opportunities.The government has expanded theblood transfusion programme to 100sub-district level hospitals (out of atotal of 466 sub-districts) and equipped50 of them, and plans to equip therest in 2008. The National Policy andStrategy on Blood Safety, adopted in2007, defines minimum standardsand requirements for health facilitiesto qualify and be authorised to screenblood for HIV before transfusion. Areference laboratory has been set up inthe Dhaka Medical College Hospitalto conduct HIV confirmatory tests.The overall number of blood centres,however, is still inadequate.2.6 Monitoring andEvaluationIn Bangladesh there is a NationalAIDS Monitoring and EvaluationFramework and Operational Plan2006-2010. The National AIDSMonitoring and Evaluation Frameworkand the Operational Plan for NSP II,both developed in 2007 by NASP withassistance from UNAIDS, will soon bedistributed among stakeholders. TheOperational Plan includes detailedassessments of the resources required24

for planned prevention, treatment andcare activitiesThe National Strategic Plan logicallyplaces the custodial role of HIV dataand the monitoring and evaluationprocess in the hands of the NASP.However, it does not elaborate on otherkey components of a monitoring andevaluation (M&E) system, such asindicators with specific data sourcesand frequency of reporting. The overallgoal of the national M&E frameworkis to guide the gathering of strategicinformation needed to improve theefficiency, effectiveness and impact ofresponses to the epidemic, as well asensure accountability of all partnerswho are contributing to the nationalAIDS response. The national M&Eframework goes further in specifyingthose details. Building on existingM&E sub-systems and practices, theframework spells out the data needsand sources for assessing programmeperformance and measuring the overallgoals of the national response – whichare to reduce the spread of HIV andimprove the quality of life of those whoare affected and infected (NSP missionstatement). There is HIV relatedsupportive supervision using checklistsfor VCT, ART, PMTCT, and STI butsupervision is weak. Quality data is notavailable specially to analyse HIV statusby age and sex. However this M&E plandoes not have any structure to show theintegration of SRH programmes.Most of the respondents have theirown organisational monitoring systemsavailable for the services they provide.3. Service DeliveryAccording to all respondents thereare no direct integrated SRH andHIV services available for the clients.To some the services that are beingprovided are not at satisfactory levelsbecause NGOs and private hospitalsare providing services to clients underspecific guidelines and procedures.IDUs are the most vulnerable groupsfor HIV transmission. Many PLHIVare discriminated during HIV testing/diagnosis by health care providers(doctors, nurses, laboratory techniciansetc.). Given the level of discriminationfaced by PLHIV while getting treatmentfrom government hospitals, local clinicsor from health care providers, some havedecided not to go to a hospital whenneeded. Many also face discriminationfrom their work place. One of the mainreasons behind this is the issue ofstigmatisation. Though HIV tests areavailable in some private health settings,in many cases there is no guarantee ofcounselling support or confidentiality.Many HIV positive people testedboth in private and governmentfacilities have seen their names andother personal details published in thelocal or national media. Social values,lack of adequate information, thestigma attached to HIV and AIDS,and the lack of confidentiality are notencouraging for people, especially theyounger population, to seek out HIVtests.Activities to prevent transmissionin health care settings have focusedon: training health care providers onuniversal precautions to prevent HIV inhealth care settings, and more recently,25

BANGLADESHCAMBODIANEPALPHILIPPINESon the provision of HIV-related clinicalservices, including VCT, management ofSTIs, antiretroviral therapy (ART) andtreatment for opportunistic infections.Steps have also been taken to improvethe safety of Bangladesh’s blood supplyby upgrading 19 hospitals and bloodbanks, training staff, supplying screeningkits, recruiting volunteer donors, andinstituting quality assurance. Goodprogress has been made in decreasingprofessional blood donations (that aremore likely to be infected) from 70 percent to 19 per cent of the supply, andincreasing voluntary donations from10 per cent to 31 per cent (20 years ofHIV, 2009).NGOs like FPAB, HASAB, AAS andMukto Akash who provide preventionand management of STIs services,also provide counselling on FP. VCTservices and psycho-social supportare also provided as part of generalcounselling through provider initiatedtesting and counselling. Condom,specific HIV information to FSWsand migrant labour are also part of theprovision of services.According to all respondents there isa shortage of equipment and of spacefor offering private and confidentialcounselling. Staff time and trainingis insufficient, and staff supervision ispoor. As a result, staff motivation is low,also due to a low pay scale in relationto work load. Some respondents werealso of the opinion that the linking ofSRH and HIV services has not hada major impact because they have notbeen well matched. No efficient serviceis available. Stigmatisation of servicesstill exists. Added to this is the workload and time of service providers.ObservationMost married women are vulnerableto HIV and other sexually transmittedinfections. This is attributed tohusbands who have unprotected sexwith sex workers, and continue to haveunprotected sex with their wives. Manybi-sexual men who have sex with mendo not necessarily identify themselves.Some men who buy sex from other menrarely use condoms and continue tohave sex with their wives. Men havingsex with men are largely hidden due tothe powerful stigma and discriminationthey face in society.Many people in both the rural andurban areas in Bangladesh have heardabout the HIV epidemic but theirknowledge is limited with regard tohow it is transmitted and how theycan protect themselves. Low condomuse, risky behaviour and a general lackof understanding about HIV are notlimited to clients of sex workers. Infact these traits are widespread andheighten the chances of a HIV epidemicin Bangladesh. The HIV prevalenceamong the general public is not fullyknown; currently available surveillancedata only covers high risk groups. Thisambiguity is partly because voluntaryand confidential counselling and testing(VCT) services are not widely availablein Bangladesh.A strong linkage between sexualand reproductive health services andHIV programmes in the countryis required to contain HIV andenhance the range of treatment, careand support. The successful linkagesbetween RH and HIV/AIDSprogrammes and services can only26

e accomplished if there is supportand commitment by the governmentat the policy level, development ofappropriate institutional mechanisms,coordination and collaboration, ratherthan simply expanding and linkingthe vertical. Linked response shouldbe institutionalised in all policiesrelated to RH, HIV/AIDS and interministerialcoordination is requiredamong different ministries includinghealth, education and home affairs.Prevention should be a key elementin the national response to HIV.One of the four key priorities of theUNICEF and UNAIDS global Unitefor Children, Unite against AIDScampaign is - ‘preventing infectionamong adolescents and young people’ -is especially pertinent in Bangladesh.The cornerstone of HIV prevention issafer sex. Young people need practicalhelp in the form of appropriate lifeskills and youth-friendly health serviceswhere they can seek advice, have theirqueries answered and obtain condomsand treatment for STIs. Young peopleneed and have the right to accesscomprehensive information aboutSTIs, HIV and AIDS prevention andpositive living, and to make informeddecisions about sex and sexuality.At the policy level, linkage betweensexual and reproductive health servicesand HIV programmes are graduallybecoming a necessity in addressingHIV. However, integration in terms ofservices is posing a big challenge.There is an urgent need to promotesynergistic approaches between SRHand HIV. SRH and HIV/AIDSresponse is separately administered,funded, and supported by differentdonors and technical agencies, andstill mainly managed and implementedseparately. This reduces opportunitiesfor developing comprehensive linkingapproaches at programme and servicedelivery levels.Given the limited resources in thecountry, planning, integration ofexisting settings and interventions witha common approach can meet broaderhealth and social needs of people,instead of providing services separately.Mainstreaming of HIV will help inremoving stigma and discriminationagainst people living with HIV/AIDS(PLHIV), utilising service deliveryand ensuring human and reproductiverights. This could also ensure an endto discriminatory behaviour againstPLHIV.The lack of linkage means low coverage ofservices, poor access to information andcommodity, higher rate of unsafe sexualand risk taking behaviours, frequentsexually transmitted infections andpoor uptake of voluntary counsellingand screening centres. It was pointedout that existing social stigma aboutHIV, lack of male partner participation,and lack of information pose majorchallenges in addressing HIV relatedissues. Lack of information ormisinformation increases vulnerability.UN and donor agencies could play animportant role by providing funds andputting pressure on GO and NGOs tolink SRH and HIV programmes. Achange in donor interest and fundingmechanisms could make the linkage ofservices possible.27

BANGLADESHCAMBODIANEPALPHILIPPINESA mechanism for better coordinationand linkage between the two divisionsmanaging SRH and HIV programmeswithin the MoHFW should be initiatedthrough formal and informal platformsfor joint planning, financing, monitoringand reporting systems. At the sametime the training curriculum shouldconsider training service providers howto deliver integrated SRH and HIVservices.Major Gaps andChallengesLinked SRHR and HIV programmescan play an important role in effortsto achieve universal access to HIVprevention, treatment, care and supportand universal access to reproductivehealth. SRHR and HIV linkagesand interventions through policy andprogramming in all settings ensurethe achievement of the goals of theprogramme. Access to integrated serviceswill benefit the sector most vulnerableto HIV and sexual and reproductive illhealthlike sex workers, drug users, menwho have sex with men, adolescent girlsand boys, discordant couples, people inconcurrent partnerships, migrants andthose living in conflict situations. Somecritical issues have been raised fromthis study. An agenda for collaborationand synergy both at the policy, systemand service delivery levels needs tobe articulated. This requires specificrecommendations to address thegaps and challenges to foster betterlinkage to improve the effectiveness ofa linked HIV and SRH response inBangladesh.a. HIV/AIDSorganisationalpolicies, practices andorganisational culture• The institutional and organisationalarrangements of the nationalresponse have not been adequatelyplaced and sufficiently empoweredto facilitate more comprehensiveaction on HIV/AIDS and SRH.• HIV/AIDS issues go beyond thedomain of the health sector but arestill largely considered a problemto be dealt with mostly through thehealth sector in Bangladesh.Limited articulation and awarenessabout national policy on HIV/AIDS among government sectors.b. CoordinationLack of coordination and networkingamong NGOs involved in HIV/AIDS and SRH due to lack of apartnership framework, and capacityconstraints of the STI/AIDSnetwork.There is no clearly defined mechanismfor effective coordination amongdonor agencies working in the fieldof HIV/AIDS and SRH, resultingin duplication and overlap of someinterventions and initiatives.Lack of smooth coordinationbetween players has been a majorhindrance in providing services.Within the government, multipleministries need to be engaged toensure the active involvement of keyservices such as law enforcement; thishas not been carried out effectively.28

In addition, not all services canbe provided through the HIVprevention programmes or SRHservices separately.Inadequate resources (personnel,funding, infrastructure) for theNASP, which is the governmentbody responsible for coordinatingthe national response to HIV inBangladesh, has prevented themfrom playing a more proactiverole in effective planning andcoordination at the national level.This inadequacy has translated intointerruptions in service delivery atthe field level as well as inadequate,inappropriate and irregular suppliesof materials (condoms, lubricants,sterile injection equipment, and STIdrugs).c. Programme PlanningGoB and NGOs identified highriskpopulation groups as keypriority and emphasised targetedinterventions for HIV/AIDS. Butthere is no baseline data to set targetsto accelerate coverage.Lack of an integrated communitybased programme model thatwill enhance social mobilisationand behaviour change, as well asempowerment of the community.Planning for sustained HIVprevention programmes is essentialfor an effective response. In order todo this, not only is it important tohave knowledge and understandingof the local situation, but there alsoneeds to be capacity to developa strategic plan based on thatknowledge.d. Implementation• Quality of the interventions variesconsiderably due to lack of initiativesfor strengthening and upgrading theskills of the implementing agencies.• Lack of a comprehensive packageapproach. All programmes aresingle minded approaches to HIVprevention, leading to partial deliveryof a fully responsive preventionpackage. For example, implementersoverlook multiple risks that MARPsmay be facing. For IDUs, the stressis on safe injections, safe sex is oftenignored and condom distribution ispoor. For sex workers, drug use is notaddressed and neither is mobility.• The policies and strategies, manuals,medical standards/SOPs, guidelinesthat are developed are the mainobstructions for linkage andimplementation because they havea narrow focus and the aims aredifferent.e. Scaling upFunding of HIV/AIDS and SRHis mostly project oriented ratherthan programme related. There isno comprehensive projection and noresource mobilisation plan for scaleupof responses.Evidence shows that when the HIVprevention programmes were smallerthey were more effective. Scaling uphas possibly led to a dilution of theeffect of services in many cities; ithas also resulted in lower coveragethan in previous years.Scaling up has often been done using29

BANGLADESHCAMBODIANEPALPHILIPPINESpackages that were effective in onesetting or locale. They may not befully applicable in all other settingsas wellLack of adequate skilled personnel isalso a major barrier.f. Mainstreaming HIV/AIDSLack of understanding andexperience among NGOs tomainstream HIV/AIDS into othersectors in low prevalence settings.There is poor facilitation and lack ofpolicy dialogue within the variousministries and the MOHFW forlinking SRH and HIV services.DGHS and DGFP appear tobe at cross purposes despitea common mandate. Theirwork is polarised and they lackcooperation. More significantly,existing policy, institutional andfinancial management are thebarriers to linking HIV and SRHprogrammes.g. Integration of HIV/AIDSand SRHAt the policy level there is verylittle linkage between SRH andHIV services. Although all policiesand strategies mention HIV andSRH, the focus is very different. Inpopulation policy, a health policy ismentioned. However in the HIVpolicy and strategy paper, SRH hasnot been included. At present thereis no policy guidance for linkagebetween SRH and HIV fromMOHFW.Not all types of HIV/AIDS relatedservices can be integrated intoSRHS and vice versa. Howeverseveral targeted SRH and HIVprogrammes can include the keyservices that meet the needs in boththese areas.The HIV/AIDS programmeis mostly a vertical project notwell integrated with SRH, withinadequate focus on behaviourchange communication.There has been no functional linkagebetween SRH and HIV services inservice centres that offer both SRHand HIV services, especially STIservices, condom provision, VCTand ART.h. Involvement ofPLHIV and affectedcommunitiesConservative attitudes, a fixedmindset, intolerance, are some of thediscriminatory attitudes displayedby service providers. They are ofteninsensitive and averse to PLHIV.A lack of in-depth knowledge onthe needs of MARPs. In generalthe intervention programmes forall MARPs are focused on safe sexor safe injections for preventinginfections. The programmes do nottake into consideration that eachof these marginalised populationgroups has deep seated issueslike violence, social exclusion andhumiliation which are part of their30

daily lives and take priority overHIV.Their more immediate and urgentconcerns such as shelter, food, drugs,must be alleviated before they willbe concerned about the more distantand abstract fear of HIV. Thisbasic premise has to be taken intoconsideration if programmes are tosucceed.There is strong stigma anddiscrimination towards PLHIV,perpetuating isolation and socialexclusion, thus worsening theepidemic and its consequences.i. Quality assurancePeople engaged in high-riskbehaviours often have limited accessto health care. The main constraintsare cultural values, norms andpractices. Added to this, those whoare responsible for providing supportand services are themselves notcomfortable talking about condoms,RTI/STI, problems of SRH andHIV issues. The major challenge isto overcome the problem of socialstigma which is one of the barriersfor implementing programmes ofHIV and SRH in rural areas.Lack of an effective monitoringand documentation system to seechanges in knowledge, perceptionand practice levels.Lack of uniformity and inadequatetesting facilities and campaignmaterials.j. Research andevaluationLack of qualitative evaluation of theprogramme and inadequate actionresearch.Data gathering through surveillance,surveys and research has beenunder-resourced.In order to havethis knowledge it is essential thatdata is gathered regularly, not onlythrough surveillance, but throughdifferent sources. Research studieshave received little priority inBangladesh.k. AdvocacyCulturally service providers feelrestrained to engage in open andfrank discussions about the use ofcontraceptives. For example, teachersfind difficulty to teach the section onHIV that has been included in textbooks.A rights based approach in SRHand HIV programmes has not beenfully endorsed. This has resulted instigma and discriminatory attitudescontinuing to exist among serviceproviders.Lack of standard precautionsfor infection control and limitedprovision of essential supplies andcommodities.HIV positive men and womenneed to be able to make informedSRH choices and have access toSRH services such as FP advice andcontraceptive supplies.Generally people and MARPs need31

BANGLADESHCAMBODIANEPALPHILIPPINESto know about HIV and have accessto information for SRH servicesincluding HIV information in theprogramme.Conclusion andRecommendationsSRH and HIV/AIDS linkedprogrammes and services can work moreeffectively if they encompass notions ofintegration, collaboration, coordinationand independent action. Furthermorethe linkage will also help to achievethe aim of RH and HIV/AIDS in thecountry because the majority of HIVinfections are sexually transmitted orassociated with pregnancy, childbirthand breastfeeding. The risk of HIVtransmission and acquisition can beincreased by the presence of sexuallytransmitted infections. Again SR illhealthand HIV share root causes,including poverty, harmful gender/cultural norms, rights violations,inequality and social marginalisationand criminalisation of the mostvulnerable populations. There is also alack of availability and accessibility toSRH services and HIV counselling andtesting, along with HIV/AIDS relatedstigma and discrimination prevalentin the society. Therefore linking SRH,HIV and rights interventions canimprove access to and uptake of services,provide better care in a more integratedway, challenge the social factors thatinfluence SRH and HIV, reduce stigmaand strengthen rights-based policiesand laws.There are several linkages between HIVand SRH services that will virtuallyeliminate mother-to-child HIVtransmission, provide an ideal platformto deliver the entire recommendedminimum package of antenatal,maternal, child health and reproductivehealth services.This would ensure that pregnant womenare not only offered HIV screening,but that they and their partnersare also offered services to preventHIV and other sexually transmittedinfections, unwanted pregnancies andsexual violence. PMTCT services toANC services could be another majorbreakthrough in the area of linkingthe two programmes. A concreteinstitutional commitment is essentialto HIV/AIDS including SRH issues.Here are some recommendations thatwill help to overcome the challenges:There should be meaningfulparticipation of differentstakeholders, through analysis of thefindings, development of a commonvision, identification of acceptablestrategies and also programmemanagement.There is a need to develop anapproach that will be more peoplecenteredwith a multi-sectoralplanning and decision makingprocess that increases access toresources.Scale up behavioural change activitiesand health promotion interventionsfor high-risk behaviours andvulnerable groups, particularly IDUsand sex workers.Expand advocacy and awarenessamong the general populationthrough multi-sectoral agencies.32

Promote the social acceptability ofcondom use and ensure adequatesupply and access.Reduce discrimination againstthose infected with HIV, or groupsengaging in high-risk behaviours,through appropriate advocacy,policies, and related measures.Promote NGO capacityfor programme planning,implementation, and supervision ofinterventions.Policy makers and programmemanagers should be sensitised toadvocate for the benefits of linkagebetween SRH and HIV services.Donors, UN agencies shouldprovide support for key linkagesbetween RH and HIV/AIDSpolicies, programmes, and services,and ensure funding for linkagesbetween SRH and HIV/AIDS incurrent international and nationalpolicy statementsThere should be more researchcarried out for linking the SRH andHIV programmesThere should be more platformsand strengthening of mechanismsfor collaboration and coordinationwithin and between government,the nongovernmental sector,development partners, and otherstakeholdersPlanning should be more peoplecentredwith a multi-sectoralapproach in decision making.Ensure HIV/AIDS mainstreamingin concerned ministries anddepartments for effectiveintervention. For example, if theEducation Ministry has a desk forHIV/AIDS then they should beresponsible for conducting trainingfor teachers in relation to new policiesin text books. They should alsoconduct monitoring and evaluationof the programme, to ensure that itis being properly taught in schools.Strengthen the government’s capacityfor programme implementation,management, and monitoring ofprogramme activitiesLinking HIV with SRH is alsoimportant to increase accessibilityand availability of services for peopleliving with HIV (PLHIV).Government hospitals should bemore equipped for HIV affectedpersonsExpand the collaboration andnetworking with stakeholders tobuild a stronger foundation forlinked responseTraining of programme managersshould integrate linked responseinterventions such as integration ofSRH into voluntary counselling andtesting (VCT); prevention of motherto child transmission (PMTCT);condom promotion and distributionfor dual purpose; combined SRHand HIV/AIDS messages; etc.The new ARH strategy shouldbe for good coordination andpartnership development withvarious stakeholders: communityparticipation, advocacy, health33

facility availability and knowledgetransfer are key areas, as well assupport of local gate-keepers.An advocacy strategy should bedeveloped to mobilise support forlinked services among policymakers,programme managers, serviceproviders, clients, people living withHIV, and other key stakeholders.RH and HIV services should beintegrated to include STI/HIVprevention information, voluntarycounselling and testing services,general health care, psychologicalsupport, including support forvictims of gender based violenceMaternal health services which focuson the needs of married adolescentsto provide support and careTrainer needs to be oriented inappropriate fashion and mobilised toeducate people about the preventionof HIV/AIDS and promote RH.For example, teachers, nurses, otherservice providers need to have propertraining so that they feel comfortabletalking with the clients.There should be standardised, youthfriendly and equitable services acrossthe country (confidential, technicallycompetent etc.) with guidelines forthe quality of careNew strategies on RH for PLHIVshould be introduced throughcommunity outreach workers toreduce stigma and discriminationGO and NGO should ensure thatthere is space available for clientscomfort and confidentiality.GO and NGO should have provisionfor building staff motivation andaddressing providers’ workloadThere should be more training forservice providers to overcome theirattitudes to stigmaThere should be a monitoringprovision for service providers toregularly review service statistics,such as the number of RH clientsreferred to HIV-related servicesor HIV clients referred to RHservices.BANGLADESHCAMBODIANEPALPHILIPPINES34

