Linking Sexual and Reproductive Health and HIV/AIDS - Gateways to Integration: A Case Study from Serbia

This 24-page case study is part of a series of joint publications of the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the United Nations Joint Programme on HIV/AIDS (UNAIDS), and International Planned Parenthood Federation (IPPF) on the issue of strengthening linkages between sexual and reproductive health (SRH) and HIV/AIDS. The document is based on country experiences in Serbia and is the result of a joint effort of national experts and a group of public health professionals.

Opening sections of the document explore the history and rationale behind the strategy of linking SRH and HIV/AIDS. Reflections on the process of turning theory into practice are also offered. For instance, the reader learns that "[t]here is currently no globally accepted definition of the terms 'linkages', 'mainstreaming' and 'integration'" in the context of SRH and HIV. Working definitions are proposed here.

The case study begins with a look at the context of work by the Institute for Students' Health (ISH) - a government institution established in 1922 - to address the fact that students in Belgrade receive no sex education in school; this is a taboo subject in most homes. Thus, the emphasis at the ISH is on equipping young people with the knowledge and skills to adopt healthy sexual behaviours. Building on the steps towards integration made in the late 1990s, the decision was made in 2002 to physically integrate SRH and HIV services and to create a combined centre for HIV and sexually transmitted infection (STI) prevention. The HIV clinic was moved to a small building behind the Institute; it is equipped with 2 counselling rooms and a reception area where information materials and condoms are made freely available.

The STI/HIV centre is built upon a 6-step model of care (communication-related elements are summarised below):

1.  Upgrading skills - Staff receive training in basic knowledge and skills for voluntary counselling and testing (VCT).
2. Securing funding.
3. Expanding services - The centre offers VCT for HIV and Hepatitis B and C and diagnosis and treatment of other STIs. The staff use this as an opportunity to counsel clients on behaviour change, and as an entry point for other SRH services. The centre has mechanisms in place to refer clients to the ISH next door for other services, such as family planning or mental health.
4. Mentoring staff - The centre offers ongoing psychosocial support for people living with HIV as well as their partners, family. and friends. No one wears a uniform or a white lab coat when working at the centre. This is a deliberate policy to abolish hierarchy and to put clients more at ease when talking with health professionals.
5. Reaching key populations - The centre now runs programmes - directly or through affiliates such as the Jugoslav Association Against AIDS - for high school students, sex workers. and young people with disabilities.
6. Building partnerships.

ISH has set up a satellite clinic for reaching vulnerable young people below university age. The head of the clinic is a general practitioner with special training in youth counselling and VCT, who is a mother of 3 teenage daughters. When students arriving at the residence come in for their required medical check-up, she takes this opportunity to counsel them on sexual relationships, contraception, and infection prevention, and to tell them about the centre. She and her colleagues make sure that the clinic is an inviting place for young people, with freshly painted white walls, potted plants, and colourful rugs, and lots of information materials they can take away.

ISH has developed strategies to invest in young people and get them involved in SRH services - not just as clients, but as service providers. For instance, a mobile team of young people has been trained in counselling skills. In an effort to take information and education to young people wherever they are, the team organises parties where condoms and information materials are distributed and there are competitions with prizes to test young people's knowledge of HIV and SRH issues. A youth mobile team also runs a telephone hotline on HIV and SRH issues. Reportedly, "the anonymity of the telephone service is welcomed by stigmatized people, such as those who use drugs and men who have sex with men, who find it particularly hard to access information and services."

IRH also conducts outreach with sex workers. ISH was the initial home of the Jugoslav Association Against AIDS, a non-governmental organisation (NGO) set up in 1991 by a group of doctors. In September 2004, the Jugoslav Association Against AIDS started a programme - "Power of Prevention" - to deliver SRH and HIV services to female sex workers in Belgrade. The programme's team of young outreach workers makes contact with sex workers in the city's "hotspots", giving them information, supplies, and support to avoid unintended pregnancy and infection. Because treating sex workers can be illegal, the Jugoslav Association Against AIDS bought a van that it has equipped as a mobile clinic, staffed by a doctor and a counsellor, which goes out to the hotspots to provide services directly. The organisation recently held a training workshop for policemen and women to try to encourage greater understanding of and respect for sex workers and other vulnerable people living on the margins of society.

Special efforts have been made with the youth-friendly services to reach out to excluded populations such as young people with disabilities. A group of doctors run workshops for parents of children with learning difficulties to discuss issues about sexuality and relationships, family planning and disease prevention, and the range of services available. They have also provided special services for hearing-impaired children.

An excerpt from the conclusions and lessons learned sections of the report follows:

"Despite a decade of war in the Balkans, and political and socio-economic conditions unfavourable to innovation and change, the...ISH [has demonstrated]...vision, inspiring leadership and political will - such as the kind of commitment and passion that compel people to work for no pay and to fund their activities themselves, if necessary. Many health care providers comment that working with young people is inspiring because of their openness to change and because it is an investment in the future.

• ...In order to integrate services it may be necessary for public sector health staff to go beyond the boundaries of their job descriptions. This requires clear objectives, diplomacy and willingness to make personal sacrifices...The ISH takes pains to foster good relationships with the non-governmental sector in general by, among other things, providing office space to nongovernmental organizations such as the Jugoslav Association Against AIDS, and making its meeting rooms available to various groups for workshops, group supervision and other activities.
• When building capacity to provide integrated services, getting the various specialists to share their knowledge and skills with each other is an efficient and costeffective method of training and serves also to enhance mutual understanding and a spirit of cooperation in multi-disciplinary teams...
• ...All staff involved in counselling, whether at the STI/HIV Centre or as members of the sexual and reproductive health and HIV outreach teams, come together weekly for group supervision in which members of the same team share their experiences, concerns and insights. These are formal sessions, facilitated by a professional psychologist, psychiatrist or counsellor. Individual supervision is also available for staff needing it. Caring for the care-givers is an important principle at the ISH...
• Because of taboos and personal inhibitions, people are often reluctant to seek out sexual and reproductive health and HIV information and services, so providers need to use their imagination to reach potential clients...Taking education programmes to where students gather, and running telephone counselling services, are among the strategies used to good effect by the ISH to encourage people to attend. Making services as convenient as possible to clients is another way of overcoming barriers to access...
• Working effectively with vulnerable people, especially from stigmatized groups, requires service providers to examine their own attitudes critically and overcome harmful prejudices...Gaining their trust and confidence in health services means, first and foremost, that service providers treat them with respect. An effective way to promote this is to bring health professionals and representatives of stigmatized groups together as equals in training programmes. Another way is to help health workers, through training, to be comfortable with the language and expressions used by marginalized groups to describe their behaviour."