Leveraging Sexual and Reproductive Health and Rights to Reduce HIV-related Vulnerabilities in Southern Africa

In this 2-page position paper, SAfAIDS proposes that comprehensive, integrated systems and programmes for both sexual and reproductive health and rights (SRHR) and HIV will achieve greater outcomes for both issues. To date, they have remained separate and detached, despite the logical connections between them. Integrated programmes are cost effective and holistic in their approach to HIV prevention and facilitate the attainment of other targets relating to HIV prevention, such as gender equality, elimination of discrimination, stigma, and gender-based violence. In this way, SRHR can be used to reduce HIV risk of vulnerable groups including women, girls, and young people, among others. A rights-based approach emphasising sexual and reproductive health and rights can slow down the spread of HIV.
According to the position paper, there is evidence of increasing risk among key populations. The level of resources for these key groups is typically low. These populations include the following:

• Women and young girls: In nine southern African countries, HIV prevalence among women aged 15-24 is three times higher than it is for men of the same age group (UNAIDS, 2009). Recent studies in Lesotho highlighted that physical and sexual violence were key factors in the country's HIV epidemic, with 47% of men and 40% of women maintaining that women do not have the right to withhold sex from their partners. Such violations of basic (as well as sexual) rights heighten risk for women and girls. Addressing SRHR issues can reduce risk for women and girls as they become informed and as SRH services become available to them. Such services include counselling, testing, and treatment and should extend to law enforcement agencies.
• Women living with HIV: HIV counselling, testing, and prevention services in antenatal services provide opportunities to prevent mother to child transmission (MTCT), as well as to protect the health of HIV positive mothers. Where preventive services for mothers are available, gaps in treatment remain. Combination regimens where multiple drugs are used are more effective in preventing transmission. However, in a number of countries including Malawi and Zimbabwe, a majority of women on PMTCT programmes are still receiving single dose treatments.
• Men and young boys: The sexual and reproductive health rights of men and boys include the right to information on SRHR, access to services and products such as condoms and Voluntary Counseling and Testing (VCT), and support for HIV-positive men wishing to have children. In addition, men can play a major role in promoting safer sex practices and in promoting sexual and reproductive health. Engaging men and boys is essential to improving their health as well as the health of their sexual partners and children.
• Mobileworkers: Mobile populations including truckers, migrant labourers, and cross border traders face increased vulnerability to HIV infection due to the likelihood of multiple concurrent partnerships (MCPs) and the likelihood of purchasing sex from commercial sex workers (CSW). Access to SRH services can reduce HIV infections in such cases.
• Sex workers: Sex workers remain at heightened risk of sexually transmitted infections (STIs) including HIV. Programmes in SRHR can increase knowledge of links between STIs and HIV as well as educate against sexual violence.
• Men who have sex with men (MSM): Research has found that men who have sex with men have significantly higher rates of HIV infection than other men – in some cases as high as 33.9%. MSM remain a 'hidden' population due to stigma, discrimination, and criminalisation. This increases HIV risk for female partners of MSM. Highlighting SRHR can help address stigma and discrimination towards MSM, paving the way for people to access preventive services as well as treatment.

The paper makes the following recommendations: Recommendations for governments/policy makers:

• Implement key national strategies and frameworks relating to SRHR and HIV such as the SADC Sexual and Reproductive Health Strategy 2006-2015, as well as key commitments such as the Maputo Plan of Action 2007, and Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA).
• Allocate adequate resources to facilitate health system-wide improvements and linkages for SRH and HIV. Investing in HIV alone is not enough, provide access to SRH and HIV services by making such services affordable and enforce laws relating to sexual and reproductive rights. This includes laws relating to sexual assault and right-to-abortion laws where applicable. Enforce gender-sensitive law enforcement procedures.

Recommendations for civil society:

• Track implementation of key continental and national SRHR policy frameworks to enhance accountability, facilitate government accountability in providing and/or supporting much needed integrated SRH and HIV services.
• Facilitate knowledge of SRHR and HIV through advocacy and partnerships with key players and equip women and young girls with knowledge of their sexual and reproductive health rights as a way of discouraging unreported sexual violence.
• Equip women and young girls with knowledge of their sexual and reproductive health rights as a way of discouraging unreported sexual violence.

Recommendations for Donors:

• Support governments in translating policy instruments at national level and support their implementation. There is a continuing need to strengthen HIV prevention, support civil society in planning, implementing, and evaluating integrated SRHR and HIV programmes.
• Support civil society in planning, implementing, and evaluating integrated SRHR and HIV programmes.