Effective integration of HIV and SRH services requires not only behavioral change interventions for health care providers (Provider Behavioral Change) but also increased understanding of beneficiaries to respond adequately to their needs based on their knowledge, attitude, and risk perception. As demonstrated by González, Kadengye & Mayega, (2019) in their nationally representative household survey focused on young Ugandans, high levels of SRH/HIV knowledge and risk perception did not curb risky sexual behaviors despite the context of generalized HIV epidemic (prevalence of 2.1% among 15–24 years old). The authors asserted that effectiveness gaps in the integrated SRH/HIV response should be addressed holistically at individual and structural level [9].
A marginalized group among key populations in Sub-Saharan Africa, women who inject drugs, received attention in this supplement. Sylvia Ayon et al. (2019) used action research to identify the process, impacts, and challenges of integrating SRH into community-based HIV prevention and harm reduction programs in coastal towns in Kenya. Their findings highlight low utilization of family planning and other SRH services, and provide critical insight on the acceptability and opportunities for successful integration at community level [19].
A cross sectional study conducted in Kenya by Raymond Mutisya et al. assessed the level of integration of family planning across six other services delivery areas (ANC, maternity wards, postnatal care clinic, child welfare clinic, HIV counselling and testing, HIV/AIDS services in comprehensive care clinic settings). Their findings validate what has already been documented on the positive correlation between provider knowledge, skills and attitude and service quality [15].
A systematic review of the integration of HIV testing services into family planning services by Narasimhan et al. (2019) revealed that HIV counselling and testing was generally higher in integrated sites as compared to non-integrated sites, including in adjusted analyses through outcomes varied slightly across studies. Similar to Kiersten Johnson et al. findings, this review concludes that global progress and success for reaching SRH and HIV targets depends on progress in Sub-Saharan Africa where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV [16].
In a 2015 State of the World Report, UNFPA stated that the many crises, wars, and natural disasters around the globe, and especially in Africa, are leaving women and adolescent girls facing a significantly heightened risk of unwanted pregnancy, maternal death, gender-based violence, and HIV acquisition. It is only befitting that this supplement includes a literature review by Roxo, Walker, Mobula, Ficht & Yeiser, (2019) on prioritizing the SRH and rights of Adolescent Girls and Young Women (AGYW) within treatment and care services in emergency settings. Their review revealed that the plurality of competing needs in emergency settings crowds out dedicated time and space to effectively integrate HIV and SRH interventions and that greater political will is required to advance the integration agenda [20].
Two of the supplement’s articles discuss key findings on the availability of family planning and HIV-related integrated services in Sub-Saharan Africa, with one addressing the quality component. Studies by Kanyangarara, Sakyi & Laar, (2019) and Barden-O’Fallon, Mejia & Close, (2019) restricted analyses to health facilities offering HIV/AIDS care and support, not just HIV testing and counseling, and FP services. Using secondary analysis of Service Provision Assessments (SPA), Service Availability and Readiness Assessments (SARA) (2012–2015) for 10 countries including six in West and Central Africa), Kanyangara et al. found that 93% of facilities offering HIV care and support services also reported offering integrated services, but merely 29% were classified as having onsite integrated FP services based on the availability of structural and process of care inputs (e.g., equipment, guidelines, trained providers, and FP commodities). Further, 94% of facilities reported routinely offering FP counselling to HIV/AIDS clients and 80% had three or more contraceptive methods in stock at the time of the surveys [17, 22].
Matching SPA measures and a Quick Investigation of Quality indicators for FP quality in integrated compared with non-integrated lower-level HIV/AIDS care and support facilities in Malawi (2013–2014) and Tanzania (2014–2015), Barden-O’Fallon et al. found that 79% of facilities in Malawi and 38% in Tanzania offer FP services. In keeping with the Bruce/Jain Framework of Quality Care, 22 quality indicators were analyzed and showed integration status was significantly associated with three indicators for Malawi: “facility has all (approved) methods available: no stock outs”, “facility has received a supervisory visit in the past 6 months”, “look and write on client record”. For Tanzania the indicators associated with integration status were “facility has adequate storage of contraceptives and medicines”, “facility has all (approved) methods available: no stock outs”, “waiting time acceptable (negative)”, and “facility has mechanisms to make programmatic changes based on client feedback” [17].