References20 years of HIV in Bangladesh: Experiences and Way Forward. December 2009.World Bank, UNAIDS and ICDDR,BBangladesh Demographic Health Survey (BDHS) 2007. Published March 2009Bangladesh Serological Surveillance Survey 2006Bangladesh Urban Health Survey (2006), Dhaka BangladeshBaseline HIV Survey among Youth in Bangladesh 2006, NASP, Save Children-USA, ICDDR,BGovernment of Bangladesh 2008The National Communication Strategy for FamilyPlanning and Reproductive Health Dhaka: Ministry of Health and FamilyWelfare, GOBGovernment of Bangladesh (GOB) 2004b Health, Nutrition and PopulationSector Programme July 2003-June2006, Dhaka: Ministry of Health and FamilyWelfare, GOBGovernment of Bangladesh (GOB) Bangladesh Population Policy, NASP, Dhaka:Ministry of Health and Family Welfare, GOBGovernment of Bangladesh (GOB) National HIV AIDS Strategic Plan for HIV/AIDS (2004-2010), NASP, Dhaka: Ministry of Health and Family Welfare,GOBGovernment of Bangladesh (GOB), 1995 National Policy on HIV/AIDS and STDrelated Issues, Dhaka: Ministry of Health and Family Welfare, GOBGovernment of Bangladesh (GOB), 2003, Adolescent Reproductive Health inBangladesh Status, Policies, Programmes and Issues Dhaka: Ministry of Healthand Family Welfare, GOBGovernment of Bangladesh (GOB), 2008 National Health Policy (An Update),Dhaka: Ministry of Health and Family Welfare, GOBGovernment of Bangladesh World AIDS Day Report 2008National AIDS/STD Proramme (NASP0 [Bangladesh] and Ministry of Healthand Family Welfare (MoHFW) 2009, 2010 UNGASS Bangladesh countryProgress Report, Dhaka, Bangladesh: NASP and Ministry of Health and FamilyWelfareNational End Line HIV Survey among Youth in Bangladesh 2008, NASP, SaveChildren-USA, ICDDR,BUNAIDS Bangladesh Country Advocacy Brief Injecting Drug Use and HIV FactSheet 2009UNICEF HIV and AIDS in Bangladesh Country Fact Sheets January 2010UNICEF, UNAIDS and WHO, Children and AIDS: Country Fact Sheets 2008UNICEF, UNAIDS and WHO, Children and AIDS: Country Fact Sheets 2008USAID, Family Planning Couple Years of Protection (CYP) – 2009 http://www.usaid.gov/our_work/global_health/pop/techareas/cyp.htmlWorld Bank HIV/AIDS in Bangladesh Fact Sheet February 2009WINGS’PETEN PROJECT CONTINUES DESPITE VIOLENCE, Couple Years ofProtection (CYP) http://wingsguate.org/en/cyp.html35

Annex 4The List of Policies taken for HIV/AIDS in various for successful implementation ofHIV/AIDS programmes1. The National Harm Reduction Strategy for Drug Use and HIV, 2004-20102. The National ART Guidelines, 2006;3. National STI Management Guidelines, 2006;4. Training Module for Health Managers on HIV/AIDS, 2006;5. National Standards for Youth Friendly Health Services, 2007;6. Training of Trainers Manual for School and College Teachers and FacilitationGuide, 2007;7. The Training of Trainers Manual on Mainstreaming HIV/AIDS for NGOs andFive Key Ministries, 2007.Below is a list of some of these guidelines and policy documents:1. The Safe Blood Transfusion Act (passed in 2002)2. The National Harm Reduction Strategy for Drug Use and HIV, 2004-20103. National HIV Advocacy and Communication Strategy 2005-104. National Anti Retroviral Therapy Guidelines, 20065. National STI Management Guidelines, 20066. National Policy and Strategy for Blood Safety, 20077. Guidelines for VCT8. National Standards for Youth Friendly Health Services (YFHS) 20079. Standard Operating Procedures for Services to People Living with HIV and AIDS,20092BANGLADESHCAMBODIANEPALPHILIPPINES36

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Annex 5CYP is easy to calculate from data that programs routinely collect; these data cancome from a variety of sources and are relatively easy to track. The term “CYP” reflectsdistribution and is a way to estimate coverage and not actual use or impact. The CYPcalculation provides an immediate indication of the volume of program activity. CYPcan also allow programs to compare the contraceptive coverage provided by differentfamily planning methods.5BANGLADESHCAMBODIANEPALPHILIPPINES38

Annex 6: Figure 2: National AIDS Monitoring and Evaluation FrameworkFigure 1: National AIDS M&E frameworkGoals of natinal AIDS response1. Reduce the spread of HIV2. Improve quality of life those who areaffected and infectedNATIONAL AIDS M&E FRAMEWORKAIndicatorsImpactOutcomesFew ne infectionsSurvival of PLHIVImproved knowledge, reductionof risky behaviourswithwithBiological andBehaviouralsurveillanceEvaluation/Assessments/ResearchInformed byOutputsInputsIncreased coverage forprevention, treat, care, supportIncreased gov. expenditure forHIV and AIDS, policy andleadership supportwithwithProgrammemonitoring dataBData sourcesBio and bahvioural surveillanceBDHS, MICSResearch, evoluation, studiesProgramme monitoring dataModelling, other data sourcesProvide programmermonitoring dataHIV intervetionsTargeted interventionsPrevention in general populationSafe blood tramsfusionTreatment, care & supportFSubmitted to and analysed byCNational AIDS/STD Programme (NASP)Ministary of Health & Family WelfareProvided funding forimplementingGeneratesDM&E reportsQuarterly monitorng reportsAnnual surveillance reportsPeriodic updates, country reportsReported No. of HIV casesDisseminated toStakeholders and nationaland global levelsPolicy levl forumsCivil societyGlobal meetingsE39

Annex 7BANGLADESHCAMBODIANEPALPHILIPPINES40

INSTITUTIONALCAPACITY FORHIV/AIDS ANDSRHR LINKAGESChapter 2Case Studies inCambodiaSamareth Sovannarith,Kim Bunna, Ngauv Bora41

BANGLADESHCAMBODIANEPALPHILIPPINES42

AbstractBackgroundThe HIV epidemic became a keyreproductive and sexual health issuebecause the majority of HIV infectionsare sexually transmitted, or associated withpregnancy, and breastfeeding. Accordingto the HIV Sentinel Surveillance (HSS)report in 2006, the HIV prevalence was thehighest in the region (0.9 per cent), withan estimated 1.1 per cent among pregnantwomen attending antenatal care (ANC)clinics. This indicated that the HIV/AIDS epidemic is becoming generalisedand family planning, safe motherhood, andprimary HIV prevention services in healthcentres are more critical for a comprehensiveresponse between health services. Accordingto the Cambodia Demographic and HealthSurvey (CDHS), only 12.3 per cent ofmarried women have ever been tested forHIV, with very few women being tested inthe course of ANC (12 per cent in 2005).The risk of transmission from mother tochild remains high. Among women whotested HIV positive in the 2005 CDHS,2.2 per cent were pregnant at the time,and 35.9 per cent were in the less than24 months post-partum group. Thesefigures recognise that linkages betweenreproductive health and HIV are crucialto comprehensive management and carefor patients who need concomitant care forrelated health conditions.MethodsThe methodology used for this report wasboth a standard questionnaire for interviewand reviewing secondary materials. Thein-depth interview was carried out amongthe heads of programmes and serviceproviders, to obtain information on sexualreproductive health (SRH) and HIV/AIDS. The secondary analysis of data wasobtained from available documents onSRH and HIV/AIDS in Cambodia.ResultsIn early 2006, the Ministry of Health(MOH)’s National Strategy forReproductive and Sexual Health (NSRSH)in Cambodia (2006-2010) was designed toensure an effective and coordinated responseto reproductive health (RH) needs in thecountry. The NSRSH covers a number oftechnical programme areas: maternal andnewborn health, adolescent reproductiveand sexual health, family planning,reproductive tract/sexually transmittedinfections (STIs), gender-based violence,and early detection of cervical cancer. Thelinked response approach is aligned withthe overall framework between the HIVstrategic plan and prevention of motherto child transmission (PMTCT) strategicplan, including reproductive healthstrategies, in collaboration with two centresthe National Centre for HIV/AIDSDermatology and STD (NCHADS)and the National Maternal Child HealthCentre (NMCHC) to implement thisapproach by the joint-development of aHIV proposal, and comprehensive planswithin the continuum of care operationalframework and yearly set targets.ConclusionThere is some evidence of linkage/integration between HIV and SRHservices at service delivery level, but limitedevidence of specific policies or strategies foran integrated HIV and SRH programme.43

BANGLADESHCAMBODIANEPALPHILIPPINESList of AcronymsANCARSHARTARVBCCBSBSSCoCCDHSCHAICoPCTCPACUPDfIDDPCTHPITCIPCTEWFBHSDFHCFPAntenatal CareAdolescent Reproductiveand Sexual HealthAntiretroviral TherapyAntiretroviralBehaviour ChangeCommunicationBirth SpacingBehavioural SurveillanceSurveysContinuum of CareCambodian Demographicand Health SurveyContinuum of Prevention toCare and TreatmentCondom Use ProgrammeDepartment forInternational Development,UKHealth Provider InitiatedHIV Testing andCounsellingEntertainment WorkerFacility Based HealthService DeliveryFamily Health ClinicFamily PlanningGFGFATMGNIHBCHCHIVHPITCHSDHSPHSSHSSP 2IECIPDKFWMARPMCHMMMMNBHMOHMPAMSMMTCTNCHADSNGOGlobal FundGross National IncomeHealth CentreHuman ImmunodeficiencyVirusHealth Service DeliveryHealth Strategic PlanHIV Sentinel SurveillanceInformation, Education &CommunicationIn-Patient DepartmentMost At Risk PopulationMaternal Child HealthMondol Mith Chouy MithMaternal and NewbornHealthMinistry of HealthMen who have sex with menMother-to-ChildTransmission [of HIV]National Center for HIV/AIDS Dermatology andSTDNon-governmentalorganisation44

NMCHCNRHPNSRSHNational Maternal ChildHealth CentreNational ReproductiveHealth ProgrammeNational Strategy forReproductive and SexualHealthRTISAPACSOPSRHReproductive Tract InfectionSafe Abortion and Post-Abortion CareStandard OperatingProcedureSexual Reproductive HealthODOIOperational DistrictOpportunisticInfectionsSTITBSexually TransmittedInfectionTuberculosisPACTBATraditional Birth AttendantPEPUNFPAPLHAPLHASGPLHIVPeople Living with HIV/AIDsPeople Living with HIVUNICEFUSAIDUS-CDCUS Center for DiseaseControlPMTCTRHPrevention of Mother-to-Child Transmission [ofHIV]Reproductive HealthVCCTWHOVoluntary ConfidentialCounselling and TestingWorld Health Organisation45

BANGLADESHCAMBODIANEPALPHILIPPINESBackgroundThe HIV epidemic became a keyreproductive and sexual health issuebecause the majority of HIV infectionsare sexually transmitted, or associatedwith pregnancy, and breastfeeding.According to the HSS report only1.1 per cent among pregnant womenattended ANC clincs. This indicatedthat the HIV/AIDS epidemic isbecoming generalised and familyplanning, safe motherhood, andprimary HIV prevention services inhealth centres are more critical for acomprehensive response between healthservices. According to the CDHS, only12.3 per cent of married women haveever been tested for HIV, with veryfew women being tested in the courseof ANC (12 per cent in 2005). Therisk of transmission from mother tochild remains high. Among womenwho tested HIV positive in the 2005CDHS, 2.2 per cent were pregnantat the time, and 35.9 per cent were inthe less than 24 months post-partumgroup. These figures recognise thatlinkages between reproductive healthand HIV are crucial to comprehensivemanagement and care for patients whoneed concomitant care for related healthconditions.The NCHADS is responsible for thehealth sector response to HIV/AIDSand sexually transmitted infection(STI) care and treatment, implementedat the operational district level througha continuum of care package andSTI control. Voluntary confidentialcounselling and testing (VCCT)and HIV testing among pregnantwomen are entry points for PMTCTservices and inpatient and outpatientcare for HIV/AIDS, together withopportunistic infections (OI) and antiretroviraltherapy (ART) services. Thecontinuum of care package also offerslinked services between health servicesand communities (HBC, Mondol MithChouy Mith (MMM), PLHASG)and HIV prevention with STI clinics.The CNMCHC is responsible forother reproductive health services,including ANC c , PMTCT, safedelivery, maternal and newborn health(MNBH), family planning (FP), andpostpartum care.The current health system in Cambodiaprovides access to HIV/AIDS, OI/ART, STI, ANC, FP and MNBH.However, these closely related servicesare often not available at the same healthfacility, and some operational districtsdo not offer the full package of services.As a result, the linkages betweenrelated health services are weak, aswell as those between health servicesand the community care services. Also,the linkage between SRH and HIV islimited and not directly linked to eachother. The linked response approachincluding PMTCT and other SRHprogrammes (ANC, FP, MNBH)hasbeen established and implemented bytwo national programs (NCHADSand NMCHC) to strengthen thecurrent health system, to improve thelinkages between health facilities andcommunity health services.This paper aims to assess the linkagesand integration of SRH and HIVservices at the health facility andcommunity services by an integratedpolicy and strategy, planning and46

management system, and health servicedelivery. This assessment also aimsto ensure that health care servicesat all levels provide comprehensivereproductive health and HIV/AIDSprevention, care, and treatment, andfind the gaps and needs in order toimprove, strengthen and scale-up theintegrated HIV and SRH services.ObjectivesThe purpose of this paper is to assesspolicies and strategies, planning andmanagement, and health servicedelivery related to SRH and HIV, andto find the gaps and needs for SRH andHIV programmes.Method and ProcedureReview of policies, strategic plans,guidelines and standard operatingprocedures (SoPs) related to HIVand SRH collected from nationalinstitutions and non-governmentalorganisations (NGOs) involved inHIV and SRH programmes.Key informant interviews for inputon SRH and HIVKeys FindingsPOLICY AND STRATEGY1. National HIV Strategy andPolicyThe strategic plan for HIV/AIDSprevention and care programme wasdeveloped since the first detection ofHIV in Cambodia in 1991. This wasthen revised every two or three yearsaccording to the needs and trends of theHIV epidemic.Since 1998 the NCHADS, underthe Ministry of Health (MOH), hasbeen coordinating and collaboratingto develop a policy and strategic planfor the implementation of an HIV/AIDS and STI prevention and careprogramme in the health sector asfollows:The National Strategic Plan forHIV/AIDS and STI Prevention andCare 1998 – 2000, was developedby the MOH, and identified 12strategic areas in which activitieswere to be undertaken.Early in 2000, as a result ofanalysis of the epidemiological andbehavioral data from the HSS andBehavioural Surveillance Surveys(BSS), NCHADS undertook areview of the National HIV andSTI Strategic Plan. This led to thehealth sector Strategic Plan forHIV/AIDS and STD Preventionand Care, 2001-2005. Underthis Strategic Plan, NCHADSdeveloped a series of specificpolicies, strategies and guidelinessuch as HIV counselling and testingfor surveillance, for AIDS care, foroutreach, for STD case management,and guidelines for the introductionand implementation of variousprogrammes and interventions (e.g.100 per cent condom use, homebasedcare, counselling and testing,STD services).In 2003, NCHADS undertook amid-term assessment of its strategicplan, with technical assistancefrom the US Center for DiseaseControl (US-CDC) the WorldHealth Organisation (WHO), the47

BANGLADESHCAMBODIANEPALPHILIPPINESUniversity of New South Wales andthe Department for InternationalDevelopment, UK (DfID). Thismid-term assessment considered thechanging epidemiological situation,technical aspects of strategydesign and implementation, andadministrative and managerial aspectsof programme implementation.These developments fed into a reviewand up-dating of the HIV and STIstrategic plan for 2003 to 2007, withprimary objectives to respond to thechanging epidemiological situation,and to align with the new HealthSector Strategic Plan 2003-2007.The component interventions of thisupdated strategic plan for controlof HIV/AIDS and STDs weregrouped into four packages, with anumber of components in each: 1)the prevention package (includingbehaviour change communication/information, education andcommunication (BCC/IEC),outreach and peer education, 100per cent condom use and STImanagement); 2) the continuumof care package, which includedestablishing the continuum of careitself, health facility-based careincluding ART, home-based care,VCCT and universal precautions,as well as collaboration with otherdepartments and centres of the MoHfor TB/HIV and PMTCT; 3) theresearch and surveillance package;and 4) the management package(which included planning, reporting,monitoring, administration, logistics,and data management).During 2007, NCHADS workedwith stakeholders in the relevanttechnical working groups to reviewachievements under the previousstrategic plan, to prepare necessarynew approaches and plans, and toset targets for the next period. Aseries of consultation meetings wereheld to review the overall situation,the epidemiology and dynamics ofthe epidemic given the latest data,and to consolidate the componentplans into this strategic plan forHIV/AIDS and STI preventionand care programmes for 2008-2010. This updated strategic planrepresents a major achievement forHIV/AIDS and STD programmesin the health sector in Cambodia.Firstly, it recognises the value andcontribution of all stakeholders;secondly, it responds to the changingepidemiological situation in thecountry; and thirdly, it recognises theimportance of expressing the HIV/AIDS and STD strategy within thecontext of the overall health sectorstrategy, integrating the HIV/AIDS and STD programmes intothe health sector programme. Withthis updated strategic plan are newstrategies to improve the linkagebetween health facility based andcommunity based services to supportfollow up and compliance of peopleliving with HIV/AIDS (PLHA) toHIV/AIDS treatment and care, andto strengthen referral and follow-uplinkages within health facility andcommunity based services (VCCT,OIs and ART services, tuberculosis(TB), PMTCT, STIs, reproductivehealth and nutrition).In mid 2010, this strategic plan wasrevised and updated to meet the48

universal access to HIV prevention,care and treatment services accordingto the MoH Strategic Plan 2011-2015 (to eliminate MTCT by 2020).In accordance with this strategicplan, the two main components are:1) continuum of prevention and careand treatment (CoPCT) focusedon the linking of health services formost at risk population (MARP)at linked response sites and at thereferral hospital where the familyhealth clinics (VCCT, OI/ART,STI and reproductive tract infection(RTI) care and treatment) arealready integrated. 2) strengthenedhealth service delivery for peopleliving with HIV (PLHIV) with theintegration of the 3 I’s strategy forTB-HIV and a package of positiveprevention activities for PLHIV thatincludes (i) advice and counsellingon condom use; (ii) counsellingon ART adherence; (iii) advice onbirth spacing/condom use and safeabortion services; (iv) TB infectioncontrol services; (v) STI preventionand case management.2. National SRH Strategyand PolicyIn 1994, the MoHcreated the NationalReproductive Health Programme(NRHP) within the NMCHC to meetCambodia’s reproductive health needs.The NRHP oversees implementationof the reproductive health policiesand strategies, contributing towardachieving the Health Strategic Plan(HSP), and the National StrategicDevelopment Plan. The NRHPmission is to contribute to the improvedwell-being of the Cambodian peoplethrough (i) better reproductive healthnationwide, (ii) increased gender equity,and (iii) a more sustainable balancebetween population, resources, andsocio-economic development.In early 2006, the MOH’sNSRSH(2006-2010) was designedto ensure an effective and coordinatedresponse to reproductive health (RH)needs in the country. The NRSHstrategy covers a number of technicalprogramme areas: mnbh, adolescentreproductive and sexual health(ARSH), FP, RTIs/STIs, genderbasedviolence, and early detection ofcervical cancer. The objectives of thestrategy are to increase availabilityand strengthen delivery of qualityreproductive and sexual health services;strengthen community understandingof reproductive and sexual health needsand rights, and increase demand forservices; and to expand the evidencebase to inform policy and strategydevelopment.3. Linkages between SRH andHIV in the countryThere is no specific policy and strategyon bi-directional linkages betweenSRH and HIV in the country. Based onthe current health system in Cambodiawhich provides access to HIV/AIDS,OI/ART, STI, ANC, FP and MHBHservices, these closely related services arenot always available at the same healthfacility. Some operational districts donot offer the full package of services.Because health staff are often specialised(FP, STI management, ANC etc.), theymay miss opportunities to providecomprehensive information and to referpatients to relevant health centres for49

