Strengthening Integration of SRH- HIV services*

23 January 2020


*Please note that this IFP is only meant for shortlisted agencies who have received a Google Form from UNFPA to submit their proposal.

I.    Background

The rate of decline of new HIV infections in India has been declining over the past 7 -8 years. Many people seeking SRH services are at high risk of contracting HIV infections, however, they   are not provided important counseling to help prevent or detect their status. At the same time, the SRH needs of key populations seeking HIV testing are often not fulfilled, e.g. unintended pregnancies, and unplanned births.  Further, assessment of HIV risk of a person is also needed before providing Family Planning services, as highlighted by research linking the risk of HIV infections with certain hormonal contraceptives.  

SRH services provide an opportunity to prevent, detect and manage HIV infections. Evidence shows that integrated approaches to manage them might be able to encourage safer behaviors, increase the detection rates, bring higher number of people on treatment, and at the same time, offer cost benefits to the health system through using the same channels for multiple services.   Hence, it makes sense to offer SRH and HIV services in an integrated manner. 

Facts about India  (Source: India HIV Estimations 2017 (NACO, and MOHFW) 
1.    2.14 million people with HIV in India in 2017
2.    HIV prevalence among adults: 0.22% 
  • The prevalence is higher than the national average among 8 states, which include 3 states in North East India (Mizoram, Manipur, Nagaland) and 3 southern states (Andhra Pradesh, Telangana, Karnataka).    
3.    New HIV infections: Approx. 87,000  in 2017
4.    Of 2.1 million persons living with HIV, only 1.6 million are diagnosed
5.    0.6 million people diagnosed but not on treatment ( 1.18 million on treatment) 
6.    The rate of decline of HIV has slowed down in recent years (27% decline between 2010- 2017, compared to 59% between 2000-2010). 


Some of the major challenges in prevention in India are: 
1.    Insufficient integration between SRH and HIV programs: 

2.    Identification of high risk populations operating though virtual platforms: Nearly three fourths of key populations of FSWs and MSM have started contacting their clients through virtual platforms, which makes it difficult to reach put to them through traditional ways. 

3.    Gaps in implementation of prevention strategies. For example, the rate of condom use reported by men and by female sex workers (FSWs) at last paid sex varies – from 48% to 91%. Female condoms and lubricants are not covered under social marketing.

4.    Lack of confidentiality and stigma related to HIV testing 

Under joint UN plans for AIDS (UBRAF working group), eight UN agencies worked together to address the issue of HIV in India, and focused on the state of Gujarat in 2018-19. It was decided to focus on one state to achieve impact rather than spreading our efforts and resources in different states. 

Based on last available HIV estimates, the State of Gujarat was selected because it has the highest number of new HIV infections in the country and is among the States with highest number of AIDS-related deaths and big size of key populations (MSM, TG, FSWs) and high rates of migration. On the positive side the State has lot of potential to improve the HIV/AIDS epidemiological situation within the next two years, because of its good governance. 

In 2018-19, UNFPA has implemented an intervention for integration of SRH and HIV in selected districts of Gujarat. The interventions included facility level integration in 6 districts, capacity building of medical college faculty and support to CBO in 3 districts for collectivization. This is aligned to Strategy Result Area 8 - People-centered HIV and health services are integrated in the context of stronger systems for health.

In the next phase 2020-21, UNFPA proposes to consolidate its work for strengthening the integration of HIV and SRH services, and initiative interventions for community level and for enabling integrated monitoring, training and enabling sustainability in integrated services. 

II.    Objectives

1.    Strengthening SRH-HIV integration at facility and medical college level in 6 districts of Gujarat

2.    Pilot interventions for community level integration of SRH and HIV services in 3 selected districts  of Gujarat

3.    to facilitate policy level integration at levels of monitoring for SRH-HIV programs, training and for availability of supplies in the state 

4.    To document the intervention and prepare a clear roadmap for rolling out integrated SRH HIV services in other states of India and initiate actions in lessons other states 

III.    Strategic interventions

1.    Midterm assessment: A rapid assessment will be done in 6 districts with the following objectives: 
(a)  To assess the extent to which SRH counselling and services are being provided at HIV service sites including ICTC centres, ART centres, PPTCT centres, by TI clinics, by mobile ICTC services and by outreach workers. 
(b)  To assess the extent to which HIV counselling, screening and testing services are provided by SRH service providers/ at SRH service sites and by community-level workers.
(c)  To assess the experiences of key populations in interacting with community-based and facility-based SRH and HIV services.

2.    To map out clear areas for enabling integration and support the state government in ensuring integration of SRH HIV at levels of training of providers, monitoring of programs, and in ensuring supplies of SRH and HIV commodities in respective sites.

3.    To provide onsite mentoring and support to providers and managers in approx. 70 facilities of selected 6 districts to ensure integration of SRH and HIV services

4.    To undertake necessary actions to ensure integration of SRH and HIV at level of community outreach workers in 3 districts, and to enable community-based testing, including capacity building workshops for ASHAs/ ORWs and their supervisors/ trainers. 

5.    Adapt technical guidance & information materials for provision of integrated SRH-HIV services

6.    Increasing awareness among KP (particularly FSWs) on Reproductive Rights, Intimate Partner Violence and seeking integrated SRH-HIV services in 6 districts

It is expected that these interventions will result in critical areas of integration of convergence of HIV interventions with reproductive, maternal and adolescent health departments. 

IV.    Geographic coverage    

•    Situation analysis, onsite mentoring and community level interventions: it is expected that interventions for SRH/HIV  integration will be undertaken in selected 6 districts of Gujarat 
•    For policy advocacy and ensuring integrated training, monitoring and supplies, the interventions will be at the state level with implications for all districts of Gujarat 
•    While most of work would be in Gujarat, high level technical support, and supporting training of district monitors in aspirational districts will also be needed in other UNFPA states. 

V.    Duration:  2 years (January  2020 - December 2021)

VI.    Prerequisites for implementing agency

The project requires that the agency has expertise of SRH as well as HIV service delivery issues at primary care level and an experience of working with the public health system. The agency should have competence in conducting research studies, as well as policy advocacy for enabling integration at different levels, for different areas including for training, monitoring and supply chain. 
The project will require dialogue and advocacy with MoHFW, NACO, department of medical and family welfare as well as with State AIDS Control Societies.