The objective of this adaptable tool is to assess HIV and sexual and reproductive health bi-directional linkages at the policy, systems and service-delivery levels. It is intended also to identify gaps, and ultimately contribute to the development of country-specific action plans to forge and strengthen these linkages. While this tool focuses primarily on the health sector it can be adapted to cover other sectors such as education, social services,
Importance of the tool: There is international consensus around the need for effective linkages between responses to HIV and SRH including recommendations for specific actions at the levels of policy, systems, and services. Stronger bi-directional linkages between SRH and HIV-related programmes could lead to a number of important public health, socioeconomic and individual benefits, such as:
• Improved access to and uptake of key HIV and SRH services;
• Better access of people living with HIV to SRH services tailored to their needs;
• Reduction in HIV-related stigma and discrimination;
• Improved coverage of underserved/vulnerable/key populations;
• Greater support for dual protection;
• Improved quality of care;
• Decreased duplication of efforts and competition for scarce resources;
• Better understanding and protection of individuals’ rights;
• Mutually reinforcing complementarities in legal and policy frameworks;
• Enhanced programme effectiveness and efficiency, and
• Better utilization of scarce human resources for health.
Strengths of the tool Linkages between core HIV services (prevention, treatment, care and support) and core SRH services (family planning; maternal and newborn health; the prevention and management of sexually transmitted infections; reproductive tract infections; promotion of sexual health; prevention and management of gender-based violence; prevention of unsafe abortion, and provision of post-abortion care) in national programmes are thought to generate important public health benefits. This tool can assess linkages between all these programmes, and also provides the opportunity of assessing not only services but also policies and systems. In addition, perspectives on linkages need to be broad-based addressing not only the health sector and the direct impact on health, but also the structural and social determinants affecting both HIV and SRH.
It is generic, therefore ready to be adapted to different settings, and it provides clear information on the process of adaptation. As it is a rapid assessment tool, it can be conducted in a short time, with a modest budget
This guide also acknowledges that people living with HIV are not a homogeneous
group and that addressing their SRH and HIV needs will require a comprehensive response. Their meaningful involvement in this rapid assessment is therefore a key
part of its application.
Limitations of the tool There is no single formula for approaching linkages.
The modalities for linking SRH and HIV vary according to a number of national
• Political commitment and approach to the issues;
• Structure and functioning of the health system and of other sectors;
• Sociocultural and socio-economic context;
• Dynamics of the HIV epidemic within the country;
• Status of sexual and reproductive health, and
• Availability of human and financial resources at all levels.
This guidance tool has been developed to address the SRH and HIV requirements of all people. However, the SRH issues that need to be addressed may vary according to gender, HIV status, age and other factors. Users of this generic guide may need to adapt the questions to suit specific audiences. There are also a number of services specific to men or women that have not been mentioned directly, for example: cervical cancer screening and management; erectile dysfunction treatments; prostate cancer diagnosis; and infertility treatments. Variations of the tool can provide nuanced responses to questions related to these kinds of services.
The importance of linking SRH and HIV and AIDS is now widely recognised. The majority of HIV infections are sexually transmitted or are associated with pregnancy, childbirth and breast-feeding. The risk of HIV transmission and acquisition can be further increased by the presence of certain sexually transmitted infections. In addition, sexual and reproductive ill-health and HIV share root causes, including poverty; limited access to appropriate information; gender inequality; cultural norms, and social marginalisation of the most vulnerable populations. The international community agrees that the Millennium Development Goals will not be achieved without ensuring access to SRH services
and an effective global response to the HIV epidemic.
The following points represent a philosophical foundation and commitments upon which linkages policies and programmes must build:
• Address structural determinants: Root causes of HIV and sexual and reproductive
ill-health need to be addressed. This includes action to reduce poverty, ensure equity
of access to key health services and improve access to information and
• Focus on human rights and gender: Sexual and reproductive rights of all people
including women and men living with HIV need to be emphasized, as well as the rights
of marginalized populations such as intravenous drug users, men who have sex with
men, and sex workers.. Gender-sensitive policies to establish gender equality and
eliminate gender-based violence are additional requirements.
