Approximately 80% of HIV cases are transmitted sexually and a further 10% perinatally or during breastfeeding. Hence, the health sector has looked to sexual and reproductive health programmes for leadership and guidance in providing information and counselling to prevent these forms of transmission, and more recently to undertake some aspects of treatment. This paper reviews and assesses the contributions made to date by sexual and reproductive health services to HIV/AIDS prevention and treatment, mainly by services for family planning, sexually transmitted infections and antenatal and delivery care. It also describes other sexual and reproductive health problems experienced by HIV-positive women, such as the need for abortion services, infertility services and cervical cancer screening and treatment. This paper shows that sexual and reproductive health programmes can make an important contribution to HIV prevention and treatment, and that STI control is important both for sexual and reproductive health and HIV/AIDS control. It concludes that more integrated programmes of sexual and reproductive health care and STI/HIV/AIDS control should be developed which jointly offer certain services, expand outreach to new population groups, and create well-functioning referral links to optimize the outreach and impact of what are to date essentially vertical programmes.

Globally, abortion mortality constitutes at least 13% of maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing abortion mortality and morbidity in countries where they remain high is a matter of good public health policy, based on good medical practice, and an important part of initiatives to make pregnancy safer. This paper examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands: changes at national policy level; abortion training for service providers; the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally. Ó 2000 Bulletin of World Health Organization. Published by Elsevier Science on behalf of Reproductive Health Matters.

Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.Une traduction en français de ce résumé figure à la fin de l'article. Al final del artículo se facilita una traducción al español.

Unsafe abortion and associated morbidity and mortality in women are completely avoidable. This paper reports on an analysis of the association between legal grounds for abortion in national laws and unsafe abortion, drawing on an unpublished study and using estimates of the incidence of and mortality from unsafe abortion using information from the sources used to estimate the incidence of unsafe abortion and associated mortality in 2000. Although legal grounds alone may not reflect the way in which the law is applied, nor the quality of services offered, a clear pattern was found in more than 160 countries indicating that where legislation allows abortion on broad indications, there is a lower incidence of unsafe abortion and much lower mortality from unsafe abortions, as compared to legislation that greatly restricts abortion. The data also show that most abortions become safe mainly or only where women's reasons for abortion, and the legal grounds for abortion coincide. This is a compelling public health argument for making abortion legal on the broadest possible grounds. A wide range of actions have formed part of national campaigns for safe, legal abortion over the past century, covering law reform, provision of safe services, ensuring quality of care, training for providers and information and support for women. Safe abortion is an essential health service for women, as essential for sexual and reproductive health as safe contraception, and safe pregnancy and delivery care. In spite of sometimes powerful opposition and terrible setbacks, the public health imperative is gaining ground in many parts of the globe.

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Although more than one method of abortion has been available for many years, in most countries the provider chooses the method and may be skilled in one method only. This paper discusses choice and acceptability of medical abortion from the perspective of both women and abortion providers and argues that choice of method is important for both. Safety, efficacy, number of visits, how the method works, how long it takes for the abortion to be complete and cost all affect acceptability. Medical abortion is considered more natural because it happens in women's own bodies and can take place at home before nine weeks of pregnancy; surgical abortion with vacuum aspiration is simple and over quickly. Unless the costs of both methods are similar, however, women and providers will tend towards whichever is the cheaper option, limiting choice. Medical abortion is effective from when a woman misses her period through 24 weeks of pregnancy, and more women and providers need to be made aware of this. In legally restricted situations, complications tend to be less serious and easier to treat with early medical abortion than after unsafe invasive methods. Ideally, both medical and surgical methods should be available, but each can be provided without the other.

HIV and AIDS have a myriad of effects on sexual and reproductive health and rights, and sexual and reproductive health services are critical for women and men with HIV and AIDS. Yet there has been a dearth of visible, in-depth mainstream attention to the links between sexual and reproductive health and prevention and treatment of HIV/AIDS since the early 1990s among major stakeholders internationally. This paper argues that access to essential sexual and reproductive health care should be provided in HIV/AIDS prevention, care and treatment programmes, and appropriate forms of prevention and treatment of HIV/AIDS should be included in all sexual and reproductive health services as a public health priority, particularly in sex education, family planning and abortion services, pregnancy-related care, sexually transmitted infection (STI) services and services addressing sexual violence. The paper analyzes existing barriers to linking and integrating these services, e.g. at country level due to the traditional training of health workers to implement vertical programmes, separate sources of funding for National AIDS Control Programmes and sexual and reproductive health services, and in international donor programme and UN agency structures. This paper calls for leadership to be exercised by donors, all the UN agencies working together, governments, health service managers and providers, NGOs and advocates in both fields to develop and implement these linkages at country level. Finally, it is crucial that UNAIDS, WHO, UNFPA, UNICEF, the Global Fund to Fight AIDS, TB and Malaria and those working to reach the targets set by the Millennium Development Goals come on board in these efforts.

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