BANGLADESHCAMBODIANEPALPHILIPPINESappropriate treatment.As a result, the linkages betweenrelated health services need to bestrengthened, as well as those betweenhealth services and the communityat large. Since 2007, the NCHADShas worked with the National MCHCentre in collaboration with partners(WHO, CHAI, US-CDC) to developa new strategy called a linked responseapproach to establish and implementa pilot project at operational districtlevel. This approach aims to focuseffectiveness at the operations district(OD) level by building capacity to: (1)increase access to comprehensive HIVprevention education, HIV testing, careand treatment; (2) strengthen existingreproductive health services includingPMTCT; and (3) contribute to thestrengthening of Cambodia’s overallhealth care system. This approachwas started in 2008 and continuesto be expanded to other operationaldistricts to prevent maternal-childHIV transmission including sexualreproductive health and HIV infection,while strengthening the referral systembetween OI/ART, STI, ANC, FP,safe abortion, adolescent health, andMNBH.The linked response approach is alignedwith the overall framework betweenthe HIV strategic plan and PMTCTstrategic plan including reproductivehealth strategies. In collaborationwith two centres (NCHADS andNMCHC) the plan is to implementthis approach by a joint-developmentof a HIV proposal and comprehensiveplan within the continuum of careoperational framework and targets setyearly.4. HIV strategy includes SRHissuesHIV testing and counseling services areonly available at referral hospitals, andselected health centres. ANC clinicslocated in public health centres canprovide on-site counselling and testingand education to women on preventingHIV transmission during pregnancy.According to the Strategic Plan forHIV/AIDS and STI Prevention andCare in Health Sector from 2008 –2010, the focus is on strengthening theexisting health care system in order toincrease access to comprehensive HIVprevention and education, to improvethe referral and linkage between healthand community based services (betweenVCCT, OI/ART, STI, ANC, familyplanning, safe abortion, adolescenthealth, and maternal & newbornhealth), and to provide a framework ofactivities for the acceleration of timelyresponse to achieve the goal of universalaccess of HIV and reproductive healthprevention and care and treatmentfor all people by 2010. Therefore,NCHADS works with NMCHC toestablish the linkage programme toimplement a linked response approach(including PMTCT and reproductivehealth). Included as part of the strategyplan is a core strategy to increase accessto HPITC at health services (ANC, FP,STI and TB patients) where it is vitalto provide complete care to clients – toencourage them to seek HIV testing,and to provide counselling related tofertility and reproductive choices forPLHIV.50

In order to support the linked responseapproach FP services located in healthcentres should provide women witheducation about birth spacing, theprevention of HIV and STIs, andPMTCT services. All clients, includingwomen and their partners, should beencouraged to receive HIV testing.Also all pregnant clients should beseen for ANC services. HIV-positivewomen should be referred to a site withART and PMTCT services whereARV prophylaxis are provided.Working closely with village healthvolunteers, traditional birth attendants(TBA) and unofficial medicalpractitioners plays an important role inconducting outreach activities to bringpatients into health care facilities fortesting, counselling, care and treatment.This integration will also allow facilitybasedproviders to identify morepatients in need among those seekingcare in the linked response network.In addition, home-based care teamsand self-help support groups can workclosely with referral hospitals andhealth centres to scale up referrals andinitiate follow-up.HIV in Cambodia is primarilytransmitted through heterosexualintercourse, via commercial and quasicommercialsex. HIV has become aholistic issue and affects everyone.According to the CDHS, only 12.3per cent of married women have everbeen tested for HIV, and very fewwomen have been tested in the courseof ANC (12 per cent in 2005). Therisk of transmission from mother tochild remains high. Among womenwho tested HIV positive in the 2005CDHS, 2.2 per cent were pregnant atthe time, and 35.9 per cent were in theless than 24 months post-partum group.With this result, the NRHP locatedwithin the NMCHC identified severalentities responsible for developing orstrengthening linkages and partnershipswith key ministries, departments,programmes, and sectors. In workingwith the NCHADS and NMCHC,the NRHP has developed policies andstrategies which were related to HIVand STI, and reproductive and sexualhealth strategies by linking health andcommunity based services (as describedin linked response SoP).PMTCT services are offered withinexisting maternal child services. In2001, the PMTCT service started ademonstration project using an “opt in”testing approach in a few sites, providingsingle dose of Nevirapine, and scalingupnationwide.In 2006, provider-initiated testingin PMTCT services was introducedby the MoH. At the same time, theCambodia PMTCT guidelines wererevised in line with the 2006 WHOPMTCT recommendations, andemerging scientific evidence to includemore efficacious combination regimensfor women who do not qualify for ARTfor their own health, and ART forwomen with more advanced disease.In late 2003, the HIV continuum ofcare system including VCCT serviceand ARV treatment for PLHIV wasestablished, and then expanded to otheroperational districts where mothers andtheir babies can be referred for ARVprophylaxis.51

BANGLADESHCAMBODIANEPALPHILIPPINESThe SoP for CoPCT for entertainmentworkers (EWs) is to implement areproductive and sexual health approachin transactional sex service environmentsby developing and monitoring EWcommunications strategy to outlinebehavioural communications objectivesand key messages/channels.Implementation of areproductive and sexualhealth approach intransactional sex serviceenvironmentsAccording to the joint statement,between the NCHADS and NMCHC,the establishment of a linked responseapproach, including PMTCT of HIVand reproductive and sexual healthprogrammes, will be prioritised andexpanded to 55 operational districts by2012. The NCHADS is responsiblefor the health sector response to HIV/AIDS and STI care and treatment.This is implemented at the operationaldistrict level through a continuumof care package and STI control thatincludes VCCT and HIV testingamong pregnant women as entry pointsfor PMTCT services. The linkedresponse approach includes inpatientand outpatient care for HIV/AIDSwith OI and ART services, and thestrengthening of referral mechanismswithin and between community-basedsupport and facility-based services.The NMCHC is responsible for otherreproductive health services, includingANC, PMTCT, safe delivery, MNBH,FP, and postpartum care.With the continuation of the continuumof care (CoC) HIV/AIDS programmeand its expansion into the wider healthsystem, plus improving PMTCTservices and other reproductive andsexual health programmes, Cambodiais facing financial resource gaps for theimplementation of these programmes.There are separate funding sourcessupporting the implementation of HIVand SRH programmes from USAID,US-CDC, WHO, and GFATM, withfunding support for SRH programmesmainly from HSSP2 including UNFPAand KFW. According to the GlobalFund (GF) HIV proposal Round 9, allHIV care and treatment and PMTCTprogrammes, including linked responseand reproductive and sexual healthactivities, are funded by the GF grant.There is a separate monitoring systemfor HIV and SRH programmes. In2010, NCHADS, NMCHC, and otherpartners developed a joint monitoringtool and reporting format to monitorthe linked response approach, includingPMTCT and reproductive and othersexual health activities.Addressing gender, stigmaand discrimination inHIV and SRH strategies/policies.Based on the national strategy for SRHprogrammes in Cambodia, genderis inseparable from reproductiveand sexual health and is essentialfor the effective development andimplementation of programmes andservices. Women and girls are oftenmore vulnerable in Cambodia, due totheir lower status within the family andcommunity. Their biological differencesincrease their vulnerability to gender-52

ased violence, unplanned pregnancy/childbirth, and an increased HIV risk.Male involvement in reproductive andsexual health activities is an importantstep towards increasing gender equity,and the successful implementation ofSRH programmes.Since the CoC programme wasestablished and expanded to otherODs, stigma and discrimination amongPLHIV has been reduced. Because ofthe CoC programme, HIV/AIDScare has not only focussed on medicalcare but has also included a wide rangeof services, such as psychological,social, and legal support. The needfor comprehensive care is thereforecrucial. People at risk need infectionprevention support, and preventionefforts need to be closely linked to careand treatment. These should cover arange of important areas - raising theawareness of PLHA how not to infecttheir loved ones, helping those at highrisk protect themselves by identifyingtheir status, and avoiding infection.One of services of the CoC is theMMM programme which is offered byreferral hospitals. These programmesare conducted via half-day monthlymeetings that provide a cruciallink between PLHA and healthprofessionals at the hospital. The MMMprogramme also aims to reduce stigmawithin the referral hospitals, as well asself-stigma experienced by PLWHA.Through MMM meetings, healthcareproviders gain an understanding ofnon-clinical issues, daily struggles andthe gaps in medical understandingof PLWHA. PLWHA receiveinformation about their illness andtheir treatment programme, and howto access all the resources available tothem. They also learn from each other,sharing their successes and challenges,gradually becoming more confident andcompetent in self-care and appropriatehealth-seeking behaviourPolicies, Strategies,Guidelines and StandardOperating ProceduresSince the HIV epidemic was detectedand became a major health issue inCambodia, some important and timelypolicies, strategies, guidelines, andstandard operating procedures havebeen developed, updated and adaptedaccording to the needs and scope ofprogramme implementation.Data analysed from the HIV and STInational survey, political commitment,the joint-national programme for HIV/AIDS, STI, and other reproductiveand sexual health programmes form thebases upon which the changing HIVsituation is managed.Policies, strategies, guidelines, andstandard operating procedures havebeen updated and are available tosupport the implementation of HIV/AIDS and STI/RTI programmes,PMTCT and other reproductivehealth programmes. These are:Health Sector Strategic Plan 2008 –2015The Strategic Plan for HIV/AIDSPrevention and Care in Health Sector2008 – 2010 is composed of HIVprevention and care components suchas: i) BCC; ii) STI/RTI, prevention53

BANGLADESHCAMBODIANEPALPHILIPPINESand care; iii) CoC at operationaldistrict level; iv) health facility-basedcare services to strengthen and supportthe referral and follow-up linkagesof CoC within different health careservices including adult OI/ARTservices, pediatric AIDS care services,PMTCT and other reproductive andsexual health services; v) communityand home-based care services to ensurereferrals, linkages, follow up andadherence of PLHA to HIV/AIDScare and treatment including VCCT/OI/ART/STI/RH/FP, safe abortion,vi) VCCT to strengthen and supportlinkages between different health careservices within the CoC; vii) HIV andSTI surveillance; viii) HIV research; ix)planning, monitoring and reporting; x)data management; logistic management;and other components including linkedresponse approach to support PMTCTof HIV, FP and other SRH services.National Strategic Plan forreproductive and sexualhealthOperational framework for the CoCfor PLHIV in Cambodia includingactivities to support MNBH byproviding education on MNBH andHIV/AIDS; encouragement andreferral of pregnant women to ANCservices; provision of information,support and referral of pregnant womento PMTCT services; follow-up ofpositive-diagnosed mother and child;referral of pregnant women to healthcentres, VCCT, and birth spacingservices.Policy for implementationof VCCTSoP for PEP in health facility services.There are no guidelines as yet for PEPfor sexual assault.Policy for 100 per cent condom useprogramme that was updated to SoPfor CoPCT for EWsThe Policy, Strategies, Guidelines,and SoPs related to HIV/AIDS andSTD, and PMTCT and other RSHprogrammes has been developed overa three to five year period, and willbe updated every two or three yearsaccording to the need and changingHIV situation.The guiding principles of the NSRSH,outline four key components thatunderlie the strategy. These includehuman rights/empowerment; genderequity; multi-sectoral partnerships,linkages, and community involvement;and evidence-based interventions andapproaches. The results clearly indicatethat gender issues cannot be separatedfrom reproductive and sexual healthissues.Women and girls are often morevulnerable in Cambodia, due totheir lower status within the familyand community and their biologicaldifferences that often lead to genderbasedviolence, unplanned pregnancy/childbirth, and HIV risk. In addition,the strategic plan mentions that theincreasing involvement of men is animportant means to promoting genderequity. It also helps to improve men’shealth-seeking behaviour, at the sametime helping men and their familiesprevent HIV infection and otherinfectious diseases.54

The essential services package forreproductive health is provided byboth public and private facilities andintegrated into other health servicedeliveries such as STI/RTI careservices for the general population, andfamily health clinics for entertainmentworkers, PMTCT, ANC and FP.The general services package furtherincludes condom use, diagnosis andtreatment of RTIs, primary preventionfor HIV, and VCCT for HIV.In order to explain to PLHIV the levelof risk of HIV and STI transmissions,positive prevention messages can beoffered at all HIV health care services.Messages such as the use of condomsamong PLHIV and their partners andHIV stable couples, and information toHIV positive women and their partnersthat they have the right to choose tohave children or not.The strategic plan for HIV/AIDS2008-2010 and SoP to initiate alinked response proposes to strengthenexisting reproductive services, and toincrease access to HIV preventioneducation, VCCT, and care andtreatment among target populations,i.e. the general population of pregnantwomen and their babies, PLHIV, andother MARPs such as EWs and menwho have sex with men (MSM).The linkage between health facility andcommunity based services to improvereferral systems is the main strategy andactivity of the linked response approachto increase patient access to healthservices (STI, OI/ART VCCT, ANC/PMTCT), FP, PAC, and MNBH.It aims to increase the coverage ofoutreach activities implemented bycommunity and home based services,allowing more patient referrals to healthfacility services.The SoP for a continuum of care andtreatment approach for female EWsin Cambodia was approved in late2008. This replaces the previous SoPfor outreach and peer education, and100 per cent condom use programmefor sex workers in Cambodia, whichfocused on linkage between HIVprevention and care, treatment andsupport, and other health care servicesincluding SRH services for most at riskpopulation (e.g. EWs, MSM, and otherMARPs).This more recent SoP outlines clear rolesand responsibilities, and a coordinatedstructure for EW networks using peereducators and facilitators. Accessto and coverage of EWs and otherMARP groups has increased, with theprovision of awareness-raising issues onHIV among MARPs and an improvedreferral system to access health careservices. Strategy 3 of the SoP forDPCT relates to a reproductive andsexual health approach in transactionalsex service environments, and is focusedon:Developing targeted SRHcommunication tools for EWs andother MARPs;Ensuring the availability ofcondoms/lubricants and RH/FPinformation in and around targetedentertainment establishments andhigh-risk areas; andProviding information on otherFP methods through the active55

BANGLADESHCAMBODIANEPALPHILIPPINESpromotion of RH/FP servicesThere are no specific policies onconfidentiality and disclosure for HIVrelatedservices whether administeredthrough SRH or HIV-relatedprogrammes. However, there are someHIV policies and strategies such as thepolicy for VCCT service (HIV testingand confidentiality), the guideline forthe use of ARV drugs for children,and the SoP for implementation oflinked response which describes HIVcounseling and testing, providingcare and treatment for HIV infectedchildren, and referral of patients toother health care services.There were no specific SRH and HIVpolicies supporting condom use. Asdescribed above (No 7), the policystrives to respond to the changingface of the epidemic in Cambodia.The past five years have recorded atremendous increase in the number ofwomen working in non-brothel basedentertainment establishments, andchanges in the nature of transactionalsex.The approach also responds to changesin Cambodia’s policy environment,particularly the promulgation of the2008 Law on the Suppression ofHuman Trafficking, which has made itmore difficult to implement the existing100 per cent condom use programme(CUP). Finally, the approach identifiesprogrammatic solutions to reachCambodia’s universal access targets(EWs and MSM) and strengthenthe implementation of a revisedresponse at the operational district andnational levels. This SoP outlines mainprogramme strategies that include:(1) strengthened policy framework,coordination, outreach and servicelinkages from OD to national level inorder to link and strengthen healthand non-health referral mechanismsat OD level; (2) improved services andservice provision for women in theentertainment industry and for otherMARPs, to improve access of thetarget groups to health care services; (3)implementation of a reproductive andsexual health approach in transactionalsex service environments, to promotedual protection for HIV prevention andRH/FP among high risk populationsby:Ensuring the availability ofcondoms/lubricants and RH/FPinformation in and around targetedentertainment establishments andother MARP within risk areas;Promoting condoms and lubricantsat formal and informal educationalcontacts though peer outreachactivities; andProviding information on other FPmethods, and actively promotingRH/FP servicesThe core strategic components thatare aimed at HIV and STI preventionand the provision of HIV, STI/RTIinformation and unwanted pregnancies,especially among PLHIV, are asfollows:STI/RTI components within theStrategic Plan 2008-2010 aimedat improving the quality of STIclinics to increase coverage of at-riskpopulations, to strengthen the linkbetween STI/RTI prevention and56

care, and VCCT and ANC;Family planning servicesoffering contraceptives andcondoms to clients; a guide forthe implementation of positiveprevention methods for PLHIV:HIV infected women and theirpartners provided with counsellingand information on birth spacingand their right to have children ornot, by providing clear options;unplanned pregnancy - availabilityof and access to contraceptives inaddition to condom use;Conceiving when one partneris HIV-positive - reducing riskduring pregnancy, delivery andfeeding, and maintaining thegood health of the mother afterchildbirthAs mentioned in the guide forimplementing positive preventionmethods, key messages for positiveprevention are provided to PLHIVat MMM/mmm through volunteers;nurse counselors, clinicians, and homebasedcare teams who have a keyrole in providing positive preventionknowledge and messages to PLHIVthrough their daily activities.There are no stand-alone policies forSRH and HIV services. These areexplained and delivered within otherpolicy strategic plans, and SoPs such asthe National Strategy for RSH 2006-2010, the National Policy and Strategyfor prevention and care on STI/RTI,and the SoPs for implementation of alinked response.Based on annual operationalcomprehensive plans, the main sourcesof funds supporting HIV/AIDS andSTI are from GFATM, US-CDC,WHO, UNICEF, USAID, nationalbudget, CHAI, and other partners.The main funding sources supportedfor SRH programmes are from HSSP2including UNFPA, and KFW directlysupporting SRH programmes.FundingFunding is dependent on donorsor national programme proposalsrequesting support funds. Donorsupport for SRH and HIV relatedwork is usually received within the sameprogramme. Round 9 of the GF HIVgrant proposes to maintain and extendcomprehensive care and treatmentfor PLHA through the continuumof care (CoC) framework and linkedresponse approach. This is aimed atstrengthening HIV, PMTCT, ANCand other SRH care and treatmentprogrammes in Cambodia. TheGFATM grant is the main source offunds to improve the linkage betweenHIV and maternal and child health careprogrammes, including ANC, FP andSRH in Cambodia, using the linkedresponse approach integrated into theHIV continuum of care implementedin operational districts.There are no specific cases ofdonors placing restrictions on HIVprogrammes with SRH componentsor vice versa. HIV and PMTCT,ANC and other SRH are integratedinto one “linked response approach” tostrengthen the linkage between healthfacility and community based services.57

