Remarks by Thoraya Ahmed Obaid, Executive Director UNFPA

Today, I want to be very practical. I want to answer the question: Why should we link HIV/AIDS with sexual and reproductive health.

Deputy Secretary-General Louise Frechette has mentioned several reasons why the two should be linked:

• Because they are intimately linked—three quarters of all HIV infections are sexually transmitted.
• Also, because it would be more effective.

So, we musk ask ourselves: Why have HIV/AIDS and sexual and reproductive health gone their own separate ways? As far as I can tell, there are several reasons:

• One reason is that the AIDS community initially saw little value in working with family planners or even the much wider context of reproductive health, because AIDS was first viewed as a disease of men having relations with men.
• Another reason is that, as the epidemic grew more and more serious, people wanted to elevate the urgency of HIV/AIDS to obtain greater awareness, more funding, more political leadership and support and, thus, acknowledged legitimacy. And this approach has resulted in the formation of the Joint United Nations Programme on HIV/AIDS (UNAIDS), of which UNFPA is proud a co-sponsors. Actually, I believe UNAIDS is one of the most successful inter-agency coordination mechanisms, if it is not the most successful one. The UNAIDS model is in the spirit of United Nations reforms calling for increased coordination and partnerships—all necessary in the fight against AIDS. The Global Fund was also established for many reasons among which was giving greater visibility to HIV/AIDS and ensuring that resources were devoted to this very destructive disease. This approach has been well supported by many of the traditional donors of both reproductive health, with the good intention of giving visibility to the crisis of HIV.
• Another reason why the two fields have gone down divergent paths is political. This is especially relevant today. Some elements do not want to link HIV/AIDS prevention or treatment with sexual and reproductive health because they believe that it will somehow lead to abortion. Some critics oppose family planning and women’s rights and reproductive rights. So they want to keep HIV/AIDS separate.
• But many supporters of both agendas – the fight against HIV/AIDS and reproductive health – also want to keep the two apart to protect HIV/AIDS prevention and treatment from possible threats to its resources, since reproductive health, as articulated in Cairo Programme of Action and implemented by UNFPA, has not only been threatened, but actually defunded by the United States. Therefore, some of our colleagues see the importance of keeping them apart, to safeguard the much-needed resources for the fight against HIV/AIDS.
• Another reason is that people working within the sexual and reproductive health field have been slow in articulating and showing the benefits of linking with HIV/AIDS.

But I am pleased to report that, recently, more discussions are taking place around this important issue. I am hopeful that we will see more links in areas where such integration makes sense, most specifically, in interventions that affect women, especially poor women. We’ve moved beyond talking and are now even holding hands in some cases. And it’s about time.

We at UNFPA know that we must put join others in order to make this necessary link and, thus, win a real war against a threat to humanity, the killer HIV/AIDS. We are optimistic that our friends in the HIV/AIDS prevention and treatment community are beginning to come to the same realization. If we do not combine our efforts, we will certainly lose the war against HIV/AIDS. Without linking our efforts, we cannot scale-up our responses, and HIV will spread much faster than our efforts to save people’s lives.

We now have a range of proven, effective ways to prolong life and control the spread of HIV/AIDS. Our real challenge is to work together to scale-up the interventions we have. By doing so, we can: 

• Expand the reach of prevention and treatment programmes;
• Bring it closer to the people who need it;
• Make it easier for them to access what they need at one multifaceted service facility and through coordinated interventions;
• Do so in a most cost-effective way;
• Increase access to services for preventing transmission from mother to child;
• Increase the number of people receiving life-saving drugs and
• Reach more young people with reliable information on how they can protect themselves from HIV infection.

There are many efforts underway to further the discussions and expand the understanding on the linkages between sexual and reproductive health and HIV/AIDS, including the recent meeting in Glion and the UNFPA technical round table in New York.

It is no coincidence that the General Assembly special session Declaration of Commitment on HIV/AIDS, and the Millennium Development Goals build on the agreement reached at the fifth-year review of 1994 the International Conference on Population and Development. It was the Cairo programme on Population and Development that began the articulation of a comprehensive approach to reproductive health, including HIV/AIDS.

We have also found that voluntary counselling and testing can be carried out quite effectively in reproductive health settings. This is important because there is now an urgent need to expand access to voluntary counselling and testing as an entry point to both prevention and treatment.

Results from pilot projects in the Côte d’Ivoire and India—and experience in Kenya, Rwanda and Ethiopia—show that integrating voluntary counselling and testing into sexual and reproductive health services produces exponential benefits.

• It reduces stigma associated with HIV/AIDS;
• Strengthens awareness of healthy sexual behaviour;
• Increases access to and use of services;
• And results in considerable cost savings.

The cost of providing voluntary counselling and testing within existing reproductive health settings is lower than setting up freestanding sites.

Together with the International Planned Parenthood Federation (IPPF), we have found that the necessary linkages, and even integration, in some areas of work:

• Made it easier for some clients to use voluntary counselling and testing services, since they were not marked solely as HIV testing sites, which often led to stigma and discrimination.
• That men would seek services in traditionally women-dominated settings if they were of high quality and welcoming to all. During a six-month period in a clinic in Ethiopia, voluntary counselling and testing were equally sought by women and men.
• That the counselling of couples during voluntary counselling and testing, if conducted in a skilled manner, could play a role in reducing gender violence, discrimination, isolation and abandonment experienced by some women who tested HIV-positive.