• Promote a coordinated and coherent response: Promote attention to SRH priorities
within a coordinated and coherent response to HIV that builds upon the principles
of one national HIV framework, one broad-based multi-sectoral HIV coordinating body,
and one agreed country-level monitoring and evaluation system (the “Three
• Meaningfully involve people living with HIV: Women and men living with HIV need to be
fully involved in designing, implementing and evaluating policies and programmes and
research that affect their lives.
• Foster community participation: Young people, key vulnerable populations, and the
community at large are essential partners for an adequate response to the described
challenges and for meeting the needs of affected people and communities.
• Reduce stigma and discrimination: More vigorous legal and policy measures are urgently
required to protect people living with HIV and vulnerable populations from discrimination.
• Recognize the centrality of sexuality: Sexuality is an essential element in human life and
in the individual, family and community well-being.
The following specific steps are recommended:
1. Establish an assessment team: The team conducts the assessment and is made up of leaders from a variety of types of organizations, including HIV, SRH, networks of people living with HIV, as well as representatives from key populations and clients of services who are committed to and interested in guiding and monitoring the assessment. This broad representation will help prevent the assessment from drifting towards a more limited focus on SRH or HIV as opposed to the linkages between them.
2. Select a coordinator: The assessment team selects a coordinator to manage the assessment process. Health and social sciences and experience in both SRH and HIV programming are an appropriate background for the coordinator.
3. Conduct a desk review: The coordinator, with assistance and advice from the assessment team conducts a desk review, i.e. collects and analyzes background documents (see Appendix 2 for further information on conducting a desk review).
4. Outline the process of the linkages assessment: The coordinator arranges a meeting of the assessment team to:
• Review the objectives and the process of the assessment and seek consensus.
• Obtain suggestions on the assessment process and commitment to participate
in the assessment.
• Review and add to the relevant documents, studies and evaluations investigated
in the desk review.
• Review the planned data collection process and the generic tool and adapt the tool as
necessary to the appropriate context.
• Determine tasks and responsibilities related to invitations and letters of request
• Select appropriate individuals to participate in group interviews and a wide spectrum of
service-delivery sites for individual interviews of providers and clients.
• Arrange for the tabulation and analysis of the data collected and for drafting
the final report, and
• Arrange for a follow-up meeting to discuss results of the assessment and recommendations for next steps, including dissemination, priority setting
and an action plan.
5. Host group discussions with policy and programme stakeholders and programme managers: The coordinator holds group discussions to answer the questions with a variety of policy and programme stakeholders (for the Policy section), and programme managers (for the Systems section). The coordinator arranges for a record of the answers developed in the discussion groups to be taken down.
6. Train interviewers and supervise field interviews: The coordinator trains interviewers, and organizes and supervises field interviews with providers and clients of many types of services.
7. Analyze data and compile report and presentation: The coordinator supervises the input of data from the provider and client interviews, analyses the data and develops a report and a presentation on all findings, highlighting linkage successes, gaps, and possible next steps.
8. Review findings and decide on next steps: The assessment team arranges a follow-up meeting with stakeholders to review the findings and plan next steps.
These may include further dissemination of the findings, adjusting or developing
new training programmes
Partners This tool was developed by IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives. It should be conducted with these core partners, in collaboration with national governments of the country in which the assessment is being carried out, representatives of key populations, networks of people living with HIV and
Target The results of the needs assessment tool are particularly relevant to policy-makers, programme managers, service providers, clients, donors and partners in health. Illustrative examples of designated interviewees and group discussion participants follow:
A. Policy decision-makers and programme planners:
1. Director-general/executive head of health, HIV& AIDS, finance, social
and education services.
2. Programme directors of various ministries, such as education, health,
women, and youth.
3. Programme managers of planning, clinical services, PHC, nursing, SRH,
STI, and HIV.