BANGLADESHCAMBODIANEPALPHILIPPINESAlthough separate funding sourcesfor SRH and HIV programmes areavailable, there is no estimation ofproportion of budget allocated to eachprogramme. According to GF Round9 HIV grant, 23 per cent of the totalbudget was allocated to implementationof a linked response approach includingrunning cost for maternal and childcare and PMTCT, HIV and SRHcare, and treatment within HIVrelatedprevention, care and treatment.The budget allocated to support mainactivities within health facilities andcommunity based services did notinclude the budget for STI and ARVdrugs, and HIV testing.SYSTEM SUPPORT FOREFFECTIVE LINKAGE OFSRH AND HIVThe linked response approach is ajoint planning framework betweenHIV and PMTCT, ANC, FP, andother reproductive and sexual healthprogrammes that focus on prevention,care, and treatment related to HIV/AIDS and sexual reproductive healthissues. The linked response approachprovides comprehensive care for patientsthrough linkages between health facilityand community based services. Thejoint planning and strategies for theimplementation of a linked responseapproach are:Strengthening referralsbetween HIV/AIDS, OI/ARV, STI,ANC, family planning, safe abortion,adolescent health, and maternal andnewborn health;Providing a core package for ANC- all pregnant women are encouragedto seek antenatal and maternity care,and receive referrals to family planningcounselingProviding VCCT and counselingto educate all clients (adult andadolescent males and females,) aboutHIV and STI, PMTCT and theavailability of health care services;referrals to HIV testing, PMTCT, FPand other health care services.STI services provided as a corepackage. In order to support linkedresponse, all clients and their respectivepartners should be encouraged toreceive HIV testing.Family planning as a core package,to support linked response. Theeducation of women on birth spacing,prevention of HIV and STIs, andPMTCT services.Maternal and newborn healthservices provided as a core package - allclients, particularly pregnant women,should be encouraged to receive HIVtesting, (or their blood samples shouldbe sent for HIV-testing).OI/ART should be provided as a corepackage - HIV-positive clients referredfor TB screening, and HIV-positivewomen referred to family planning andANC/PMTCT if pregnant.No clear procedures are evident for jointplanning of SRH and HIV programmesto be undertaken. What is available isindication of the availability of SRHand HIV information and educationdocumentation. These are: STI andHIV information in the guide onreproductive and sexual health amongadolescents, contained in the National58

Strategy for RSH in Cambodia 2006 -2010.Basic information and educationon HIV/AIDS and STI integratedinto the training curriculum fortraditional birth attendants, andtraining modules on family planningin the community.Limited joint SRH and HIVprogrammes undertaken throughCoC, PMTCT and HIV programmeimplementation on linked responseapproach.There is limited representation fromHIV programmes involved in the SRHplanning process. In some cases, theHIV programme representative wasinvited to participate in joint strategyand curriculum developments.Likewise, there is also limitedrepresentation from SRH programmesinvolved in the HIV planningprocess. Similar to the planningprocess mentioned above, the SRHprogramme representative was invitedto collaborate on a joint STI strategyand policy development, and for STI/RTI training sessions.Collaboration between SRH andHIV for programme management andimplementation exists through variouscoordination bodies including technicalworking groups and committees suchas the continuum of care committeeand PMTCT technical working group.SRH and HIV programmes havebeen improved to provide a linkagebetween facility services (HIV, SRH,ANC, FP and PMTCT) through theimplementation of the linked responseapproach.There is some evidence to suggest thatSRH services have been integrated intoHIV services, and of HIV servicesbeing integrated into SRH services. Theimplementation of the linked responseapproach is to expand to all operationaldistricts, to improve linkages betweenHIV services and SRH services.HIV counselling and testing has beenintegrated into antenatal care andmaternal and child care services. Also,the guide for implementing positiveprevention allows the integration ofbirth spacing services into HIV careand treatment services.Capacity BuildingOverall, SRH services includingANC and FP services are integratedinto health centres which are run bygovernment health institutions. Withthese services, it provides clients withcounselling on HIV, STI informationand education, and access to HIVtesting.The joint statement betweenNCHADS and NMCHC focuses onimproving PMTCT services, includingSRH, ANC, and FP, through theimplementation of the linked responseapproach in operational districts. Thepublic STI clinics established in healthcentres is the primary service entityproviding STI/RTI care and treatmentbased on a syndromic approach andintegrated with reproductive health,birth spacing/family planning andmaternal/new born healthIf the provision of integrated servicesfor HIV and SRH becomes embedded59

BANGLADESHCAMBODIANEPALPHILIPPINESin the healthcare system, health careproviders including HIV clinic staffand nurses at all levels of health servicesshould receive counseling training onreproductive and sexual health andcontraceptive and family planning..SRH staff at health centres also needbetter training on HIV counselling andbasic HIV education.Capacity building among health careproviders should be guided by theprinciples and values of HIV andSRH education, to avoid stigma anddiscrimination, improve understandingof gender and reproductive health,increase male involvement, improveattitudes towards PLHIV, and improveawareness of reproductive rights andchoices, especially among PLHIV.MMM (friend help friend centre whichforms a part of the HIV continuum ofcare framework), organises monthlymeetings at the end of each month toprovide opportunities for PLHIV tomeet and share experiences of HIVcare with each other, and to improvethe relationship between health careproviders and PLHIV. These forumsare also used as a platform to referPLHIV to the required health careservices.One new approach introduced to healthcare providers at HIV care and treatmentservices to improve comprehensivecounselling is positive prevention ofHIV transmission among PLHIV, andthe choice of falling pregnant amongPLHIV. Since 2010, family planningservices have been included as a formof positive prevention for PLHIV atART service.Training CurriculumComponents of STI/RTI, HIV basiceducation, drug use, pregnancy, andgender and reproductive health, havebeen included in training curriculum.These were based on modules fromthe 2007 “Reproductive Health andAdolescents” SRH program.SRH education has been includedin the curriculum of STI/RTI basictraining developed by NCHADS.There is also a plan to include specificmodules on SRH in HIV, OI/ARTand VCCT training curriculum.ChallengesThe challenges faced in relation tointegrating SRH and HIV are:inadequate staff working on SRHand HIV serviceshealth care staff with specific tasksand responsibilities at health careservice centresworkload of staff if integrated HIVand SRH services are introducedcapacity building for health staff atall health facility services related toSRH and HIV.staff motivationimproved quality of health careservicesThe national strategy for reproductiveand sexual health indicates an increasedgrade and benefits for key reproductivehealth providers, particularly qualifiedmidwives. The MoH is committed tohave at least one trained midwife ineach health centre.60

Logistics management proceduresfor both SRH and HIV programmeshave been integrated into the MoHsystem through central medical stores.While “integrated laboratory” facilitiesare available at some HIV clinic sites,the complete SRH laboratory packageis not readily available to clients. Forexample, pregnancy testing is notroutinely available to PLHIV womenin the OI/ART cohort.Within the next five years, the MoH andkey stakeholders will need to developa long-term strategy for reproductivehealth commodity security, withmonitoring and evaluation structures inplace to capture client access to servicesin both SRH and HIV programmes.Based on documentary evidence statedbelow, the indicators being used tocapture integration between SRH andHIV are:a. Strategic Plan for HIV/AIDS andSTI Prevention and Care 2008-2010:Proportion of women accessingANC services who are tested forsyphilis (UA 35)Percentage of ANC attendeeswith positive syphilis test (UA36)Number and percentage ofpregnant women who were testedfor HIV and received their testresultsNumber and percentage of HIVinfectedpregnant women whoreceived a complete course ofARVb. National Strategy for Reproductiveand Sexual HealthPercentage of married womenusing modern birth spacingPercentage of pregnant womenwith 2+ (two or more) ANCconsultation with skilled healthpersonnelpercentage of HIV pregnantwomen aged 15-49 visiting ANCNumber and percentage of HIVinfectedpregnant women whoreceived a complete course ofARVPercentage of young people aged15-24 reporting use of a condomduring sexual intercourse with anon-regular sexual partnerc. The Guide for Implementation ofPositive Prevention among PLHIVNumber and percentage ofPLHIV who received informationon condom use and condoms forpreventing HIV and STINumber of PLHIV who arereferred to ANCNumber of PLHIV who arereferred to FP clincsd. The SoPfor CoPCT among EWNumber of referral slips collectedfor STI/RTI services and RH/FP5. There are separatechecklists between SRHand HIV programmes tomonitor at health servicedeliveries.61

BANGLADESHCAMBODIANEPALPHILIPPINESSERVICE DELIVERYOverall, the integrated and linked SRHand HIV services have been offered atselected referral hospitals and healthcentres. The SRH services includingANC, FP, maternal and child health,STI and other SRH services areoffered at health centres and integratedor linked to HIV services established inoperational districts.Based on the Guide for Implementationof Positive Prevention among PLHIV,the positive prevention message andfamily planning service can be offered atselected health facilities where PLHIVaccess care and treatment.According to the draft of strategicplan 2011-2015, HIV continuum ofcare and support components havebeen revised, with a restructuredcollaboration diagram that indicates thelinking of comprehensive health careservices between all levels in operationaldistricts. In the draft of the revisedstrategic plan health service delivery(HSD) is one of the HIV care andtreatment components that includes allhealth services at MPA and CPA levelsavailable to PLHIV. HIV testing (entrypoint to care) and OI/ART services areessential parts of the HSD.The HSD for PLHIV has been recentlystrengthened through the linkedresponse approach with an integrationof the 3 I’s strategy for TB-HIV and apackage of positive prevention activitiesfor PLHIV that includes 1) adviceand counselling on condom use; 2)counselling on ART adherence; 3)advice on birth spacing/condom andsafe abortion services; 4) TB infectioncontrol services; 5) STI prevention andcase management, and the provision offamily planning services.Constraints of the integrated/linkedSRH and HIV services that may arisewithin the next five years could be:Shortage of equipment for offeringintegrated servicesShortage of space for offeringprivate and confidential servicesShortage of staff timeShortage of staff trainingInappropriate/insufficient staffsupervisionLow staff motivationLinking SRH and HIV services couldimpact on the increased cost of healthservices, cost for clients, workload ofhealth care providers, space and privacy,and the need for equipment, suppliesand drugs.ConclusionThe results indicate that there is limitedspecific policies or strategies for anintegrated HIV and SRH programme.Currently, integrated/linked HIVand SRH services have been deliveredbased on separate policies, strategies,guidelines, and SoPs. However, somelevel of integration/linkage betweenSRH and HIV programmes has beeninitiated at the service delivery level,strengthened through the introductionof the linked response approach andpositive prevention for PLHIV.62

ReferencesStrategic Plan for HIV/AIDS and STI prevention and Care programme in HealthSector from 1998-2000, from 2001 – 2005, from 2003 – 2007, and from 2008– 2010.National Strategy for Reproductive and Sexual Health in CambodiaSoP for Implementing Linked Response ApproachStrategic Plan for PMTCTSoP for the Continuum of Care for PLHIV in CambodiaNational Policy and Strategies for prevention and Care on STI/RTI 2006-2010Joint NCHADS-NMCHC Statement on the Implementation of the HIV PMTCTCurriculum training for STI/RTI (initial training)VCCT curriculum trainingThe Guide for Implementation of Positive prevention among PLHIVSoP for Implementation of Community Prevention, Care and SupportHIV Sentinel Surveillance in Cambodia 200663

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INSTITUTIONALCAPACITY FORHIV/AIDS ANDSRHR LINKAGESChapter 3Case Studies inNepalDr. Lakhsmi Narayan Thakur,MBBS, M.Sc.65

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ABSTRACTBackgroundThere are a number of health policies andstrategies, guidelines for reproductive health(RH) and HIV/AIDS programmes in Nepal.They are the National Health Policy (1991),National AIDS Policy (1995), Second LongTerm Health Plan (1997-2017). NHSP-IP I(2004-2009), National HIV/AIDS Strategy(2006-2011), Three Year Interim Plan (2008-2010) and NHSP-IP II (2011-2015). TheMinistry of Health and Population (MoHP)includes sexual reproductive health (SRH)and HIV as a priority one programme.While the Family Health Division (FHD)under the Department of Health Services(DoHS) manages delivery of RH servicesthough primary health care delivery systemsthroughout the country, HIV programmesare managed by the National Center for AIDSand STD Control (NCASC) in selectedinstitutions predominantly for preventionof mother to child transmission of HIV(PMTCT), voluntary counselling and testing(VCT) and antiretroviral treatment (ART).The focus of the National HIV/AIDSStrategy is for the most-at-risk populationstargeted by the national response to HIVand AIDS and includes: injecting drug users(IDUs), female sex workers (FSW), men whohave sex with men (MSM), migrant workers,and sexual partners/spouses of the migrantpopulation groups. The GFATM, USAID,DfID, World Bank and INGOs are the majordonors supporting the implementation ofSRH and HIV programmes in Nepal, bothtechnically and financially.MethodsAll information for this assessment wascollected through standard questionnairesdeveloped for the bidirectional linkage(rapid assessment tool). The following healthfacilities were visited for interview with serviceproviders to ascertain the linkage between RHand HIV services (FPAN, Pulchowk, SACT,Kathmandu, Maternity Hospital, Thapathali,Kathmandu and Infectious Disease Hospital,Teku).ResultsThe findings of this study demonstrate thatthere is no systematic approach to linkingSRH and HIV at policy and system levels;there is no specific strategy for a health systemresponse to HIV and AIDS through its linkwith other SRH services. While the majorityof funding for RH services is provided by andmanaged through the government budget,the majority of HIV funding is administeredby External Development Partners (EDP),including Global Fund Principle Recipients.The HIV programmes in Nepal have beendesigned in a way that encourages rapidresponse towards most-at-risk-populationsthrough civil societies and networks of peopleliving with HIV and/or AIDS (PLHIV),and expansion of the programme, but notthrough the government health system. Thereis no national policy guidance for integrationof SRH and HIV/ AIDS services. Theresponse of the MoHP lacks clear guidelinesin relation to linkage of SRH and HIVservices. The donors have neither pushednor put any restrictions on linking SRH andHIV because of their mandate, territorialinterests and different funding mechanisms.A rights-based approach to SRH and HIVprogramming has not been fully endorsed bypolicy in Nepal, despite the commitments toseveral international declarations includingthose taken at the International Conferenceon Population and Development (ICPD), theMillennium Development Goals (MDGs)and the United Nations General AssemblySpecial Session on HIV/AIDS (UNGASS).The government of Nepal (GoN) in theInterim Constitution of Nepal has endorsedhealth as a basic human right. HIV andAIDS issues have been incorporated intodifferent medical standards and protocolsand training manuals on RH. But the HIVand AIDS strategies have not outlined howHIV services will be integrated with otherRH services. The Country CoordinatingMechanism (CCM) managing the GlobalFund grants has been weak in facilitatingpolicy dialogue and consensus for integrationof SRH and HIV services. Most of therespondents of the assessment were of theopinion that the current policy and programmeimplementation will not be successful inaddressing linkages between SRH and HIVunless there is strong leadership roles playedby the donor community.ConclusionMany of these gaps and challenges should beaddressed at the policy level by multilateraland bilateral donors, national and localgovernments, and community-based groupslooking for linkages between SRH and HIV.67

BANGLADESHCAMBODIANEPALPHILIPPINESBACKGROUNDA. Sexual andReproductive HealthProgrammes in NepalBased on the National Health Policy(1991), the MoHP developed a 20-year Second Long-Term Health Plan(SLTHP) for 1997-2017. The SLTHPvision is a healthcare system withequitable access and quality services inboth rural and urban areas. The aimsof the plan are to guide health sectordevelopment in the improvement of thehealth of the population, particularlythose with unmet health needs,addressing disparities in healthcare,assuring gender sensitivity andequitable community access to qualityhealthcare services. The SLTHPintends to provide a guiding frameworkto build successive periodic and annualhealth plans that improve the healthstatus of the population; to developappropriate strategies, programmes,and action plans that reflect nationalhealth priorities that are affordableand consistent with available resources;and to establish co-ordination amongpublic, private and non-governmentalorganisation sectors, and developmentpartners. SRH is a focus programme inthe SLHTP.The Nepal Health Sector Programme-Implementation Plan (NHSP-IP)2004-2009 and 2010-2015, and theThree Year Interim Plan includes SRHas a priority programme under theEssential Healthcare Services (EHCS)package. The commitment of the GoNin strengthening the integrated healthprogramme to provide comprehensiveand integrated SRH services wasreflected through the development ofthe National Reproductive HealthPolicy (NRHP) in 1998, based on therecommendations from ICPD 1994.This policy included guiding directionsfor implementation of programmesfor eight health components, namely,safe motherhood, sexually transmittedinfections (STIs), family planning(FP), HIV and AIDS, RH of theelderly, adolescent reproductive health(ARH), infertility and post-abortioncare services. Based on the differentpolicy guidelines, protocols andstrategies, action plans were developedfor implementation through the formalhealth system.SRH services are available through allgovernment health facilities in Nepal,while HIV services are availablethrough selected health institutionsof the country. SRH forms part ofthe government health service deliverysystem managed by the FHD under theDoHS, delivered through the districthealth office/district public healthoffice (DHO/DPHO) from districthospitals, primary health care centres(PHCC), health posts (HP) and subhealthposts (SHP). Logistics for allhealth institutions in a district aremanaged by the Logistics ManagementDivision of the DoHS in coordinationwith the FHD and the DHO/DPHO.Some NGOs like the Family PlanningAssociation of Nepal (FPAN), NepalRed Cross Society (NRCS) andSunaulo Pariwar Nepal/Marie StopesInternational (SPN/MSI) also provideRH services in the districts throughtheir own clinics, managing theirlogistics but reporting to the DHO/DPHO. The FPAN receives family68

planning products from DHOs/DPHOs.Although the National RH strategyincludes eight components, onlythe safe motherhood and the familyplanning components have a nationalcoverage. Scaling up of adolescentsexual reproductive health (ASRH)programmes, despite the NationalAdolescent Health and Developmentstrategy (2002) and implementationguideline (2008), have still a long wayto go in Nepal. The other componentsof RH are either available throughselected health institutions or throughthe private sector only.The current statistics of key RHindicators produced from the NepalDemographic and Health Survey 2006are presented in the table below:B. HIV and AIDSProgrammes in NepalThe first case of HIV in Nepalwas reported in 1988. In 2009, theestimated number of people living withHIV in Nepal was about 64,000 (rangeof 52,000–77,000); the estimated adultHIV prevalence was 0.39 per cent,(NCASC 2010b).As of June 2010, atotal of 15,945 HIV cases and 2,403cases of AIDS have been reported(NCASC 2010a). About 31 per cent ofreported HIV cases were women aged15-49 years.Nepal has concentrated HIV epidemics,with levels of the epidemic varyingacross different geographic areas as wellas different population groups. Thecountry has been broadly divided intofour different geographic zones withinthe context of responding to HIV andAIDS. The 26 districts of the Teraihighway zone accounted for 50 per centof PLHIV in 2007.169

The Far Western Hill zone, sevendistricts where most of the migrants toIndia are residing, accounts for 16 percent of all infections. The KathmanduValley, the capital city with threedistricts, accounts for another 16 percent of all infections. The RemainingHills zone, covering 39 mountainousdistricts, accounts for 19 per cent ofpeople living with HIV.II. METHODOLOGYAll information for this assessmentwas collected through standardquestionnaires developed for thebidirectional linkage (rapid assessmenttool). The following health facilitieswere visited for interview with theservice providers to ascertain thelinkage between RH and HIVservices (FPAN, Pulchowk, SACT,Kathmandu, Maternity Hospital,Thapathali, Kathmandu and InfectiousDisease Hospital, Teku).III. NATIONAL RESPONSETO HIVHIV and AIDS have been accordedhigh priority. Many national policiesand documents (PRSP, National threeyearInterim Plan, National HealthSector Plan – II, UNDAF, the NationalAIDS Policy (1995) are in the processof revision. The country has providedcontinuity in developing a multi-yearbudget within the National ActionPlan (2008 -2011) to operationalisethe National HIV and AIDS Strategy(2006 -2011).Nepal’s national programme targetsthe country-identified most-at-riskpopulations - IDUs, MSM, FSWs andMSWs, clients of FSW and seasonalmale migrant labour and wives ofmigrants.The main thrust of the programme isneeds-based and tailored to the specificcharacteristics of the population group.Primary prevention is given high2BANGLADESHCAMBODIANEPALPHILIPPINES70

priority. A large part of the preventionprogramme is currently supported bythree major grants from USAID, DFIDand the GFATM (Round 2, Round 7),with activities being implemented by asizeable number of community basedorganisations and national NGOsincluding PLHIV.So far the most notable institutionalmechanism is the National AIDSCouncil (NAC) chaired by the PrimeMinister. This is the highest levelbody providing the highest level ofleadership, multi-sectoral policy andguidance to the HIV/AIDS responsein Nepal. However, the NCASC hasremained the key institution in thenational response to HIV. In view ofchanging needs within the institutionalarrangement, the HIV/AIDS andSTI Control Board (HSCB) was setup under the chair of the Ministry ofHealth, along with representation fromcivil society organisations, to furtherpromote policy development, multisectoralcoordination and monitoringthe national response.Government service delivery outlets haveincreased - particularly for VCT, ARTsites, sub ART sites and OpportunisticInfections (OI) management sites- along with additional service sitesimplemented by various NGOs andINGOs. However, the uptake ofservices has only marginally increased.Detection of positive cases has almostremained constant and utilisation rateper VCT centre has gone down. Asof July 2009 there were 3,236 peopleon ART. In December 2009, thatnumber increased to 3,540. Despite anincreased uptake of ART from 11 percent in 2008 to 19 per cent in 2009,the coverage is still low. This indicates71

