Tensions and exclusions: the knotty policy encounter between sexual and reproductive health and rights and HIV

The International Conference on Population and Development or ICPD (Cairo, 1994) provided a global policy framework centred on reproductive rights instead of population control. Global standards on sexual and reproductive health and rights (SRHR) and on HIV rapidly expanded throughout the 1990s.1 Considerable activist mobilisation in both arenas advanced health issues as politically salient decision-making venues where human rights and health advocacy were urgently needed, rather than scientific and technical showcases. The ICPD, quickly followed by the Fourth World Conference on Women (1995), stressed that reproductive rights are anchored in governments’ human rights obligations and development commitments, including to gender equality, health, bodily autonomy and the full spectrum of rights. The ICPD foregrounded individual rights that had been denied to women, whether in decision-making on if, when and with whom to have children, or accessing quality reproductive health services without violence, coercion or discrimination. While the ICPD advanced an expansive understanding of sexual health and sexuality, and of HIV within a broad SRHR agenda, intergovernmental negotiations rejected an understanding of sexual rights per se, despite vociferous advocacy by many civil society groups engaging the process. In the face of difficult negotiations at the ICPD, compromise language of “sexual and reproductive health and reproductive rights” was finally agreed. Some of this has been ameliorated in later intergovernmental negotiations, although strong mobilisation of conservative forces has stymied these efforts. Still, SRHR actors continue to struggle with resistance to encompassing the full expression of gender and sexual diversity and integrating all key populations. Policy and programming dialogues on HIV proceeded parallel to and sometimes intersecting with that of SRH. While the ICPD focused on SRHR, the Global Strategy Framework on HIV/AIDS2 advanced a human rights approach with a commitment to greater participation of people with AIDS. It also insisted on attention to those most at risk of contracting HIV. However, it failed to articulate the understanding of HIV as part of a broader SRHR agenda. As a result, critical SRHR issues have been left out of the HIV response, well-documented with regard to several issues such as the neglect of gender-based violence, abortion, and cervical cancer in the HIV response.3,4 Global HIV framworks, in contrast to the broad scope articulated in the ICPD process, have tended to advance a vertical appraoch. However, critics have called for a horizontal approach that:would attend to structural health inequity. These critics have further drawn attention to the need to strengthen health system, though this is emerging more recently as a global health priority.5,