While I have been talking about integrating voluntary counselling and testing into reproductive health clinics, we can also integrate reproductive health – including family planning, and sexual health into the counselling services.

Preventing Mother-To-Child Transmission Plus

Working together, we can increase access to services to prevent mother-to-child transmission. There is no reason why the great majority of HIV-positive women in the poorest countries should not have access to effective prevention of mother-to-child transmission plus.

This intervention can and should be incorporated into routine antenatal care along with voluntary testing and counselling.

Programmes to prevent the transmission of HIV to pregnant women, mothers and their children must become a routine component of maternal care, for the sake of the women and their children.

A survey of antenatal clinics offering prevention of mother-to-child transmission plus in 11 African countries found that, on average, 80 per cent of women accepted voluntary counselling and testing. This shows that prevention of mother-to-child transmission plus is also a promising entry point for the provision of anti-retrovirals.

Diagnosis And Treatment Of STIs

Another area in which greater cooperation is possible is in the diagnosis and treatment of sexually transmitted infections (STIs).

Fortunately, the methods used to prevent HIV can also be used to prevent other STIs. These include ensuring the right of adolescents to abstain from sex, delaying the onset of sexual activity, reducing one’s risk of exposure by remaining mutually faithful to one partner, and correctly and consistently using male and female condoms.

The dual protection function of condoms, to simultaneously prevent unwanted pregnancy and infection from HIV and other STIs must be promoted.

STI diagnosis and treatment should be available wherever possible and, certainly, wherever anti-retroviral services are offered. STI programmes are a critical aspect of integrating prevention and treatment.

Expanding Access to Treatment

Another area where we should cooperate is in increasing access to treatment. People living with AIDS have been demanding greater access to treatment for years. Now that the World Health Organization (WHO) has committed itself to providing 3 million people with anti-retroviral treatment by the end of next year, we are faced with the challenge of doing so.

To ensure the right of women – who are often marginalized and vulnerable – to receive treatment, we must establish a system that links the reproductive health services that women seek and anti-retroviral services. If they are not integrated, they should at least be on one location, with a referral system established. If such an arrangement is not envisioned from the very beginning, we will be forced to encounter women – who are the real face of HIV/AIDS – having less access to services to prolong their lives. As it is, women are vulnerable and, thus, victims initially not of HIV per se, but of the irresponsible behaviour and practices of their male partners. Such practices, along with women’s inability to negotiate their relationships, will make women, in turn, victims of HIV—thus, double victimization. Denying them treatment would triple the degree of their victimization. If that happens, what human rights shall we be talking about, we should ask ourselves.

Reproductive health centres, most of which are community-based, provide entry points to the acquisition of life-saving drugs to many people. Conversely, where HIV/AIDS services stand alone as vertical programmes, they, too, should address their clients’ reproductive health needs.

Moving Forward

I want to stress that we may talk about integrating services endlessly, but unless we tackle the underlying forces driving the AIDS epidemic, we will make little progress. Reproductive health and HIV/AIDS are both multisectoral challenges that cut across socio-economic, cultural and gender issues. Reducing the spread of HIV/AIDS and improving reproductive health, therefore, require simultaneous efforts on many fronts.

We know too well that power dynamics between the sexes shape the context within which their relationships are determined. In most cases, men have the upper hand. Therefore, male involvement and responsibility are critical needs.

Also critical are greater efforts for the empowerment of women and girls, including education, life skills, income-earning opportunities and legal rights. We must move from an approach that focuses on risk to another that focuses on vulnerability, and the empowerment of the poor. We must address the vulnerability of women and girls and improve their status in society. We must work with communities in a culturally sensitive way to tackle discriminatory attitudes, harmful traditional practices and violence against women and girls. Both reproductive health and anti-HIV/AIDS prevention and treatment work will gain immeasurably from such coordinated efforts.

I would like to stress that we should link not only at the service-provision level, but also at the policy level. We need to work together to ensure that effective multisectoral policies are established to make the best use of scarce resources, thus allowing the leveraging of both external and domestic resources. This applies to building effective responses across sectors; training health care workers and counsellors; producing protocols, procedures and guidelines; and monitoring and reporting. All policies to eradicate poverty should address as a core concern the rights of women and men to receive reproductive health and HIV/AIDS services. Such policies must also recognize this right as one of those that poverty eradication will address.

This also means working to achieve the THREE ONES announced by Peter last year and reiterated in subsequent statements.

It is important to learn from past lessons. We have learned the hard way from family planning, prior to the Cairo consensus, that vertical programmes, which are not integrated, do not work. They drain the fragile resources of countries and end up being unsustainable in the longer term. We should move forward with this important lesson in mind. And that is that the “Call to Commitment” is all about.

I just would like to reiterate that, if we link HIV/AIDS prevention/treatment and sexual and reproductive health, we can be more effective, can use resources more wisely and can be better able to meet the needs of individuals. I believe that people would welcome going to just one location to receive a comprehensive package of services.

Finally, we need to think of this whole matter as one intervention that would create a supportive environment in which the poor, deprived, marginalized and vulnerable could exercise their human rights to life, a life of dignity, and to the many other rights enjoyed by the rich and the powerful. The bottom line is this: the most vulnerable people in the world have a right to development.