BANGLADESHCAMBODIANEPALPHILIPPINESthe need to scale up ART services toreach those who are in need. SimilarlyPMTCT uptake at 3.29 per cent (in2009) calls for urgent attention toscale up the programme. The difficultgeographical terrain, compounded bythe lack of adequate information aboutexisting services, greatly limits theaccess and full utilisation of availableservices.IV. LIMITATIONS OF THEASSESSMENTThe focus of the assessment was toanalyse experiences relevant to thelinkages of SRHR, and HIV and AIDSfrom the policy, strategy, systems andservice delivery perspectives. Althoughrequisite information relating to thestudy was generated through in-depthinterviews with key informants fromconcerned organisations, adequateinformation related to service deliveryoutside Kathmandu could not begenerated during the assessment due tolack of time.V. FINDINGSPoliciesA. National Policies andGuidelinesNepal has both the national HIVpolicy (1995) and national HIVstrategy (2006-11). Both these policyand strategy documents are in theprocess of revision. Similarly there is anational SRH strategy (1998) in linewith the ICPD programme of action.This strategy was revised in 2006 butrespondents working in the area of SRHreported that the revised strategy wasnot endorsed by the MOHP. Althoughthe revised strategy was not endorsedmany people interviewed were of thenotion that gender based violence wasadded as the ninth component of theRH strategy.There was mixed response on the statusof bi-directional linkages betweenSRH and HIV. While majority of therespondents from NGOs and civilsociety groups do not see clear linkagesbetween the two programmes, someGoN officials reported that there isbidirectional linkage.A civil society memberremarked that “Linking theSRH and HIV service is not thepriority of PLHIV”.A UN respondent said that “In aweakened health system, linking the twoprogrammes may dilute the strength ofone or the other”.A senior level manager from the GoNexpressed that SRH stakeholders arereluctant to link HIV/AIDS becauseof the focus on high-risk groups, andbecause of fear of stigmatisation thatcould risk losing some newly wongains, particularly ICPD-relatedachievements. While the AIDS sectorcontinues to focus on MARPs forprevention, the SRH field failed to seethat many in these groups were potentialclients for SRH services that couldboth prevent HIV and ensure theirreproductive and sexual health rights.He opined that expanding PMTCTservices to antenatal services could be72

the major breakthrough in linking thetwo programmes.“Donor agencies are notinterested in linking these twoprogrammes because of theirterritorial interests, and fundingmechanisms, otherwise theseservices could have been linkedby now”.Few respondents remarked that “HIV isnot a priority programme of the GoN;these are donor supported programmes.Therefore if some EDPs can push it orfacilitate it, there will be linkage. Someargued that advocacy for linkage shouldcome from the grass roots level.Upon further questioning, NGOsand GoN officials both reported thatthe national RH strategy (1998)1 hasidentified HIV as one of the eightcomponents of RH. Linkages havebeen made into the National SafeMotherhood and New-born Health –Long Term Plan (2006-2017).Most of the respondents agreed that thelinkage is weak and not systematicallydesigned. Few respondents alsoargued that the strategies and policieswere developed at different points oftime, further reducing the ability todesign a linkage between policies andprogrammes. Most of the NGO andcivil society respondents remarked thatbecause of the specific mandate of theorganisations, these two programmesare running independent of each other.While the MoHP is responsible foroverall policy, the FHD is responsiblefor SRH planning; and the NCASC isresponsible for HIV/AIDS planningat the departmental level.Some of the respondents from GoNacknowledged that there is jointplanning between the two departmentsat the DoHS and the MoHP levelon an annual basis. Civil society andNGO partners view that as a mereadministrative exercise, rather than ameaningful discussion for linking SRHand HIV. Neither departments haveraised concerns for linking SRH andHV or vice versa.Nepal is party to several human rightstreaties including the Conventionon the Elimination of All Formsof Discrimination Against Women(CEDAW). While strategy emphasisis on integrated service delivery, intersectoralcoordination of all healthprogrammes endorses internationalconsensus documents related to SRHand HIV, such as the declarationsarising from ICPD 1994, UNGASSDeclaration on the Universal AccessInitiative and the Three Onesprinciples, CEDAW Beijing Platformof Action, and the 2000 UnitedNations Millennium Declaration.The strategy is also well linked to theWHO/UNAIDS Universal AccessInitiatives by recognising that in Nepal’sconcentrated HIV epidemic, 70 percent of MARPs should be reached byHIV prevention programmes.The Tenth Five Year DevelopmentPlan, 2003-2007, NHSP II andThree Year Interim Plan and UNDAFidentifies the HIV epidemic as a highpriority programme in the healthsector. The plan focuses on the need73

BANGLADESHCAMBODIANEPALPHILIPPINESfor prevention programmes within abroader framework that addresses theneeds for treatment, care and supportof PLHIV. The National HIV/AIDSStrategy was developed as a policy inthe context established by the five yearplan, and recognises the links betweenHIV control efforts and broaderdevelopment goals.The National HIV/AIDS Strategy,2006-2011 aims at achieving all HIVand AIDS commitments and targetsincluded within these initiatives. TheMDGs declare that the spread ofHIV should be halted by 2015 withdecreasing epidemic levels.The strategic plan prioritises reducingthe spread of the HIV epidemicand ensuring access to preventionprogrammes. The strategy recognisesthat more effort is required to achievean adequate coverage of MARPs.Many respondents reported thatthere is a joint planning for PMTCT,especially community based PMTCTprogramming between SRH and HIVdepartments. The SBA policy andtraining guidelines include PMTCT.HIV strategy favours Venereal DiseaseResearch Laboratory (VDRL) testswhere the services are available. Postexposure prophylaxis (PEP) is onlyavailable for service providers but notfor survivors of sexual assault. Most ofthe participants reported that protocolsand manuals are being used for bothRH in health facilities and PMTCT,VCT and ART service delivery sitesfor HIV.Most of the respondents were unawareof any law on gender based violence.However all expressed the view thatthis is in the preparation process withsupport from rights activists for thelaw on GBV (Forum for Women, Lawand Development). However theywere of the opinion that the media’shighlighting of the issue of GBV hasled to the increase in case reporting. Theenforcement of law has been weakenedfor some time in the country due to theon-going peace process and politicaltransition. Nepal is in the process ofdrafting a new constitution for a federalrepublic through 601 members of theConstituent Assembly (CA).HIV strategy and policy includes familyplanning in PMTCT and programmingfor dual protection. Both are budgetedin the national plans. However, SRHstrategy is not included and is therefore,not budgeted as a part of the nationalplans. The HIV strategy addresses HIVrelated stigma and discrimination andvulnerability factors related to MARP(MSM, SWS, IDUs and migrants, andyoung populations within the contextof MARPs).There is no clinical guideline on SRHfor women living with HIV. PEP isnot available for survivors of sexualassault but male and female condomsare described in the SRH protocols.There is no guideline for routine testingfor HIV and syphilis among pregnantwomen, although the strategy favoursroutine VDRL testing, where servicesare available.Although VDRL tests are carried outroutinely, testing for HIV is done in thePMTCT and VCT sites only. Mostof the respondents routinely consultthe national standards, protocols and74

guidelines especially those related toVCT, PMTCT and ART.However it was noted that saidguidelines, especially RH relatedprotocols, are not used in the privatesectors, including medical colleges inNepal. These institutions are guidedby their own hospital guidelines andprotocols.Pursuant to the Eleventh Amendmentto the Muluki Ain (code of conduct),the legal age for marriage for both sexesis 20 years; however, where the parentsor guardians consent to the marriage,the minimum age is 18 years for bothsexes. Generally, a marriage must beperformed with the consent of bothparties. Marriages entered into withoutthe free and full consent of both partiesare voidable.In Nepal, the legal age of consentfor HIV testing is 18 years. Anyone18 years or older requesting VCTis deemed able to give full informedconsent. Children (below 14 years) andminors (under 16 years) cannot legallyprovide consent.Under the following circumstances,HIV testing may be recommended tominors:Children born to HIV positivemothers (HIV exposed children)Children and adolescents withclinical indicators of HIV/AIDSVulnerable children and adolescentsat increased risk of HIV infection(e.g. street children)Children and adolescents whoengage in high risk behaviour suchas sex work or injecting drug useChildren and adolescents who havebeen sexually abusedAdolescents who are sexually activeor are marriedIn these circumstances, the counselloror clinician will need to explore with theminor and/or their parent/guardian:Whether it is in the best interest ofthe minor to be tested for HIVWhether the minor and/or parent/guardian would benefit fromcounselling and testingWho will provide consent?Whether, when and how the minorwill be informed of the HIV testresult (disclosure to children)Consent for HIV testing ofadolescents (young peopleunder the age of 18)All young people under the age of18 accessing VCTs should haveaccess to preventive counsellingregardless of their marital status andwhether or not parents or guardiansconsent. Counselling should includeinformation on SRH and FP. HIVtesting may be undertaken withoutparental consent on a case-by¬-casebasis, if the counsellor determines thatthe minor has sufficient maturity tounderstand the testing procedures andresults. Adolescents can be designatedas ‘mature’ or ‘emancipated’ minors ifthey are married, pregnant, and sexuallyactive, or are already parents.75

BANGLADESHCAMBODIANEPALPHILIPPINESIn special situations, where no legalguardian is available such as in the caseof street children, orphans, etc. theVCT site can provide HIV counsellingand testing of the minor. In this case,a second health worker such as thedoctor can act as a surrogate guardian.Each case will need to be assessed bythe counsellor and a decision reachedon the basis of what is ultimately in thebest interest of the minor.Accessing SRH services is independentof marital status. Legal ages areseldom monitored because in somecommunities of Nepal, marriage takesplace at quite an early age.Legislative and policy frameworksprovide an overarching enablingenvironment for effective action on bothHIV and SRH, and promotion andprotection of sexual and reproductiverights.Laws related to issues that haveimplications for HIV, AIDS andSRH, e.g. gender-based violence andsexual coercion, discrimination, earlymarriage, are either non-existent ornot enforced. While the official statemechanism to monitor human rightsviolations of MARPs and PLHIV isnot very specific, civil societies, media,activists and professionals regularlycollect and share cases related to humanrights violations. Networks of PLHIVand other MARP groups also publishsuch cases regularly in their newsletters.In an effort to move towards a rightsbasedapproach and ensure equity ofservices, the Supreme Court legallyrecognises a third gender (TG). TheNational Citizenship Card will nowhave three options to choose from inthe “sex” column i.e. male, female, andthird gender. A national workplacepolicy and a national drug control andharm reduction strategy are amongseveral documents issued in support ofthe response to HIV and AIDS.The AIDS Bill however is taking a longtime for endorsement by parliament.This has to be endorsed for quickimplementation of the service provisionto PLHIV.However, ongoing criminalisation ofsome risk behaviours associated withHIV transmission (sex work, illicit druguse) is impeding the implementation ofother HIV-supportive policies. Furthercoordination with law enforcementagencies and the criminal justice system,with strong support and commitmentfrom the highest levels of government,is still needed.Sexual and gender minority groups(lesbian, gay, bisexual, transgender andintersex -LGBTI) face a multitudeof discrimination including access tohealth and prevention services relatedto HIV and AIDS, human rightsviolation and legal protection. TheBlue Diamond Society (BDS) is theonly organisation in Nepal working toraise awareness about the health andhuman rights of Single Gay Males - hasachieved considerable success in termsof grassroots community outreach andlegal advocacy.One of the BDS’s most significant effortshas been a petition to the SupremeCourt of Nepal, demanding the rightsof LGBTI individuals in Nepal to enjoyequal protection and standing beforethe law. In December 2007 the Supreme76

Court responded to the petition byissuing a directive to the GoN to ensurethat all individuals have the right to liveaccording to their own identity andto correct those discriminatory lawsthat violate the constitutional rightsof LGBTI individuals. Identifyingall SGMs as “natural persons” underthe law, the Supreme Court orderedthe government of Nepal to reformall legislative provisions referringexclusively to men and women only andinclude the Third Gender. Furthermore,the decision ordered the issuing of legaldocuments, including citizenship cardsand passports with an identity categoryfor Third Gender, and confirmed theright to same-sex marriage underNepal’s legal framework.This was a major breakthrough in theprocess of rights recognition for sexualminorities in Nepal. Throughout theentire process, the BDS obtainedsupport from human rights activists,lawyers and civil society leaders.Most of the respondents expressed theneed for orientation and training onlinkage and integration between SRHand HIV, proposal writing, advocacy,monitoring and evaluation, and others.So far, no training on linkages has beenoffered.B. Funding and BudgetarySupportIn 2007, Nepal received US$22,681,199for HIV and AIDS-related initiativesand spent US$ 17,661,653 on activitiessupporting these initiatives. Overall, theabsorption rate was almost 80 per cent.Of the total spending for HIV-relatedactivities in 2007, US$8,187,202 (46per cent) was spent on a preventionprogramme, and US$2,936,452 (17per cent) on care and treatment relatedactivities. Over 28 per cent (US$5million) was spent on programmemanagement and administration. Moreinformation and analysis is necessaryto be able to detail expenditure onprogramme management in the contextof strengthening the national spendingcapacity for programme interventions.Partners committed about US$33million for the two-year period 2006-2008 (about US$17 million a year)compared to the US$64 millionbudget of the National Action Plan(2006- 2008). Some US$17.5 millionwas actually spent, indicating a fairlyconsistent pattern of commitment andactual spending. However, this spendingis only 50 per cent of total requirementaccording to the National Action Plan2006-2008.Spending for the six major strategiccomponents of the programme wasless than budgeted. On the other hand,spending for advocacy and policyreform was much higher than whatwas planned. Of the total spending ofUS$17,661,653 for HIV and AIDSin 2007, 67 per cent was financed bybilateral donors, followed by multilateralsources including the Global Fund(GF) at 24 per cent. Governmentfinancing for the programme was 3per cent. International not-for-profitsources, mainly international NGOs,used about 6 per cent of total spending.Different financing sources seem tohave their specific functional focus,but all sources have consistently spenthighest on prevention, programmemanagement, and administration.77

BANGLADESHCAMBODIANEPALPHILIPPINESSpending on programme managementand administration needs careful andcautious interpretation; a detailedbreakdown of expenditure is necessaryto be able to draw meaningfulconclusions. As the financing ofnational response is heavily relianton international funding so is themanagement of funds. In other words,a large proportion of available fundsis managed (or spent) by or throughmultilateral agencies and INGOs. Only9 per cent of total funding is managedby the public sector.SystemsA. PartnershipsAs highlighted in the National AidsSpending Assessment (NASA) 2007and through the analysis in NAP 2008-2011, many external partners haveprovided support in different forms andmagnitude. Since EDPs have endorsedthe National Strategy and NAP, theirsupport has largely been within thebroad framework of the strategy. Majorfunding partners are shown below- GFATM, USAID, UN agencies,DFID and other INGOs. Governmentfunding for HIV related programmes isvery poor.Global FundNepal was successful in securing twogrants (out of 9 rounds) from theGFATM. The first grant from Round2 (2002) was US$11 million amortisedover a period of five years (2002-2006). The actual implementationwas delayed and was initiated onlyin 2004 and carried on till 2007. Thefund was managed by United NationsDevelopment Program (UNDP) andthe NCASC/MOHP as PrincipleRecipients (PRs). The country wassuccessful in securing US$36 millionthrough Round 7 (2007) to furthersupport HIV and AIDS programmingover the next five years covering mainlyIDUs, MSM, migrants and ART drugs.The Family Planning Association ofNepal (FPAN), Save the Children, andUNDP are the PR’s for this grant. Nepalis also one of the recipient countries ofthe approved Regional MSM proposalfor the Global Fund round 9.Bilateral agenciesDfID’s five year support began in 2004,focusing on IDUs, migrants, supportto PLHIV and strengthening of localNGOs capacity in implementing HIVinterventions at the grassroots level.Most of its HIV and AIDS fundingwas channeled through the UNDPand some through NCASC forstrengthening DACCs at the districtlevel. So far, DfID has spent £9.12million in HIV and AIDS support inNepal. An additional £3.38 million hasbeen pledged by DfID for HIV andAIDS activities from 2010 to March2011.USAID assistance is guided by itsstrategy developed in 2001 with threeresult areas: 1) Increased nationalcapacity to provide HIV and AIDSservices; 2) Increased access toinformation and prevention servicesfor HIV and AIDS and other sexuallytransmitted infections; 3) Increasedaccess to care and support.The USAID programme alsoemphasised national impact and78

34building on the technical strengthsof the national entities by workingclosely with the GoN to achieve theobjectives of Nepal’s National HIV/AIDS Strategy. The total budget ( Jul2006- Sept 2011) of US$21.7 millionis channeled through Family HealthInternational (FHI)/ASHA project.USAID supported the drafting ofNepal’s HIV/AIDS bill, in consultationwith civil society groups includingPLHIVs, government bodies, and atriskpopulations. The bill confirms thehuman rights of infected and affectedpeople and establishes an effectivemanagement structure for HIV/AIDSprogrammes. HSCB has finalised thedraft and it is expected to be endorsedby parliament in the near future.79