Two of the articles reviewed the knowledge and use of safer conception methods (SCM) among HIV-infected individuals on how to accommodate their safer conception needs. Both studies by Gwokyalya et al. (2019) and Schwartz et al. (2019) highlighted the need for more education and making available different methods of SCM to people living with HIV. Of the 5198 number of women interviewed at the health facilities in Uganda, 74.1% had knowledge of SCM but the number decreases to 42% with those of knowledge of more than one method. The study also underscored the lack of the involvement of partners in serodiscordant relationships in the choice and intent to use SCM. They emphasized the lack of qualified staff to undertake some of the SCM such as sperm washing. The study highlighted the increasing challenges by individuals with HIV to fulfill their fertility desire and concluded that the knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services, and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods [18, 21].
With its four-pronged approach, PMTCT prevents 90% of new HIV infections among children and thus contributes to the AIDS-Free Generation. PMTCT is also at the crossroad of antenatal and postnatal care services, FP, and HIV prevention care and treatment services. Three manuscripts in this supplement address the issue of PMTCT through the lens of antenatal, HIV, and sexual and reproductive health services integration. The authors, Rwema et al. (2019), and Parmley et al. (2019), assessed the PMTCT cascade and investigated factors influencing antenatal care services seeking behavior in a context of high HIV prevalence among female sex workers (FSW) in Port Elizabeth, South Africa [10, 11].
Rwema et al.(2019) found that 61% of FSW were infected with HIV and 52% of them knew their HIV status before the study. A gap of 40% was found regarding the systematic use of condoms by non-HIV-infected FSW with their clients and a gap of 43% in the use of long-term modern contraceptive methods among FSW living with HIV. Parmley et al.(2019) found in a similar context in Port Elizabeth, South Africa, a late discovery of pregnancy (at 4 to 7 months) among FSW living with HIV and a 40% antiretroviral therapy coverage among them. The influencing factors identified were alcohol and psychoactive substance use, as well as dissatisfaction with past health care experiences [10, 11].
Two manuscripts are respectively related to factors associated with early detection of HIV among children of HIV-infected FSW in Cameroon and partner notification in Botswana. In Cameroon, out of the 481 FSW interviewed in the study of Rao et al., 70% reported that none of their children under the age of 5 years had been tested for HIV. The factors influencing HIV testing of the children of HIV-positive FSW were antenatal services attendance (OR adjusted 2.12, 95% CI: [1.02, 4.55]), knowing HIV status (OR 3.70 [2.30, 5.93]), the character desired of the pregnancy (OR 1.89 [1.16, 3.08]) and higher education level (OR 2.17 [1.01, 4.71]). Partner notification and proper treatment of partners are essential elements for breaking the chain of transmission of sexual transmissible infections (STI) including HIV infection. The supplement includes one qualitative study done by A. Wynn et al. (2019), in Botswana. The study revealed that treatment of partners was late and most participants expressed a preference for notifying their STI to their partners at a health facility with support from the health workers. The authors concluded that important progress remain to be made along the four pillars of PMTCT especially among key populations such as FSW [12, 13].
Cervical cancer is one of the leading causes of cancer deaths in women especially in middle and low income countries. It is associated with persistent or high-risk (or oncogenic) types of human papillomavirus (HPV). Its prevalence is higher among certain vulnerable groups like people living with HIV. This supplement includes an original study on the feasibility in rural areas of Zimbabwe to integrate HPV screening within existing community-based HIV programming and immunization outreach services. Samples were collected at community level by trained community health workers. The collection was performed during scheduled outreach visits for antiretroviral medications and childhood vaccines. Community health workers explained how to perform the self-collection sample. The samples were then transferred to a health facility for analysis. This integrated community outreach model was accepted by the beneficiaries with an 82% participation rate [14].
