The bold new sexual health agenda – and what it means for HIV

‘Sexual health’ is about much more than contraception and antenatal care, says a commission of top health experts.

In their report released earlier this month, the Guttmacher–Lancet Commission present a new, expanded definition of what constitutes sexual and reproductive health and rights (SRHR), and the services it should deliver.

The findings come from a two-year analysis of 1.9 billion women (aged 15 to 49) and 2.4 billion men (aged 15 to 59) globally with the help of a broad range of SRHR experts and led by 16 top-ranking health commissioners from Africa, Asia, Europe, the Middle East, North America and Latin America.

The Commission’s new, holistic definition encompasses more than disease prevention. It includes the right to make decisions governing one’s own body and sexuality, and the right to pursue a satisfying, safe, and pleasurable sexual life.

Addressing sexual and gender-based violence, engaging men in their health and integrating SRHR into other key health services are all key tenets of their agenda.

The needs of a number of marginalised or underserved groups, including adolescents and people of diverse sexual orientations, gender identities, and sex characteristics are also newly acknowledged.

The Commission outlines seven areas of SRHR information and services that should be included in all national health plans and made universally available in order to deliver SRHR for everybody, without discrimination.

The recommended basic package now includes prevention, detection, and counselling for gender-based violence, infertility, cervical cancer and sexually transmitted infections (STIs), plus comprehensive sexuality education, safe abortion care, and counselling and care for sexual health and wellbeing.

This is alongside traditionally recognised SRHR services for contraception, HIV and maternal and new-born care.

The Commission acknowledges that some people need help getting SRHR – including adolescents, sex workers, people who use drugs, minority groups, and displaced people, among others.

While expanding services is important, they also urge governments to change enabling environments through legal, policy and structural reform; by improving health systems through interventions such as task shifting and by integrating services; by providing accessible education and communication about SRHR, and by taking advantage of technology and innovation.

The report finds the most important types of reforms to be those that promote gender equality and give people, especially women who are unequal to men in most societies in the world, greater control over their bodies and lives – something that is also essential for preventing HIV. Specifically, it highlights how gender norms that perpetuate inequality constrain all people, with particularly profound effects on women and lesbian, gay, bisexual, transgender and intersex (LGBTI) individuals. It also clearly shows the way in which men suffer from restrictive masculinity norms, which often prevents them from seeking health care and can lead, for example, to men having lower rates of HIV testing than women, and low adherence to treatment.

The Commission’s findings have broad social, economic, and political implications, globally and within countries. For this reason the Commission acknowledges that engaging communities most affected by a lack of access to SRHR will be essential for moving the agenda forward, just as civil society groups spearheaded the SRHR and HIV movements in the 1990s and 2000s.

Commenting on the Commission’s findings, the Lancet’s Elizabeth Zuccala and Richard Horton highlight recent global events which they say have led to SRHR being “under attack”, bringing about the need for a “bold and necessary” redefinition of SRHR. These events include the USA’s reinstatement in January 2017 of the Global Gag rule, which bans funding for foreign NGOs that provide abortion services, affecting an estimated US$9.5 billion in foreign aid and is likely to disrupt services for a range of other SRHR programmes, including HIV prevention.

In addition, many Latin American countries are hindering access to SRHR services, access to abortion is becoming narrower within the USA itself, Poland is moving to further restrict abortion laws, and Russia has recently relaxed laws on domestic violence.

Ms Zuccala and Mr Horton add: “Reproductive health and rights advocates will have to fight regressive agendas in the USA and other countries, and with this Commission’s report they have the evidence base to do so…Progress [on SRHR] is not inevitable and the gains made to date cannot be taken for granted.”