UN agencies and UNAIDSsecretariatThe UN system has supportednumerous activities towards combatingthe HIV and AIDS epidemic in thecountry. The nature and scope of UNsupport ranges from policy developmentand capacity building at the national andregional level, to service delivery andsocial mobilisation at the grass rootslevel. The overarching framework ofthe UN support has been the nationalHIV strategies and UNDAF as well asCommon Country Assessment. Mostimportantly, the UN system has fullyrecognised both the impact of the decadelong conflict and the new opportunityit has created for development andsocial transformation. UNAIDS, as thesecretariat of the joint UN programme,supports the GoN and works with allstakeholders to coordinate a variety ofactivities with the NCASC and theHSCB. UNAIDS is coordinating thedevelopment of the national monitoringand evaluation framework along withother stakeholders.World BankBased on numerous assessments andmission visits in 2007, 2008 and 2009to Nepal, the Bank has committedto fund a range of HIV and AIDSactivities over the next few years. TheWorld Bank has expressed interestin supporting the Pooled Fundingmechanism under the Ministry ofHealth with a provision for rapid andefficient fund flow mechanisms andan integrated logistics managementsystem.Similarly in the population and RHsector, according to a resource flowssurvey report carried out in Nepalby Health Economics Association(NHEA) and executed by UNFPAin collaboration with the NetherlandsInterdisciplinary DemographicInstitute, 2008, population andpopulation-related activities receivedRs.4109.1 million with Rs3683.5million from GoN and Rs.25.5million from NGOs. Within GoNorganisations, the income receivedfrom domestic sources was Rs.1,745.9million (47.4 per cent) and Rs.1,937.65BANGLADESHCAMBODIANEPALPHILIPPINES80

million from donors. As a percentage ofthe national budget, contribution fromthe GoN constituted 2.6 per cent.On the expenditure side a total ofRs.3,282.9 million was spent in 2008 -Rs. 2876.9 million from the GoN andRs.405.9 million from NGOs. MoHPwas the largest spender in populationactivities. Among NGOs, FPAN hascontinued to remain the single largestcontributor in population activities.Contraceptive Retail Sales PrivateLtd (CRS), Nepal Fertility CareCenter, Nepal Red Cross Society andSolid Nepal are expending budget inpopulation and SRH activities. Withthe exception of CRS, almost allother expenditure by NGOs is fromdonor support, with little coming frominternal funds. Most of the respondentsregard the FPAN as the champion forthe SRH and HIV cause.NGOs and community basedorganisations (CBOs) play anincreasingly important role in HIVresponses, in community basedmobilisation, community basedprevention and care services, and inreaching key groups, such as MSMs,and sex workers, IDUs and migrantworkers.Having worked with the community forsome years, NGOs have better linkagesand understanding of communityissues, bridging the gap between serviceand community, and often advocatingfor community rights.Civil society participation in all aspectsof HIV related activities is wellestablished.Representatives of MARPs or theirnetworks are regularly involved inall activities ranging from policydevelopment, proposal writing andimplementation, and monitoring andevaluation. MARPs are representedin policy bodies such as NAC, HSCBand DACC at the district level. Interms of programme implementationand providing inputs at strategic level,civil society organisations are not at anequal level of capability. In such cases,the stronger, better advocate gets ahigher share in terms of participationand access to resources.MARPs, vulnerable community-ledorganisations and other vulnerablegroups have set up their ownorganisations/networks. This grouphas played a crucial role in improvingaccess to services for members of theirconstituency as well as contributing tothe planning and policy developmentprocess. There are now organisationsled by recovering drug users, sexualand gender minority groups (suchas LGBTI), FSWs, and migrants, orreturned migrant groups. Networks inthese categories have a large number ofCBOs led by the constituents.PLHIV-led organisations have beenactive both in advocacy and at variousother levels, ensuring access to ARTand other services. The group has beensuccessful in many advocacy outcomesand has contributed to better accessto ART as well as ensuring ARTadherence. This group is also active inpositive prevention and ensuring therights of infected/affected children andwomen.NGOs include many current round81

BANGLADESHCAMBODIANEPALPHILIPPINESseven sub recipients and implementers,as well as networks of organisationsactive in HIV-related activities. Manyof these organisations are engaged indirect service delivery to MARPs andPLHIV (HIV TC, STI, BCC andother supportive activities) in variousdistricts. This group has also worked asa link between community and servicecentres. Religious and faith-basedorganisations have taken initiativesparticularly in HIV prevention, careand support in informal settings andare effective at community level.Few respondents expressed that ASRHis linked bi-directionally; ASRHrelated materials include HIV in theirtraining manuals and implementationguidelines. Comprehensive preventioneducation and services for young peoplecombine a range of interventions thatinclude access to youth friendly services,community based mobilisation andpeer support, and in-school education.Examples include the ReproductiveHealth Initiative for Youth in Asia(RHIYA) project in Nepal and UnifiedBudget Work plan project executedby UNFPA and implemented byFPAN in 2005-2006 in Mahottariand Kapilvastu districts. Evaluationfindings include greater self-esteemand self-efficacy, and knowledge aboutSRH issues, increased condom andcontraceptive use, reduced number ofsexual partners, and greater likelihoodof seeking appropriate treatment forSTI symptoms.Most of the respondents reportedthat although the involvement andparticipation is increasing, youth havebeen poorly involved in the responseof SRH and HIV programming. Theyare more involved in situation analysisand implementation rather thanplanning, budgeting and evaluation.The Ministry of Education hasexpanded the life skills based educationprogramme in the past two years withsupport from UNICEF. While 3.1per cent (880/27,888) of all schoolsprovided Life Skills Based Education(LSBE) in 2006, this has increased to5.6 per cent in 2007 and now in 2009has further increased to 7.56 per cent.LSBE is being implemented in over 20districts in the country through formalcurricula or extra-curricular activities(as peer education), but the coverageand expansion is slow.B. Planning Managementand AdministrationAlmost all the respondents reportedthat there is no joint planning of SRHand HIV. Of the few who reported thatthis is done at the DoHS and MOHPlevel, the detractors were quick to pointout that this is mainly for administrativepurposes. There is no integrated budget,and monitoring and coordination ofactivities are weak.Some respondents reported thatsome CBOs, NGOs, poly clinics andnursing homes, and medical colleges areproviding integrated services.C. Human Resources andCapacity DevelopmentThere is a shortage of competentservice providers. The recruitmentand retention of health professionals,particularly doctors and nursing staff,has remained problematic, particularly82

in hill and mountain districts. Frequenttransfer of health workers and theneed for constant training is anotherfactor affecting motivation and servicedelivery. Retention is more acute in theNGO sector.There is limited capacity fortraining.Trainers are not up-to-date ontraining (content and pedagogy);There is a shortage of teaching/learning equipment and material;Transport facilities for monitoringand supervision of field training arelacking.There is inadequate opportunity andcapacity for needs-based in-servicetraining on HIV/AIDSTraining needs are not knownfor different categories of serviceproviders and there are inadequatein-service training opportunities.Clinical services related to ART, HIVTC, PMTCT, OI and STI are impactedby:Challenges related to deploymentand retention of health professionals,particularly in hill/mountaindistricts.Frequent transfer of health workersleading to a need for constanttraining.Lack of supportive supervisionwithin the health system .Supervision of NGO-deliveredservices not linked to the governmentsystem.Most of the respondents agreed thatorientation and training should begiven on linkage and integrationbetween SRH and HIV, stigmaand discrimination, and counseling.Training on proposal writing, advocacy,PMTCT, VCT counseling, RHprotocols and laboratory – standardoperating procedures (SOPs) were alsoneeds that were expressed.Capacity building on SRH and HIVincorporates avoidance of stigma anddiscrimination, gender sensitivity, andconfidentiality of reproductive rightsand choices. There are separate trainingmanuals for pre-service and in-servicetraining through the National HealthTraining Center of the Ministry ofHealth and Population for serviceproviders.The curricula for secondary educationand teacher training, through Ministryof Education, has incorporated safe sex,sexual health stigma, sexual violence,condoms and reproductive rights forstudents and teachers.D. Logistics/SuppliesWhile SRH logistics and suppliesare procured and supplied throughLogistics Management Division, HIVsupplies are procured from UNDPand supplied through NCASC. Hencethere is a two track system of supplychain for drugs and test kits and othercommodities. USAID, through FHIand the DELIVER project, have alsoprovided support for the nationallogistics supply of HIV commodities.83

BANGLADESHCAMBODIANEPALPHILIPPINESThe two track system of logisticsmanagement has not been costeffective. The budget could havebeen utilised for other purposes.Civil Society RespondentE. Laboratory SupportLaboratory facilities are inadequateto serve the needs for SRH and HIVservices, being highly dependent onlevel of facilities. Respondents agreedthat comprehensive laboratory serviceswith good quality are only available inKathmandu and some regional centres.The major challenges are the lack ofdiagnostic capacity, lack of suitableinfrastructure, shortage of equipmentand re-agents, lack of mainstreamingprocurement and supply of HIVcommodities, shortage of competentlaboratory staff, lack of laboratorybench manuals/handbooks in locallanguages, and inadequate in-servicetraining opportunities.F. Monitoring andEvaluationThere is no monitoring and evaluationstructure to capture results of integrationfor SRH programmes. Monitoringof STI, condom use and PMTCTcoverage is available from HealthManagement Information systems.The disaggregated data is available byage, sex and HIV status. HIV relatedsupportive supervision using checklistfor VCT, ART PMTCT, and STIexists, but supervision is weak.Service DeliveryThe SRH and HIV linkage wasobserved at facilities level because theorganisations visited were the biggerand tertiary level organisations such asmaternity hospitals, Teku InfectiousDisease hospital and central clinic ofFamily Planning Association. Thesehospitals and clinics in general havebetter facilities than the stand aloneclinics in other parts of the country.STD AIDS Counseling Training(SACT) is a CBO offering preventionand management of STIs andproviding counselling on familyplanning. It provides VCT servicesand psycho-social support as part ofgeneral counselling through providerinitiatedtesting and counselling. Itprovides condoms, plus specific HIVinformation to sex workers and migrantlabour.For PMTCT related issues, counsellingis provided on prong 1: prevention ofHIV among women of child bearingage and their partners, and prong 2:prevention of unintended pregnancyin HIV positive women. Treatmentfor OI is also offered. Counseling, labtests and screening for children 6 to 18months as part of all infant diagnosis inKathmandu is another level of serviceoffered by SACT. Given its range ofservices, it also reports on traffickingof sex workers under the age of 18 incollaboration with STEP Nepal. Followup services extend to checking on clientsto ensure they act on referrals. This isachieved through quarterly meetingswith service providers. But resultshave been poor. Links with NAPNare maintained which help in capacity84

uilding for home-based care throughPLHIV support groups, particularlyin skill development such as flowermaking and joss stick making. A formalagreement has been established withthe Chettrapati clinic for RH services.Meetings are held on a quarterly basis.Shortage of equipment and space,insufficient staff time, lack of staffsupervision, and moderate staffmotivation are all contributory factorsfor the less than effective servicedelivery. Low salaries and a high workload were cited as reasons for low staffmotivation.Teku HospitalTeku hospital is one of the ART sitesin the country offering prevention andmanagement of STIs, provider initiatedtesting and counselling, OI treatmentand ART services. The facility followsup on ART clients every quarter andhalf yearly through NAPN and PLHIVsupport groups. It also refers clients forART in 25 districts. Although it hasno formal agreement, it works throughVolunteer Welfare community and“Sparsh” for IDU clients.Efficiency of service has suffered due totransfer of staff. As a result, workloadof service providers has increased.However, stigmatisation of HIVservices has decreased. Given the lackof space, privacy is poor. Guidelines forproviding ART are available but there islack of staff training. Motivation levelsof staff are low.Maternity HospitalMaternity hospital is one of thePMTCT sites in Nepal. The hospitalprovides family planning, maternalhealth services, prevention andmanagement of STIs, prevention ofunsafe abortion and management ofpost-abortion care; provider–initiatedtesting and counselling, treatment forOI, and HIV prevention informationand services for the general populationincluding condom provision andPMTCT comprehensive services. Itrefers clients to Teku hospital for ARTand advanced lab tests for HIV relatedcases.Shortage of space for offering private andconfidential service, low staff motivationdue to lack of training and lack oftransparency in selection for trainingwere cited as moderate constraints.With the increase in workload, skillswere developed thereby increasingefficiency. Cost of services for the clientsand facility and stigmatisation of HIVclients decreased.FPAN provides comprehensive SRHservices such as FP, prevention andmanagement of STIs (syndromic casemanagement and lab test for VDRL),prevention and management of genderbasedviolence, and prevention ofunsafe abortion and management ofpost abortion careFPAN has integrated provider initiatedHIV testing and counselling. It referscases to Sahara Plus for psycho socialsupport, counseling for PMTCT and85

BANGLADESHCAMBODIANEPALPHILIPPINESprovision of condoms. It also providestreatment for OI. It follows STIclients and uses VCT, FP and STIguidelines for the provision of services.It has an official collaboration withNAP+N. While FPAN counselorsreported no constraints for integratingservices, cost of the service (facility)and increased work load however wereagain mentioned as constraints.There is linkage in the provision ofservices. For example, HIV servicesare linked in SRH services (throughthe FPAN) and SRH services in HIVservices. There is a link with PLHIVand support groups. However, thereis an overall lack of capacity buildingand staff training to address attitudes.There are available guidelines ondifferent topics but these have not beenintegrated. The major constraints citedshortage of space for offering privateand confidential services and low staffmotivation. While the cost of servicesand facilities has decreased, work loadhas increased.VI. DISCUSSION ANDCONCLUSIONSuccessful linkages between RHand HIV/AIDS programmes andservices can only be achieved if theyare supported by commitment atpolicy level, the development ofappropriate institutional mechanisms,and through structured coordinationand collaboration, rather than throughattempts to simply expand and linkvertical programmes. Linked responseshould be institutionalised in all policiesrelated to RH, HIV/AIDS, gender andyoung people.Despite the growing realisation amongstakeholders, the need for policy andsystems linking to address SRHR,HIV and AIDS, particularly in thecontext of the commitment to universalaccess to prevention, treatment, careand support, efforts to systematicallylink SRH and HIV remains limited.This is partly because of the lack ofguidance from the MoHP in promotingsynergistic approaches between SRHand HIV. More significantly, existingpolicies, and institutional and financialmanagement are the barriers to linkingHIV and SRH programmes.UN agencies must continue to play akey role in the provision of technicalsupport and leadership, such as theUNAIDS Intensifying HIV Preventionstrategy which urges for strong linkageswith SRH.Support to sector-wide managementprocesses represents a major opportunityfor developing a comprehensive healthsector response to HIV and AIDS, tomeet universal access commitments.Currently, funds received for HIV andAIDS activities are mainly ‘off budget’and inflexible.HIV and AIDS and SRH strategyprocesses are still mainly managedand implemented separately. Thisreduces opportunities for developingcomprehensive linking approaches atprogramme and service delivery levels.National level SRH and HIV/AIDSresponse is separately administered,funded, and supported by differentdonors and technical agencies.The largest fund received for HIV86

is from GFATM. It sets targetsand deliverables, with fundingdisbursements linked to performance.Indicators tend to be linked to coverageand output, rather than to impactmeasurements. These create strongincentives to deliver quick wins throughvertical approaches that result in rapidcoverage increases, but not necessarilylonger term impact. Delivering wellfinanced vertical programmes that areeasier to manage, and which can achieveresults, encourages demands from manystakeholders at all levels, but leads tothe increasing separation of HIV andSRH programmes.The main constraints to effectiveimplementation of health plans arefrequent changes in the government,limited national resources for healthservices development, centralisedadministration, ineffective managementand supervision, difficult geographicconditions and slow economic growth(WHO, 2004)In addition, there is scarce resourcein terms of study. Documentation onthe cost-effectiveness and relevanceof integration and linkage of servicesfor a low prevalence and concentratedepidemic country like Nepal, is limited.In order to move forward and engagethe stakeholders for short and longterm commitment, these issues need tobe further explored.Looking into the future, entry pointfor the way forward could be themobilisation of UN agencies to beginpolicy dialogue and advocacy forinclusion of linkage issues in the HIVpolicy and strategy which are in theprocess of revision.Mechanisms for better coordinationand linkage between the two divisionsmanaging SRH and HIV and AIDSprogrammes within the MoHP shouldbe initiated through formal andinformal platforms for joint planning,financing, monitoring and reportingsystems.Training for service providers on howto deliver integrated SRH and HIVservices should be considered in preserviceand in-service training curriculaA national level standardised packagefor integration of SRH and HIVservices should be developed for thedifferent cadres of health serviceproviders, to inform them of their rolesin the process of providing integratedservices, and in managing referrals.It is encouraging to note that HIVrelated topics are mentioned in SRHprotocols and medical standards forfamily planning such as maternal andnewborn care, SBA policy and trainingguidelines.Based on the assessment throughdocument review, and in-depthinterview, the Nepal case study hasattempted to highlight some importantcritical issues.These issues should serve to articulatean agenda for collaboration andsynergy both at the policy, system andservice delivery levels, with specificrecommendations to address thegaps and challenges, to improve theeffectiveness of a linked HIV and SRHresponse in Nepal.87

BANGLADESHCAMBODIANEPALPHILIPPINESVII. ISSUES ANDCHALLENGESIn the context of a rights-basedapproach to health programming,Nepal’s challenge is compounded byproblems of low coverage of overallhealth services, geographic diversityrestricting access to healthcare, widespread poverty, and ramifications ofthe decade long conflict. These requirediscussions between governmentagencies and EDPs, to clarify howNepal is going to move forward interms of approaching the rights-basedsystem of health care delivery.There is a need for greater coordinationbetween SRH and HIV during the policyand strategy formulation processes.Such coordination is necessary to betterleverage on the strengths of both fieldsin service provision, in these times ofweakened health systems and verticalprogrammes. Many of the efforts tolink the two fields have been curtaileddue to lack of interest from both SRHand AIDS organisations. Territorialinterests of stakeholders and lack ofpolicy guidance from MoHP have beenthe major barriers to better linkage.While women and adolescents have beenthe focus, provision of comprehensivesexual health services for these groupshave had limited coverage. There havebeen and continues to be a lack of sexualhealth services for men. In fact, men’ssexual health has been largely ignored.Men and women are influenced by sexualconstructs and gender norms particularto their own social contexts, leavingmen vulnerable to risky behavior andinfection with HIV or other STIs. Yetmen, unlike married women, have littleor no access to reproductive and sexualhealth services. While programmes areincreasingly including adolescent boysand girls, mainstreaming of programmesby AIDS and SRH organisations hasbeen slow to address the sexual healthneeds of adult men.Bi-directionality, both the SRH and theHIV communities addressing relevantaspects of each others’ agendas hasbeen one of the hallmarks of linkages.Therefore, it is expected that linkedresponses could favourably impact onboth SRH and HIV outcomes. Suchresponses include but are not limitedto: rights-based family planningin the context of mother-to-childtransmission of HIV programmes,ending gender-based violence and childmarriage, providing HIV voluntarycounselling and testing within antenatalcare, promoting condoms for dualprotection within family planning andHIV programmes, and comprehensivesexual education for young people.However, HIV and SRH programmesstill remain largely vertical. Severalissues and challenges have contributedto this situation, including:Very little linkage between SRHand HIV services in Nepal at policyand system level except for HIVbeing included as part of the eightcomponents of RH in the NationalRH Strategy(1998) and inclusion ofHIV and AIDS as part of EssentialHealth Care Services in NHSP–IPsNo policy guidance for linkagebetween SRH and HIV fromMOHP.88

SRH and HIV programmes are runvertically with weak coordinationmechanisms and lack of jointplanning.Policies and strategies, protocols,medical standards/SOPs, guidelinesare developed at different pointsof time hindering linkage betweenthese two programmes.Although the interim constitutionof Nepal guarantees health as afundamental right, a rights- basedapproach to SRH and HIVprogrammes has not been fullyendorsed.Funding of SRH programmes is alsovertical depending on the mandate,territorial interest and fundingmechanisms.Functional linkage between SRHand HIV services has only occurredin service centres that offer bothSRH and HIV services, especiallySTI services, condom provision,PMTCT, VCT and ART.Poor facilitation and lack of policydialogue at CCM level for linkingSRH and HIV services.VIII. RECOMMENDATIONSAt Policy and System LevelPolicy makers and programmemanagers should be sensitised toadvocate for the benefits of a linkagebetween SRH and HIV services.Multilateral, bilateral and technicalagencies should provide support forkey linkages between RH and HIV/AIDS policies, programmes, andservices.Sexual and reproductive health andHIV/AIDS reside in two separateUnited Nations MillenniumDevelopment Goals (MDGs): #5Improve Maternal Health and #6Combat HIV/AIDS, Malaria andother Diseases, respectively. UnitedNations agencies should reinforcethe synergies between the two infuture decisions and guidance relatedto achieving the MDGs.Donors and decision makers need toensure their funding and guidanceare in accord with recommendationsfor strengthening key linkagesbetween family planning and HIV/AIDS, in current international andnational policy statements.Donors should harmonisereproductive health and HIV/AIDS funding, mobilise resources tosupport integrated efforts, encouragerecipients to develop programmesthat leverage this support, andrequire that recipients report onintegration-related indicators andtargets.Develop an advocacy strategy tomobilise support for linked servicesamong policymakers, programmemanagers, service providers, clients,PLHIV, and other key stakeholders.Revise national HIV policies toinclude family planning servicesfor healthy timing and spacingof pregnancies and prevention ofunintended pregnancies as partof the standard of care for HIV89

services.Revise RH policies/strategies toinclude HIV services as part of thestandard of care for RH services.At Service Delivery LevelCapacity training and taskshiftingFoster sensitivity to the RH needsof PLHIV, thereby reducingstigma and discrimination throughcommunity outreach workers such asfemale community health volunteers(FCHVs) and mothers groupsPrepare an integrated package oftools/guidelines for SRH and HIVservice provisionBuild capacity of service providersfor PMTCT, HIV counseling andtesting, and HIV care and treatment.Service providers should have thecapacity to assess clients’ fertilityintentions, offer dual protectioncounseling and condom promotion,and refer clients to FP services orsafe pregnancy services.Provide refresher training toservice providers on a regular basis,to accommodate frequent stafftransfers.Ensure that space is available forclients comfort and confidentiality.Address providers’ concerns aboutworkload, and encourage andmotivate staff.Use a checklist for monitoring theadherence to service protocols, andreviewing service statistics, such asthe number of RH clients referred toHIV-related services or the numberof HIV clients referred to RHservices.BANGLADESHCAMBODIANEPALPHILIPPINES90

