CHAU aims to contribute to improved SRHR and HIV outcomes by increasing access and use of quality, inclusive and integrated SRHR and HIV services and by promoting positive healthy sexual relationships that can contribute to reducing new HIV infections and improving SRHR indicators by reducing prevalence of sexually transmitted infections (STI), maternal mortality rate (MMR), unmet need for family planning (FP) and increasing the contraceptive prevalence rate (CPR). The SRHR/HIV integration programme gives high priority to promoting the full sexual and reproductive rights of individuals and to addressing stigma and discrimination in all its complexity, as this is imperative for removing barriers to accessing health services. Efforts to address stigma are two-fold, focusing on internalised and self-stigma with individuals and communities, while also focusing on creating stigma-free and health promoting clinical and community environments. Addressing stigma at both levels will enhance both SRHR and HIV health outcomes.
The CHAU SRHR program responds to critical gaps and weaknesses in the Ugandan SRHR response. A strong community-based response has the potential to make a significant contribution to addressing Uganda’s unmet SRHR needs, including a high maternal morbidity and mortality rate, high teenage pregnancy rate and the continuing challenge of the HIV epidemic.
Uganda has a high burden of HIV/AIDS where it is estimated that 1.5 million people were living with HIV by 2015, 28,000 estimated Ugandans died of AIDS-related illnesses and the national HIV prevalence among adults (aged 15 to 49) stands at 7.3% (UNAIDS, 2016). The number of new HIV infections in the country increased by 21% between 2005 and 2013 but have reduced from 140,000 in 2013 to 83,000 in 2015. The number of AIDS-related deaths also decreased by an estimated 19% over the same period (UAC, 2015). Uganda reached a tipping point whereby the number of new infections per year was less than the number of people beginning to receive antiretroviral treatment (UAC, 2015).
HIV prevalence is significantly higher among young women than young men aged 20-24 years (7.1% vs. 2.8%); prevalence among 15-19 year old adolescents is 3% and more than doubles in ages 20-24 (UAIS, 2011). Incidence of HIV is high among all KPs, averaging at about 4,300 new infections per 100,000 KPs (Accelerated Prevention Roadmap, 2017).
STIs and related complications rank among the leading causes of out-patient consultations in public health facilities, accounting for approximately 20% of the total. One study in rural Uganda found up to 50% of adults aged 15-49 having at least one STI (MOH, 2014).
The Contraceptive Prevalence Rate (CPR) for modern family planning (FP) methods among all women of reproductive age in Uganda is low at 30% and the unmet need for FP remains high at 34%. Given the low CPR it is not surprising that Uganda has one of the highest fertility rates in the world at 6.2 children per every woman of reproductive age (UDHS, 2011).
Women in Uganda are more than twice as likely to experience sexual violence as men. More than 1 in 5 women age 15-49 (22 percent) report that they have experienced sexual violence at some point in time compared with fewer than 1 in 10 (8 percent) men (UDHS, 2016).
HIV affects all the dimensions of sexual and reproductive health because they both have similar characteristics, target populations and desired outcomes among reproductive age populations. Similarly, the majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding and the risk of HIV transmission and acquisition can be further increased by the presence of certain STIs. In addition, sexual and reproductive ill health and HIV share root causes — for example, poverty, gender norms and inequality, cultural norms, among others. In order to address these multifaceted areas, interventions must be integrated and comprehensive in nature to increase access and utilization of available services.
CHAU focuses on the drivers of HIV and sexual and reproductive ill-health for women and young people, at individual, community, health system and structural levels in order to contribute to the achievement of NSP and SDG goals. As such, CHAU takes advantage of the current national response to the SRHR, HIV and AIDS epidemics to implement an integrated approach to SRHR and HIV; promoting the sexual and reproductive rights of young people; adopting the hot-spot strategies and “follow the infections” approach, ensuring access to commodities in close connection with related services; and addressing obstacles on the demand side and environmental factors.
In a restrictive policy environment such as currently exists in Uganda, civil society organizations have an ability to reach vulnerable populations such as young women and people living with HIV (PLHIV) to create greater knowledge and awareness of their SRHR needs; to generate demand for integrated and quality SRHR and HIV services and to advocate for such services to be made available.
CHAU currently supports selected Ugandan NGOs and CBOs to improve SRHR and HIV outcomes for vulnerable populations by adopting and taking to scale proven evidence-based programming approaches and innovations. These interventions aim to increase demand for information and services people need to maintain their sexual and reproductive health and attain their reproductive and sexual rights. The supported interventions promote the positive aspects of sex, healthy equal gender relations, intimacy and pleasure and not just the negative outcomes that result from unsafe, coerced or underage sexual activity. Significant efforts have been invested in creating spaces and opening up dialogue on issues of sex, sexuality and rights across and within generations and communities in Uganda. Strengthening the advocacy and policy-influencing capacity of NGOs is also considered crucial for securing prioritization and funding for SRHR by the government and for maintenance of improvements in service delivery. The CHAU SRHR program will deliver a programme that can contribute to changing the way that government, the private sector and civil society collaborate to address unmet SRHR and HIV needs.