Back to basics: HIV/AIDS belongs with sexual and reproductive health.

The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV/AIDS, and for advancing other development goals. The United Nations Millennium Development Goals now incorporate a target of universal access to sexual and reproductive health within the goal of improving maternal health, but combating HIV remains a separate project with malaria and tuberculosis. We present a brief history of key decisions made by WHO, other United Nations' agencies, the United Nations Millennium Project and major donors that have led to the separation of HIV/AIDS from its logical programmatic base in sexual and reproductive health and rights. This fragmentation does a disservice to the achievement of both sets of goals and objectives. In urging a return to the original ICPD construct as a framework for action, we call for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV/AIDS prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model to maximize their effectiveness and efficiency and to strengthen the capacity of health systems to deliver universally accessible sexual and reproductive health information and services.

Starting young: sexual initiation and HIV prevention in early adolescence.

The rising numbers of new HIV infections among young people ages 15-24 in many developing countries, especially among young women, signal an urgent need to identify and respond programmatically to behaviors and situations that contribute to the spread of HIV and other sexually transmitted infections in early adolescence. Quantitative and qualitative studies of the sexual knowledge and practices of adolescents age 14 and younger reveal that substantial numbers of boys and girls in many countries engage in unprotected heterosexual vaginal intercourse--by choice or coercion--before their 15th birthdays. Early initiation into male-male or male-female oral and/or anal sex is also documented in some populations. Educational, health, and social programs must reach 10-14-year-olds as well as older adolescents with the information, skills, services, and supplies (condoms, contraceptives) they need to negotiate their own protection from unwanted and/or unsafe sexual practices and to respect the rights of others.

Towards a sexual ethics of rights and responsibilities.

Sexual rights as human rights encompass individual freedoms and social entitlements. Both depend for their realisation on equally important social responsibilities on the part of individuals, couples, families, other social institutions, and the State. The principle that all persons must understand their own sexual rights and responsibilities and respect the equal rights of others - particularly those of their sexual partners - informs our interpretation of the ethical basis of sexual behaviours. We propose a conceptual framework for defining a sexual ethics of equal rights and responsibilities pertaining to five dimensions of sexual behaviour: 1) sexual relationships and the right to choose one's partner; 2) sexual expression and the right to seek pleasure; 3) sexual consequences and the right to cooperation from one's partner; 4) sexual harm and the right to protection; and 5) sexual health and the right to information, education and health services. We suggest that the ethical principles presented here pertaining to sexual partnerships should be incorporated into sexuality education, sexual and reproductive health services, and social policies aimed at promoting the health and rights of all persons regardless of gender, marital status, sexual orientation, religion, ethnicity and other personal or group identities.

Fertility regulation and reproductive health in the Millennium Development Goals: the search for a perfect indicator.

Although several key elements of sexual and reproductive health are included in the United Nations Millennium Development Goals, a measure of women's capacity to regulate their fertility safely and effectively is missing. We considered the usefulness of 3 pairs of indicators in monitoring this component of reproductive health: contraceptive prevalence and total fertility; unmet need for contraception and unplanned births; and unsafe abortion and abortion mortality. A single measure of contraceptive use is insufficient. The risks women face from unplanned births and unsafe abortion should also be incorporated into the monitoring process, either directly within the Millennium Development Goals framework or as a parallel effort by reporting governments and other agencies.

How young is "too young"? Comparative perspectives on adolescent sexual, marital, and reproductive transitions.

This study puts forth three criteria for assessing the extent to which the timing of sexual, marital, and reproductive transitions among male and female adolescents could be considered "too young": (1) the physiological maturation of the body; (2) the cognitive capacity for making safe, informed, and voluntary decisions; and (3) institutionalized concepts of "old enough" for consent to sexual intercourse and marriage as reflected in legal frameworks and international standards. Expansion of the age grouping of adolescence is proposed, from the customary 15-19 into three age categories--early adolescence (ages 10-14, or 10-11 and 12-14), middle adolescence (15-17), and late adolescence (18-19)--to better capture the age-specific variations in the trajectories of male and female sexual, marital, and reproductive events. An application of the three adolescent development criteria to the timing of transitions observed in Demographic and Health Surveys in 64 developing countries leads to the conclusion that boys and girls aged 14 and younger are universally "too young" to make safe and consensual transitions; that 15-17-year-olds may or may not be too young, depending on their circumstances; and that 18-year-olds are generally "old enough." Policies and programs should focus on capacity building and the creation of an enabling environment for making safe and voluntary transitions among all age groups, but particularly among 10-14-year-olds, whose sexual and reproductive health and rights are so clearly at stake.

The sexual ethics of HIV testing and the rights and responsibilities of partners.

The discourse of much of the international AIDS community champions the rights of individuals in low-income countries to "just say no" to routine HIV testing in health-care settings and, if tested and found positive, not to inform their sexual partner(s) if such disclosure could result in substantial personal harm. This study contends that the right of individuals to refuse testing ignores the right of their sexual partners--male or female, regular or casual--to be informed of the health risks to which they may be exposed on entering or continuing a sexual relationship or engaging in particular sexual acts. If, as the UN has declared, all persons have the right to decide freely and responsibly on matters relating to their sexuality, including their sexual and reproductive health, free from coercion, discrimination, and violence, then all persons have the right and the responsibility to know their own and their partner's serostatus and to protect themselves and their partner(s) from sexually transmitted infections (STIs). Support by AIDS activists for policies of routine STI/HIV testing, counseling, and disclosure between both partners in a sexual relationship would help to promote an ethic of equal rights and shared responsibility for sexual behavior and its consequences.