IX. REFERENCES1. Adolescent Health and Development in Nepal , Status , Issues , Programmes andChallenges , A country profile 2005, FHD , DoHS, MoHP, GoN2. ART guideline, 2004, NSASC3. Demographic Health Survey (2006), MOHP , Nepal, New ERA , and MacroInternational Inc. Nepal4. National Guidelines, Prevention of Mother-to –Child Transmission of HIV inNepal, NCASC, MOHP, GoN December 20085. National HIV Strategy(2006-2010), NCASC, MoHP, 20076. National Health Policy(1991), MoHP7. National HIV AIDS Action Plan (2008-2011, HIV/AIDS and STI ControlBoard, March 2009), GoN8. National Reproductive Health Strategy(1998), FHD , DOHS, MoHP9. National Safer Motherhood and Newborn Health – Long Term Plan92006-2107) 2006, FHD, DoHS , MoHP , GoN10. Nepal HIV AIDS Policy(1995), MoHP11. Nepal National AIDS Assessment Report 2007, HIV/AIDS and STD ControlBoard GoN /UNAIDS12. Second Term Long Term Health Plan (1997- 21017), MoHP13. Third Edition, National Guidelines PMTCT in Nepal December 2008,NCASC , MoHP , GoN14. Trainers Guideline, Health Education for Class 9-10, Curriculum DevelopmentCenter, Ministry of Education and Sports15. UNGASS Country Report Nepal 2010,16. VCT guideline, 2007, NSASC, MOHP91

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INSTITUTIONALCAPACITY FORHIV/AIDS ANDSRHR LINKAGESChapter 4Case Studies inPhilippinesOfelia Pardo Saniel, MPH, PhD95

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AbstractBackgroundThe policy support for strengtheninglinkages between HIV/AIDS and sexualreproductive health in the internationalstage has grown, beginning with theInternational Conference on Populationand Development Programme (ICPD)for Action (UN, 1994). There are nowat least nine different internationalpolicy statements calling for strongerlinkages between HIV/AIDS and sexualand reproductive health fields. Globalstatements such as these strengthen theadvocacy calls for establishing and/orstrengthening the linkages between sexualand reproductive health and HIV/AIDSin terms of policies, funding mechanisms,programmes and services.MethodsThe information included in this report wasobtained through the review of SRH andHIV policies at the national level and, whereapplicable, a review of operational plans andguidelines for programmes and delivery ofservices. The proposed and enacted billsin both Houses of Congress were revisitedto determine the existence of provisionsrelated to sexual and reproductive healthand HIV, to identify initiatives to integratethe two. The director of the Family HealthOffice of the National Center for DiseasePrevention, Department of Health was alsointerviewed. This office is in charge of familyplanning at the Department of Health. Anelectronic search for relevant information onthe internet was also done for supplementalinformation on the topic. The website of theDepartment of Education was checked fordevelopments on the proposed integrationof sexual and reproductive health educationin the curriculum at elementary and highschool levels. Similarly, the PhilHealthwebsite was also checked for circulars onthe provision of service packages related toSRH and HIV. Documents regarding theprovision of SRH and HIV-related servicesin the workplace were also located.ResultsLinkages between HIV and SRH haveonly been recently introduced. Whatcan be said as the earliest law relatingto reproductive health was focused onpopulation management since otherelements of reproductive health were notyet seen as a grouped concern, and HIVwas yet unknown at that time. Based onnew developments, it can be said that at thepolicy level, integration of HIV and SRHprogrammes is just at its very nascent stage.HIV – related strategies are now includedin the proposed bills on reproductive health.IEC campaigns on STIs are also includedin most of the proposed bills.ConclusionDespite numerous legislations passed andstill being proposed aimed at improvingsexual and reproductive health, thePhilippines is still, at its best, in the infancystage. Decades of disagreement betweenthe Catholic Church and the State havepractically led to a standstill in terms ofpromotion of reproductive health.97

BANGLADESHCAMBODIANEPALBackgroundThe policy support for strengtheninglinkages between HIV/AIDS andsexual reproductive health on theinternational stage has grown beginningwith the International Conferenceon Population and DevelopmentProgramme (ICPD) for Action(UN, 1994). There are now at leastnine different international policystatements calling for stronger linkagesbetween HIV/AIDS and sexual andreproductive health fields. Globalstatements such as these strengthenthe advocacy calls for establishing and/or strengthening the linkages betweensexual and reproductive health andHIV/AIDS in terms of policies,funding mechanisms, programmes andservices.This report is prepared as part of theInternational Council on Managementof Population Programmes’ (ICOMP)activity to assess HIV and SRH bidirectionallinkages at the policy,systems and service delivery levelsin selected countries, including thePhilippines. Through case studiessuch as this, ICOMP hopes toidentify gaps in policy, systems andservices to ultimately contribute to thedevelopment of country-specific actionplans to forge and strengthen theselinkages. The case study attempts tospecifically address three importantareas:i. the level and effectiveness, if any, oflinkages between SRH and HIVrelated policies, national laws, andconsequent operational plans andguidelines;ii. the extent to which the systemsupports these linkages; andiii. the extent to which HIV services areintegrated into SRH services, andSRH services into HIV services.The information included in this reportwas obtained through the review ofSRH and HIV policies at the nationallevel and, where applicable, a review ofoperational plans and guidelines forprogrammes and delivery of services.The proposed and enacted bills in bothHouses of Congress were revisited todetermine the existence of provisionsrelated to sexual and reproductivehealth and HIV and to identifyinitiatives to integrate the two. Thedirector of the Family Health Officeof the National Center for DiseasePrevention, Department of Health wasalso interviewed. This office is in chargeof family planning at the DOH.An electronic search for relevantinformation on the internet was alsodone for supplemental informationon the topic. The website of theDepartment of Education was checkedfor developments on the proposedintegration of sexual and reproductivehealth education in mainstreamcurriculum at elementary and highschool levels. Similarly, the PhilHealthwebsite was also checked for circularson the provision of service packagesrelated to SRH and HIV. Documentsregarding the provision of SRH andHIV-related services in the workplacewere also located.PHILIPPINES98

Demographic, Sexual andReproductive Health, andHIV Status of FilipinosFour out of the seven MillenniumDevelopment Goals (MDGs) are onsexual and reproductive health. It isheartening to note that the Philippinesis likely to achieve two out of these fourgoals. The country is likely to achievegender equality and empowermentof women. In fact, the gender gap ineducation is in favour of girls; moregirls than boys are enrolled in bothelementary and secondary levels. Infant,(under-five) and neonatal mortalitycontinues to decrease and there is alsothe likelihood that MDG 4, on reducingchild mortality, will be achieved.In 2003 there were 29 infant deaths per1000 live births and 40 deaths per 1000children under the age of five.This decreased to 25 and 34 deathsper 1000 children respectively in 2008.Considerable success has been madein combating malaria (Goal 6) but thegrowing number of HIV and AIDScases suggests that the infection hasnot been halted. As of the end of 2010,the cumulative number of reportedHIV positive individuals has alreadyreached 6,015 of which 78% are males.Unprotected sex was identified as theprimary mode of transmission.However, the goal of improving maternalhealth significantly lags behind the otherthree in terms of the likelihood of beingachieved at the end of 2015. The 2008National Demographic and HealthSurvey (NDHS) showed that whilethe total fertility rate (TFR) decreasedfrom 6.0 children per woman in 1970to 3.5, it is still high compared withneighbouring countries like Thailandand Singapore where the TFR is below2.0 children per woman. This is despitethe desire of most Filipino womento have a smaller family with 82 percent of women wishing to either spacebirths or limit childbearing altogether.Women in urban and rural areas have,on the average, 2.8 and 3.8 children,respectively. Around 26 per cent ofwomen age 15-24 years old have begunchild bearing. The level of fertility isinversely proportional to the women’slevel of education and householdwealth. It is ironic that those whoare in a better position to provide fortheir children are the ones with fewerchildren. This probably could be tracedto the sad state of the reproductivehealth programme in the country.The contraceptive prevalence rate islow. At present, only 51 per cent ofmarried women use contraceptives.The most common modern methodsused are the pill (16 per cent) followedby female sterilisation (9 per cent). Inthe 1970s and early 1980s because ofthe government’s support for familyplanning, the contraceptive prevalencerate (CPR) increased from 17 per centin 1973 to 40 per cent in 1993. However,these gains were not sustained in thesucceeding years. Since then, the CPRincreased gradually to the 51 per centthat is currently reported.Despite numerous legislations passedand still being proposed aimed atimproving sexual and reproductivehealth, the Philippines is still, at itsbest, in the infancy stage. Decades ofdisagreement between the Catholic99

BANGLADESHCAMBODIANEPALPHILIPPINESChurch and the State have practicallyled to a standstill in terms of promotionof reproductive health.The bills on reproductive health areprobably the most misunderstoodof legislations to be filed. All of theproposed bills cover all elements ofreproductive health listed below:i. Maternal, infant and child healthand nutrition;ii.Promotion of breastfeeding;iii. Family planning information andservices;iv.Prevention of abortion andmanagement of post-abortioncomplications;v. Adolescent and youth health;vi.Prevention and managementof reproductive tract infections(RTIs), HIV/AIDS and othersexually transmittable infections(STIs);vii. Elimination of violence againstwomen;viii. Education and counsellingon sexuality and sexual andreproductive health;ix. Treatment of breast andreproductive tract cancers andother gynecological conditions;x. Male involvement andparticipation in reproductivehealth;xi. Prevention and treatment ofinfertility and sexual dysfunction;andxii. Reproductive health education foryouth.Unfortunately, the bills were criticisedby some sectors of society for being ‘antilife’and for condoning, even promoting,promiscuity and immorality. Theywere criticised mainly for includingthe use of contraceptives and teachingsex education in schools. The proposedbills on reproductive health in bothHouses of Congress elicited andcontinue to invite heated debatesregarding their content. Very recently,President Benigno Aquino expressedhis support for the reproductive health(RH) framework. As expected, hispronouncement of support for RH wasmet with opposition from the CatholicChurch and the conflict betweenthe State and the Church has againsurfaced.The sections below present the resultsof the assessment of the institutionalcapacity for HIV/AIDS and SRHlinkages. There are three major sectionsof the findings:i. Policy - The level and effectivenessof linkages between sexual andreproductive health and rights andHIV-related policies, national laws,operational plans and guidelines, ifany.ii. Systems – The extent to which thesystems support effective linkagesof SRH and HIV with respectto planning, management andadministration; staffing, humanresources and capacity development;logistics and supplies; laboratorysupport; and monitoring andevaluation100

iii. Service delivery - The extent towhich HIV services are integratedinto SRH services and likewise, theextent to which SRH services areintegrated into HIV services.1. Policy on Sexual andReproductive Healthand HIVThe Philippines has no shortage ofpolicies on sexual and reproductivehealth. The country is one of thesignatories of the 1967 United NationsDeclaration on Population. Thus, theCommission on Population (PopCom)was created in 1971 through RA 6365to manage population-related issues inthe country and to develop appropriatesolutions. It worked for the inclusionof family planning as part of the broadeducational programme and to providesafe and effective means of limiting orspacing birth to couples who desire it.Upon POPCOM’s recommendation,the government officially launchedthe National Population Program(NPP) which advocated a small family(approximately 2 to 4 children) as thenorm, and provided information andservices to reduce fertility rate. To helpdisseminate information on familyplanning, Presidential Decree (PD)965 was issued. This decree requiredcouples applying for a marriage licenseto undergo a seminar on familyplanning.The administration of PresidentCorazon Aquino (1986-1992)transferred the institutional andoperational responsibility of the familyplanning programme to the Departmentof Health. Family planning thenbecame a component of the total healthprogramme and was viewed as a healthintervention. Improving maternal andchild health, instead of merely reducingfertility, became its primary concern.More SRH-related policies wereintroduced in the succeeding years.However, these were mostly in the formof Administrative Orders (AOs) by theDepartment of Health.In the absence of a legislated policy,RH has a diminished importance inthe hands of the Executive Branch ofgovernment. At the DOH, elementsof RH are lodged at the NationalCenters for Disease Prevention andControl (NCDPC) through theFamily Health and Nutrition Office.Among its several programmes, threeprogrammes strongly relate to RH ---family planning, women’s health anddevelopment, and adolescent healthand development.Meanwhile, the Commission onPopulation (PopCom), which wasattached to the DOH at the start ofthe Arroyo administration (2000), alsohas an adolescent reproductive healthprogramme. Under the proposed bills,PopCom will be in-charge of advocacy,IEC, training and orientation on SRH.A national programme on reproductivehealth is proposed in all newly-filed billsfiled in 2010 and aim for a “NationalPolicy on Reproductive Health andPopulation and Development”.In 2005, the Department of Education(DepEd) issued DepEd Memorandum# 261, series of 2005 on the“Operationalization of the UNFPAassistedproject Institutionalizing ARH101

BANGLADESHCAMBODIANEPALPHILIPPINESthrough Lifeskills-based Education.”However, implementation of thememorandum was slowed down bydisagreements between the State andthe Church. Recently, the Departmentof Education implemented a pilotstudy on reproductive health in 80elementary and 79 high schools in thecountry. Covered by the project at theelementary level are Grades IV to VIfor children between 10-12 years old.The purpose of the project is to impartlife-skills education to students. Hence,the science of reproduction, physicalcare and hygiene, correct values andthe norms of interpersonal relationsto avoid pre-marital sex and teenagepregnancy are among the topicscovered. Sex education is integratedin Science; Edukasyong Pantahananat Pangkabuhayan (EPP); Health;Heograpiya, Kasaysayan, at Sibika; andMathematics. Under Science, topics onthe reproductive system, parts of thebody, reproductive cycle, and pubertyare discussed. EPP on the other handwill integrate proper behavior amongand between peers of different genders.Health component of MaPEH(Music, arts, PE and Health) coverspersonal hygiene and reproductivehealth. Sexually transmitted infections(STI) and Human immune deficiencyvirus (HIV) and Acquired immunedeficiency syndrome (AIDS) are partof the curriculum of most subjects andtaught in Grade V who are mostly at 11years of age.In the workplace, there is activepartnership between the employersand labour unions. While RA 8504paved for the workplace componentof the AIDS Law, initiatives have beenmade even before this law was passed.In 1997, the Policy on HIV/AIDSPrevention was signed. It has five goalsbut none of them mention any otherreproductive health element:i. Prevent and control the spread ofAIDSii. Protect workers’ rights and thedignity of PLHIViii. Recognise individual responsibilityiv. Provision of benefits in highrisk occupational settingsand employment of universalprecautionsv. Establishment of a secretariatwithin DOLE.The Trade Union Congress of thePhilippines (TUCP) has integratedHIV/AIDS in its programmes onFamily Welfare and ReproductiveHealth. These programmes areoften supported by external donors.However, inadequate coverage bythe establishments regarding theimplementation of the said law and thelack of priority that the private sectorgives to HIV/AIDS are hamperingthe initiative; as of the year 2001, only2,000 out of the 40,000 establishmentsthat should be inspected have submittedreports.Other bills and administrative issuancesof the Department of Health (DOH)stipulates the creation of a PhilippineReproductive Health Program. Allelements of reproductive health werepart of the proposed service package.The National Sexually Transmitted102

Infections (STI) Case ManagementGuidelines was revised in 2003 toimprove the case management ofpeople with STIs. Two other legislatedpolicies have incorporated elementsof SRH. Protection from violence,another element of SRH, is included inan law which promotes the protectionof women.Republic Act 8504 is a law on thePhilippine AIDS Prevention andControl Act of 1998. Through thisbill, the National AIDS Preventionand Control Program (NASPCP)was created. At present the NASPCPprovides technical leadership in theSTI/HIV/AIDS response in thehealth sector, wherein it providespolicy guidance, technical assistance,capacity building and other resourceaugmentation, as well as monitoringand evaluation, within the ambit of thehealth care system.1.1 Bi-directional Linkagesbetween SRH and HIVLinkages between HIV and SRH haveonly been recently introduced. Theearliest law relating to reproductivehealth was focused on populationmanagement since other elements ofreproductive health were not yet seenas a grouped concern and HIV wasyet unknown at that time. Based onnew developments, it can be said thatat the policy level, integration of HIVand SRH programmes is just at its verynascent stage. HIV – related strategiesare now included in the proposed billson reproductive health. IEC campaignson STIs are also included in mostof the proposed bills. Conversely,reproductive health-related measuresare included in bills that call for theintegration of HIV-related servicesas part of the SRH programme. Allelements of RH, including AIDS/HIV, are covered in the bills filedwith the House of Representativesand the Senate. However, all of thesebills are still pending in Congress.The AIDS Law has provisions for thecontrol of other sexually transmitteddiseases. Integration of HIV intoRH programmes is not easy; theprogrammes on the other elementshave yet to be developed and aspectsof integration are being done throughRH elements. Well developed elementsof RH like child health are now part ofthe basic health services.At present, there is no solid strategyfor advocacy leading to the integrationof SRH and HIV. However, keyinformants from the ReproductiveHealth Advocacy Network (RHAN),the main civil society organizationadvocating for a national RH policy,said that the group extensivelydiscussed RH and HIV and AIDSintegration in the process of revisingthe bills now pending in the Senateand the House of Representatives.But rather than put details of RH andHIV integration in the proposed law,the group decided to leave the matterof crafting the implementing rulesand regulations (IRR) once the law ispassed. The fear is that it could inviteopponents to cast a quizzical look atthe already institutionalised policiesthat allow opportunities for a possiblefull integration of HIV and SRH in thefuture.103