4. Chairperson of the Country Coordinating Mechanism and National AIDS Committees.
5. Director and deputy directors of the national HIV programme.
6. Representatives of private sector and professional organizations.
B. Civil society and community leaders:
1. Women’s groups and their leaders.
2. Faith-based organizations.
3. Networks and organizations of people living with HIV.
4. Youth groups.
5. Representatives of key vulnerable and at-risk populations.
6. Community-based organizations.
C. Donors and development partners:
1. UN organizations.
2. Bilateral and multilateral agencies.
3. International and national NGOs.
D. Service providers in the following settings where SRH and/or HIV
services are available:
1. Hospitals and PHC clinics, public and private.
2. School-based services (schools as delivery points, e.g., referrals of OVCs).
3. Crisis centres.
4. Youth centres.
5. Settings relevant for key populations (e.g., prisons for incarcerated persons,
refugee camps for displaced populations).
6. Areas, such as crisis centres, where civil services/rights are accessed
E. Clients of the following services:
1. Family planning.
2. Maternal and newborn care, including ANC, and post-abortion care.
3. STI prevention, treatment and care.
4. HIV prevention, treatment, care and support.
5. HIV counselling and testing.
6. PMTCT services.
7. Community care and support programmes.
8. Men’s services.
9. IDU treatment and support services.
Methodology For the service delivery section, visit a selection of at least 15 service delivery sites. Include a balance of SRH and HIV services. Include sites run by MOH, AIDS organizations, FBO, NGO and the private sector. Balance sites providing services to women and to men. For the policy and systems sections, refer to the illustrative examples of designated interviewees and group discussion participants listed above under
This tool is divided into three sections:
III. Service Delivery
This tool can be used as a “stand-alone” activity or can be integrated into a larger review of the national response. It focuses on questions which can be answered in desk reviews and individual or group interviews (Policy and Systems sections), and individual interviews of various service providers and clients (Service Delivery section). These approaches can be supplemented with a range of other research methodologies, including: observations of services, focus group discussions among policy-makers, service providers, and clients, collection of data from clinic records, and “mystery client” surveys.
The tool is suggested for use in an assessment of policies, systems and services related to SRH and HIV linkages. The questions provide a guide to assessing these linkages but are not meant to be exhaustive. The assessment should include group interviews with the chief current and past policy and programme decision-makers, donors, and development partners, and individual interviews with providers and clients from a wide range of services. These include SRH, HIV, youth-friendly services, and male-oriented services provided by MOH, AIDS organizations, private sector organizations and NGOs. Ensure that the assessment focuses equally on the SRH and HIV components. The assessment should include members of the national HIV coordination body.
Time required Estimated time required is two months.
Human resources Refer to Appendix 3 of the tool: “Budget Outline for Estimating Cost of Conducting a Two-Month Rapid Assessment.” Generally the tool calls for a national consultant, interviewers, interviewer supervisors, drivers, data entry persons, and a translator. Each field interviewer is estimated to visit 5-8 facilities for one full day each. Each field interviewer is estimated to interview 10-16 providers or supervisors (two per facility), and 20-32 clients (four per facility). Group discussions can best be held in retreat, to avoid interruptions.
Budget line items Estimated cost is $30,000. For a sample budget breakdown refer to Appendix 3 of the Tool.
You can download the tool at (http://www.unfpa.org/publications/detail.cfm?ID=382&filterListType=)
experience with the tool This rapid assessment tool, finalized in 2008, amalgamates a number of related tools developed and pilot-tested by a range of organizations. It can be used in whole or in part to examine linkages at the policy, system and health-service level. Countries in all regions have expressed interest in conducting this assessment during 2009.
Recommendations for adaptation The tool is generic and does not attempt to cover all aspects of SRH and HIV in the country. It was developed in response to requests from countries for guidance, and should be modified as necessary. The assessment team should feel free to exclude, add, and modify questions to make them more appropriate for the country. It can be used in whole or in part to examine linkages at the policy, system and health-service level. A still more comprehensive approach might include tools to assess other sectors, for example education and social services.
Possibilities for technical assistance and contact information
Contact any of the partners involved in the development of the tool: IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives
For UNFPA contact Dr. Lynn Collins, Technical Advisor, HIV/AIDS, HIV/AIDS Branch, Technical Division, UNFPA (firstname.lastname@example.org).