BANGLADESHCAMBODIANEPALPHILIPPINES1.2 Inclusion of SRH issuesin the HIV StrategyThere is considerable overlap inthe strategies of HIV and SRHprogrammes; HIV strategies generallyinclude SRH issues and vice-versa.However, this is not surprising sinceHIV management is among theelements of reproductive health.All currently filed bills in the Houseof Representatives and in the Senateare trying to forge a National Policy onReproductive Health and Populationand Development. Agencies that canhelp facilitate the implementationof the proposed laws were created aspart of the national plans; existingagencies were tapped to help with theprogramme.The Philippine National AIDSCouncil (PNAC) was established in1992 to oversee an integrated andcomprehensive approach to HIVprevention and control. In 1998, theNational AIDS STI Prevention andControl Program (NASPCP) wasestablished to provide leadership in theDOH response against HIV, and toalso offer some aspects of RH services.Preventing mother to child transmission(PTMCT) of HIV, promoting safesex and other positive behavior, STIdiagnosis, treatment and counsellingare among the thrusts of the NASPCP.The target areas include schools, theworkplace, and the community.Tourists and Filipinos going abroad arealso among the target groups for theIEC campaign. At present, information,education and communication (IEC)on the prevention of transmissionof HIV is included in the familyplanning and adolescent reproductivehealth program of PopCom. Ageappropriatereproductive health andsexuality education is proposed in mostof the RH bills filed with the Houseof Representatives and the lone RHbill in the Senate. It is also proposedthat HIV/AIDS care shall be givenmaximum benefits as provided byPhilHealth.Conversely, broad RH servicedelivery, inclusive of treatment ofand education on HIV, is stipulatedin two bills which are still pending inCongress. Nevertheless in 1998, the“Implementing Guidelines in STDCase Management at the DifferentLevels of the Health Care System” wasissued as the basis for the provision ofSTD services at all levels of the healthcare system. In the same year, a furtherguideline was issued calling for therevised implementation arrangementfor the women’s health and safemotherhood project. The programmecluster includes maternal care, RTIsand cervical cancer.1.3 Structural vulnerabilityfactorsAmong the four illustrative structuralvulnerability factors identified, genderinequality appears to be the mostcommonly addressed. Gender equalityand equity is included as part of theguiding principles and rationale of allpending bills in the 15th Congress andin DOH administrative orders issued in2000 and 2006. The DOH continues topush for rights-based, gender sensitiveand client centered services. The means104

to address the weak participation ofmales is being studied. The bill of2006 (AO 35 s) also recognises theimportance of male involvement in HIVand SRH strategies. Male responsibilityis included in the section on Definitionof Terms in most currently filed bills,hence, it is one of the elements beinggiven importance by any possible policyto be approved.All health professionals are required tomaintain the confidentiality and protectthe identity and status of persons withHIV to protect PLHIV from stigmaand discrimination that may arise fromtheir having the disease. All related billspending in Congress provide for theactive participation by various groupsto ensure that RH and developmentplans, policies and programmes willaddress the priority needs of the poor,especially women.2. Service protocols andguidelinesAt present, protocols, manuals andguidelines are still being developed sincethere is no legislation on increasingHIV and SRH linkages. A guideline onPMTCT was issued by DOH in 2009,incorporated in the existing SRH andMaternal Newborn and Child Healthand Nutrition Services (MNCHN).This is so far the only known elementof SRH that has clear guidelines.However, with the passage of thelocal government code in 1991, theimplementation of these guidelines islargely left to the local government units(LGU). Thus, the extent to which theseguidelines are implemented cannot bedetermined.2.1 Activities to improveaccess, coverage andquality of HIV servicesThe DOH aims for the expansion ofcoverage and scope of services from thesentinel sites to the larger population.HIV services are in theory available atall government institutions and PLHIVare required to be given hospital-basedand community-based HIV-relatedservices. It also provides for the creationof a Special HIV/AIDS Preventionand Control Services office under theDepartment of Health (which is theNational AIDS and STD Preventionand Control Program). However, due tothe devolution of government servicesto the respective local government units,these services may not be available inresource-constrained areas.2.2 Policies onconfidentialityPhysicians are required to maintainpatient-doctor confidentiality. To ensurethis, all health personnel are enjoinedto observe confidentiality in handlingmedical information of persons withHIV. On the other hand, the same lawrequires PLHIV to disclose their statusto their spouse/partner at the earliestopportune time.2.3 SRH and HIV policies thatsupport condom (male and female)accessCondom access is included in mostof the pending bills. Most bills carryspecific provisions on family planningand commodities that would includecondoms105

BANGLADESHCAMBODIANEPALPHILIPPINESThere is also stipulation that bothnatural and modern methods offamily planning, including condoms,be made available at all governmenthealth facilities and are encouraged inprivate facilities. However, the primaryresponsibility for providing theseservices lies with the LGUs. It is upto the LGUs to decide on how muchthey will allocate to family planningservices and on which methods theywill support.The thrust of the currently pendingbills on RH is on family planningand preventing the transmission ofSTIs. Among the aims of the DOHis to use family planning as a meanstowards responsible parenthood andas a reproductive right for women whointend to prevent pregnancy. Policiesthat support condom access and STIprevention and management are usuallyincluded in programmes on responsibleparenthood and responsible sexuality.2.4 Donor support forSRH and HIV-relatedwork within the sameprogrammesInitiatives to integrate HIV and SRHare still being explored. These initiativesare generally small pilot demonstrationprojects such as the SALIN plus projectof FPOP for young people whichintegrates provision of access to SRHand HIV and AIDS. Where possible,donors support both HIV and SRHsince STIs management is included inthe broad spectrum of SRH. Currently,there are no donor driven initiativesthat aim to integrate HIV and SRH.Donors do not usually put restrictionson HIV programmes regardingintegration of SRH components or viceversa. Management of the project is leftlargely to the programme managers.2.5 Budget AllocationAn initial sum of 20 million pesos(about US$ 465,000) was allotted forPNAC with subsequent appropriationsprovided for in the annual budget of theDepartment of Health. However thishas not had any subsequent significantincreases through the years. HIVprevention, treatment, care and supportis heavily dependent on externalfunding, the largest of which comesfrom the Global Fund.Budgetary allocations are not discussedin detail in any of the proposed lawsexcept where these are to form part ofthe annual general appropriations law;most currently filed bills are asking thatthe budget for the law once approved beincluded as part of the annual generalappropriations so that it becomesmandatory, continuous and sustainable.Budgets are also not discussed inthe bill creating the National AIDSPrevention and Control Program(NASPCP). The budget for HIV iscoursed through PNAC, with an initialappropriation of 20 million pesos, aminiscule amount in comparison withpresent programme needs. PNAC hasnot seen a significant budget increasesince the law was passed.There is also no specific mention ofthe provision for HIV commoditiesin the SRH appropriations sectionin the pending RH bills. However,a specific provision (in section 11 ofHB 101), states that: “All serious and106

life-threatening reproductive healthconditions such as HIV and AIDS,breast and reproductive tract cancersand obstetric complications shall begiven the maximum benefits as providedby Philhealth programmes.”A nascent initiative by Philhealthwill soon provide coverage for thepurchase of ARVs. Essential sexual andreproductive health commodities thatare related to HIV and family planning,such as contraceptives like condoms,are proposed to be included in theNational Drug Formulary and in theregular purchase of essential medicinesand supplies of all national and localhospitals and other government healthunits. However, publicly fundedcontraceptives and supplies haveexperienced cutbacks since 2004.Provision of budgetary support toRH and family planning has largelycome from Congress through the socalledbudgetary insertions. ’Budgetaryinsertions’ are largely done throughthe initiative of certain supportivelegislators who manage to add a specificamount to a particular budget itembeing proposed by a department duringappropriations hearings to approvethe budget proposed by the ExecutiveBranch. In 2008, 150 million pesos (~US$ 3.5M) was ’inserted’ by Congressfor family planning and was releasedby the Department of Budget andManagement (DBM). In 2008, 1.2billion pesos (~US$28M) was again’inserted’ for family planning but it wasnever released by the administrationof President Arroyo. In 2009, 410million pesos (~ US$9.5M) wasadded by Congress and its statusof implementation in 2010 is stillunknown.Philhealth is mandated to providefinancing for universal healthcare,including reproductive health, familyplanning and HIV.It is supposed to provide coverage toall Filipinos and augment coverage toinclude the poor through the sponsoredprogramme.This programme subsidises socialinsurance payments by the poorthrough co-financing by the NationalGovernment and local governmentunits (LGUs). But through the years,Philhealth has been hobbled byseveral problems, including a) unstablesponsorship financing for the poor, b)setting of financing limits especially forserious and catastrophic cases, and c)disease or case exclusion.Firstly, flaws were noted in theenrollment of the poor and indigentsbecause of patronage politics. Politicians’favorites were being enrolled instead ofthe real poor. Secondly, there is an upperlimit on all case types being coveredby Philhealth giving rise to huge outof-pocketexpenses for poor patients.Thirdly, it is only recently that certainSRH and HIV-related cases havebegun to be covered and the processis very slow. In relation to the equityissue pertaining to future coverage ofthe poor for SRH, family planningand HIV needs, only 4.5 billion pesos(~ US$105M) was proposed by thenational government for the SponsoredProgram in the 2011 budget, whereasin the 2010 budget was 5.5 billionpesos (~ US$ 128M). In all of these,107

BANGLADESHCAMBODIANEPALPHILIPPINESit is to be surmised that Philhealth hasa long way to go in realigning SRH andHIV integration in financing.The Philippine Health InsuranceCorporation (Philhealth) has justrecently approved an out-patient HIVtreatment package. The package coversreimbursable case types of HIV thatresult in various types of infection thatentitles an HIV patient up to 30,000pesos (~US$ 700) in annual supportor reimbursements. In-patient HIVservices are treated as regular cases ofin-patient care. In a presentation by aPhilhealth official during the AlternativeBudget Initiative’s (ABI) workshop, hisdocument was silent on any possibleconnection with other RH services thatare also covered by Philhealth.3. Systems: Planning,Management andAdministrationWhile not explicitly mentioned, thereis some overlap in the planning of HIVand SRH programmes. The NationalAIDS Prevention and Control Programhas the distinct role of providingtechnical leadership in the STI/HIV/AIDS response in the health sector andhas a coordinative role in other healthprogrammes of the DOH . Initiativessuch as maternal and child health, familyplanning, adolescent RH, blood safetyand universal precaution come under itsjurisdiction. DOH and PopCom havespecific thrusts – DOH is on servicedelivery programmes on STIs andRH, and POPCOM is on educationand information provision. PopComis involved in integrated advocacy andthe IEC campaign for SRH and HIV.HIV education is included in their“Responsible Parenthood” programme,the thrust of which is family planning.HIV education is also included inthe “Adolescent Health & YouthDevelopment Program” of PopCom.The NASPCP on the other handplays a role in both HIV preventionand control and in promoting SRH.However the planning of the twoagencies (DOH and PopCom) arelargely independent of each other.Nevertheless, when the need arises, theconcerned agencies do joint planningon certain issues. Cooperation andcollaborative efforts with other agenciesis being promoted. .AIDS/HIV measures related to SRHare included in two proposed bills;age-appropriate RH and SexualityEducation is proposed to be taughtin schools. Topics include STI, HIVand AIDS, fertility awareness andresponsible relationships, to name afew. However, the specifics in the jointplanning of SRH and HIV programmesare not thoroughly discussed in any ofthe proposed laws.Some agencies who are members ofPNAC are also the same agenciesidentified in the proposed bills on SRH.Apart from government agencies, thereare also NGOs that support HIV-AIDS related programs.The initiatives on integrating SRH andHIV programme management are stillin the exploratory stage. Specifics on thecollaboration between SRH and HIVprogramme management are still at theinitial phase. The most that can be saidabout the integration measures is thatthe proposed SRH services includeeducation on HIV/AIDS.108

3.1 Systems: Staffing,Human Resources andCapacity DevelopmentRelated bills provide for the capacitybuilding of barangay health workers(BHWs) on the promotion ofreproductive health. However, the issueof who needs to be trained and whatskills to impart has yet to be determined.Implementation, however, is leftlargely to the LGUs. The capabilitiesof personnel vary from one LGU toanother. A training needs assessmenthas to be done first before proceedingwith any kind of training. Trainingmaterials are still being developed aswith capacity building strategies. Thechallenges on integrating HIV withSRH will surface once programmesand services become available. Withregard to human resource, the biggestchallenge right now is the high turnoverof programme managers.3.2 Systems: Logistics/SuppliesThere is a separate procurement systemfor HIV and SRH. The different DOHagencies submit their procurementrequest to the Bids and AwardsCommittee (BAC) which is in chargeof all the procurement in DOH.3.3 Systems: LaboratorySupportLaboratory examinations and testsare among the services that are beingoffered as part of the HIV and SRHprogrammes. However, the thrustis mostly on HIV and STI testing.The National Reference Laboratory-STD AIDS Cooperative CentralLaboratory (SACCL) at San Lazarooffers testing for STIs. It also trainsmedical technologists on HIV testing.SACCL offers an HIV proficiencytraining course and an HIV proficiencyrefresher course. The Research Institutefor Tropical Medicine (RITM) alsooffers testing for STIs and training onHIV testing for medical technologists.3.4 Systems: Monitoringand EvaluationA national M&E plan for HIV hasalready been developed. However, theplan has yet to be fully implemented.The indicators that can capture theintegration of HIV and SRH need tobe developed.4. Service DeliverySRH-related services are available inall government hospitals. However,SRH services have yet to be reorientedto accommodate the HIV needs ofPLHIV; conversely, HIV services haveyet to be reoriented to accommodatethe SRH needs of PLHIV. At present,there are special AIDS hospital wardsand diagnostic facilities such as theNational Reference Laboratory-STD AIDS Cooperative CentralLaboratory in San Lazaro (SACCL)and the Research Institute for TropicalMedicine (RITM) offering tests forvarious STIs. They also train medicaltechnologists on HIV testing. In theproposed bills, SRH and HIV serviceswill be mandated by law to be offered inall government health facilities. There isalso collaboration between LGUs anda few NGOs to provide communitybasedHIV/AIDS prevention andcare.109

BANGLADESHCAMBODIANEPALThe protocols and guidelines to supportintegrated service delivery have yetto be developed. The challenges andconstrains that may arise due to theintegration of SRH and HIV at thefacility level have yet to be determined.The impact of linking SRH and HIVservices cannot be measured until theintegration of SRH and HIV servicesis implemented in full.RecommendationsAdvocacy efforts to pressure Congressto pass all RH-related bills should befurther strengthened. There should bemuch broader support from varioussectors of society.i. Opportunities brought about by theelection of a pro-choice Presidentshould be leveraged by advocateswithin the government and amongcivil society organisations (CSOs),to push through with better SRHand HIV integration.ii. Within the government, it shouldresult in the following:iii. A restructuring in the DOHas well as PopCom, to grouptogether under one unit alldisparate units that have relevanceto SRH planning, coordination,implementation and monitoringand evaluation;iv. Provision of specific budgetsupport (not released for thepast ten years by the Arroyoadministration) for the centralprocurement of family planningcommodities, especially condomstargeted for dual protection;v. Strengthening of PNACto better perform its role inpolicy coordination, includingintegration of HIV with otherRH elements, and an increase inHIV budget support in order towean the country away from donorfinancing;vi. Designation of an internal DOHHIV/SRH integration officervii. Hastening of Philhealth’s inpatientand outpatient coverageof SRH and HIV cases includingits integration in such areas aspurchases of FP supplies includingcondoms, PMTCT, PEP for rapecases, etc. Treatment of in-patientHIV cases as special cases thatrequire higher reimbursements;viii. Among CSOs, their focus shouldbe on the following:ix. Re-orient their advocacy for theRH bill to be not only NCRorientedbut should be nationwide,with grassroots-support, tocounter the Catholic Church’sadvantage in using the pulpitsto command obedience from itsflock;x. Have experience in HIV/SRHintegration through on-goingprogrammes and projects on apilot scale, publish and disseminatematerials to government and othersectors and lead policy-relatedefforts in integration;xi. Include budget advocacy as adistinct tool separate from thetraditional policy advocacy effortsin order to secure financing forHIV/SRH integrationPHILIPPINES110

xii. Include Philhealth as a promisingarena for the conduct of advocacyas it has existing funds to devisenew programmes in HIV/SRHintegrationReferencesAdministrative Order 16, s 2009. Policies and Guidelines on the Prevention ofMother to Child Transmission (PMTCT) of Human Immunodeficiency virus(HIV) . Department of Health, Philippines.Administrative Order 1-a, s 1998. Creation of a Philippine Reproductive HealthProgram. Department of Health, Philippines.Administrative Order 26-a, s 2000. Implementing Guidelines in STD CaseManagement at the Different Levels of the Health Care System. Department ofHealth, Philippines.Administrative Order 35, s 2006. National Family and Strategic Framework on MaleInvolvement in Reproductive Health. Department of Health, Philippines.Administrative Order 43, s 2000. Implementing Guidelines in STD CaseManagement at the Different Levels of the Health Care System. Department ofHealth, Philippines.Administrative Order 5, s 1998. Implementing Guidelines in STD CaseManagement at the Different Levels of the Health Care System. Department ofHealth, Philippines.Administrative Order 50-a, s 2001. National Family Planning Policy. Department ofHealth, Philippines.Department of Education Memorandum 261 s 2005. Operationalization of theUNFPA-assisted project Institutionalizing Adolescent Reproductive Health(ARH) Through Lifeskills-based Education. http://www.deped.gov.ph/cpanel/uploads/issuanceImg/DM%20No.%20261%20%20s.%202005.pdf. Dateaccessed Sept 12, 2010Department of Education Press Release. http://www.deped.gov.ph/cpanel/uploads/issuanceImg/jun8-sex.pdf. Date accessed Sept 12, 2010Facts on Barriers to Contraceptive Use In the Philippines. Guttmacher Institute.Promoting Reproductive Health: A Unified Strategy to Achieve the MDGs.Policy Brief. Senate Economic Planning Office. July 2009.Family Planning Organization of the Philippines (FPOP). Youth Friendly Servicesfor Young People’s Sexuality in ASRH in the Philippines. Progress Report forthe Period 1 Oct 2010 to 31 March 2011.General Appropriations Act 2010. Department of Budget and Management,Philippines. http://www.dbm.gov.ph/index.php?pid=8&xid=28&id=1289.Date accessed August 31, 2011.General Appropriations Act 2011. Department of Budget and Management,111

BANGLADESHCAMBODIANEPALPHILIPPINESPhilippines. http://www.dbm.gov.ph/index.php?pid=8&id=1364&xid=28.Date accessed August 31, 2011.House Bill No. 96. An Act providing for a national policy on reproductive health,responsible parenthodd and population and development, and for otherpurposes. First regular session, 15th Congress, 2010.House Bill No. 101. (Sections 7 & 9) An Act providing for a national policy onreproductive health and population and development, and for other purposes.First regular session, 15 th Congress, 2010.House Bill No. 513. An Act Providing for a National Policy on Reproductive Healthand Population and Development, and for other purposes. First regular session,15th congress. 2010.House Bill No. 1160. An Act providing for a national policy on reproductive healthandfor other purposes. First regular session, 15th Congress, 2010.House Bill No. 1520. An act protecting the right of the people to information onreproductive health care services.House Bill No. 4110. An Act Establishing a Reproductive Health Care Act,Strengthening its Implementing Structures, Appropriating Funds, therefor andfor other purposes. First regular session, 12th congress. August 2002.House Bill No. 4244. The Responsible Parenthood, Reproductive Health andPopulation Development Act of 2011. A consolidation of six versions of the RHbills --- HB 96, HB 101, HB 513, HB 1160, HB 1520 and HB 3387National Statistics Office (NSO) [Philippines], and ICF Macro. 2009. NationalDemographic and Health Survey 2008. Calverton, Maryland: National StatisticsOffice and ICF Macro.Philhealth website, accessed through http://www.philhealth.gov.ph/circulars/2010/circ19_2010.pdf. Date accessed October 1, 2010.Philippine HIV and AIDS Registry. National Epidemiology Center, Department ofHealth. August 2010Presidential Decree 79. Revising the Population Act of 1971, 1972.Presidential Decree 965. A Decree Requiring Applicant for Marriage License toReceive Instructions on Family Planning and Responsible Parenthood, 1972.Republic Act 6365. An Act Establishing a National Policy on Population, Creatingthe Commission on Population and for other purposes. 4th special session, 7 thcongress, 1971.Republic Act 7875. National Health Insurance Act of 1995. An Act institutinga national health insurance program for all Filipinos and establishing thePhilippine Health Insurance Corporation. Third Regular Session, 1994Republic Act 8504. The Philippine AIDS Prevention and Control Act of 1998.Third regular session, 10th congress, 1997.Republic Act 9710. An Act Providing for the Magna Carta for Women. Secondregular session, 14th congress, 2008.Senate Bill 2378. An Act Providing for a National Policy on Reproductive Healthand Population and Development. First regular session, 15th congress. 2010.112

Senate Bill 3122. An Act Providing for Reproductive Health Care Structures andAppropriating Funds, therefor. Second regular session, 14th congress. 2009.Speech delivered by NEDA Director General Cayetano Paderanga on occasion ofthe Philippines MDG Summit, September 8, 2010.Resource PersonsRoberto Ador. Executive Director. Family Planning Organization of the Philippines.Dr. Aura Corpuz. Former National HIV/AIDS/STI Surveillance System ProgramManager, National Epidemiology Center, Department of Health.Dr. Honorata Catibog. Director III. Family Health Office. National Center for DiseasePrevention and Control, Department of Health.Dr. Dulce P. Estrella-Gust. COUNTRY PAPER PHILIPPINES: HIV/AIDSWORKPLACE. Second International Conference on Workplace HIV/AIDSPrevention. Dar es Salaam, TanzaniaAcknowledgmentThe author would like to thank Mr. Roberto Ador for his valuable suggestions andsubstantial inputs and Ms. Victoria Medina for her assistance in searching for thereferences as well as in the preparation of this report.113

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