Sexual and Reproductive Health (including HIV)

Last updated: 19 January 2024

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Key points

Gaps in the provision of Sexual and Reproductive Health (SRH) services to all members of a crisis-affected population will lead to increased morbidity and mortality
A Minimum Initial Service Package (MISP) for SRH needs to be ensured at the onset of an emergency and ideally within the first 48 hours, as an early expansion to comprehensive care needs to be planned from the onset
The implementation of comprehensive SRH programming should not negatively affect the availability of MISP for SRH services; on the contrary, it should improve and expand upon them
SRH services must be accessible for all crisis-affected populations, including adolescents, persons with disabilities, unmarried and married women and men, the elderly, individuals selling or exchanging sex and clients, and LGBTIQ+ individuals
SRH must be integrated into public health packages and linked to other relevant service sectors, including when strengthening SRH supply chain management

Overview

Sexual and reproductive health (SRH) is an essential component of the humanitarian response. Morbidity and mortality related to SRH is a significant global public health issue and people in humanitarian settings often face heightened risks and additional barriers to SRH services. Neglecting SRH in emergencies may lead to grave consequences including preventable maternal and newborn deaths, sexual violence and subsequent trauma, unwanted pregnancies and unsafe abortions and the spread of HIV and other sexually transmitted infections (STIs).

The Minimum Initial Service Package (MISP) for SRH is a set of priority activities to be implemented from the onset of a humanitarian crisis (ideally within 48 hours). These life-saving activities form the starting point for SRH programming and should be built upon as soon as possible with comprehensive SRH services and sustained throughout humanitarian response.

Relevance for emergency operations

During conflicts, natural disasters and public health emergencies, SRH needs are often overlooked with staggering consequences, leaving women and girls disproportionally affected. Despite many advances, it continues to be a challenge to ensure the availability of essential and quality SRH services throughout all phases of displacement. Without access to adequate delivery and emergency services both during and following pregnancy and childbirth, the risk of serious illness and death increases for both the woman and baby. It is estimated that 60% of preventable maternal deaths and 50% of newborn deaths occur in contexts of conflict, displacement, and natural disasters¹. In addition, displaced women may lose access to contraception and/or experience sexual violence, exposing them to increased risk of HIV and other STIs, unintended pregnancy, unsafe abortion and serious mental health consequences.

Adolescents in humanitarian settings are especially vulnerable to sexual violence, which further increases the risks of unintended pregnancy, unsafe abortions and STIs, including HIV. Complications from pregnancy and childbirth are among the leading causes of death for 15–19-year-old girls², while babies born to adolescent mothers face a higher risk of dying compared to those born to older mothers³. Early marriage, adolescent pregnancy and childbearing also interfere with their ability to go to school and jeopardize employment opportunities.

¹Source: IAWG (2023). Map of 2023 Countries with UN Humanitarian Appeals that Contribute to Global Maternal Deaths, Newborn Death and Stillbirths. https://cdn.iawg.rygn.io/media/IAWG-MNH-map-2023-Feb.pdf?mtime=20230327042713&focal=none

²Source: WHO (2023). Adolescent and young adult health: Key facts. https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions

³Source: WHO (2023). Adolescent pregnancy: Key facts. https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy

Main guidance

Emergency Phase

Guiding framework and lifesaving SRH priorities

In response to the clear need for SRH services in humanitarian emergencies, the international community developed a set of minimum standards for response known as the Minimum Initial Service Package (MISP) for SRH. The MISP defines which SRH services are most lifesaving and identifies priority actions that should be implemented at the onset of a crisis and prompts planning for expansion of these services to comprehensively address SRH needs. UNHCR and partners work to ensure that all MISP components are implemented as soon as possible at the onset of an emergency (ideally within 48 hours and no later than 3 months) and to scale up to comprehensive services as soon as feasible during the emergency phase and beyond.

The key objectives of the MISP are to:

Ensure the health sector/cluster identifies an organization to lead implementation of the MISP.
Prevent sexual violence and respond to the needs of survivors.
Prevent the transmission of and reduce morbidity and mortality due to HIV and other STIs.
Prevent excess maternal and newborn morbidity and mortality.
Prevent unintended pregnancies.
Plan the transition to comprehensive SRH, integrated into primary health care.

MISP Objective 1 – Coordination is essential in any emergency. The lead SRH organization puts in place the SRH Coordinator, who functions within the health sector/cluster. The SRH Coordinator ensures that all health agencies working in each of the crisis areas address SRH and implement or refer to SRH services; provides guidance on and technical support for the coordinated procurement of SRH supplies; identifies skilled health workers to implement MISP services; and identifies effective and confidential referral mechanisms between health service delivery points and between health services and other service sectors.

MISP Objective 2 – To prevent sexual violence and respond to the needs of survivors from the onset of an emergency, it is essential to: work with other sectors, especially the protection or GBV sub-sectors, to put in place preventative measures at community, local, and district levels, including health facilities, to protect affected populations, particularly women and girls, from sexual violence; make clinical care and referral to other supportive services available for survivors of sexual violence; and ensure confidential and safe spaces within the health facilities to receive and provide survivors of sexual violence with appropriate clinical care and referral.

MISP Objective 3 – To reduce the transmission of HIV and other STIs from the onset of the humanitarian response, the SRH Coordinator, health program managers, and service providers must work with the health sector partners to: establish safe and rational use of blood transfusion; ensure application of standard precautions; guarantee the availability of free lubricated male condoms and, where applicable, female condoms; support the provision of antiretrovirals (ARVs) to continue treatment for people who were enrolled in an anti-retroviral therapy (ART) program prior to the emergency, including women who were enrolled in prevention of mother-to-child transmission (PMTCT) programs; provide Post Exposure Prophylaxis (PEP) to survivors of sexual violence as appropriate and for occupational exposure; support the provision of co-trimoxazole prophylaxis for opportunistic infections for patients found to have HIV or already diagnosed with HIV; and ensure the availability in health facilities of syndromic diagnosis and treatment of STIs.

MISP Objective 4 – To prevent maternal and newborn morbidity and mortality, the following life-saving interventions must be available and accessible in any humanitarian crisis: clean and safe delivery, essential newborn care, and emergency obstetric and newborn care (EmONC) services; a 24 hour per day 7 days per week referral system to facilitate transport and communication from the community to the health center and hospital; post-abortion care in health centers and hospitals; and supplies and commodities for clean delivery and immediate newborn care (where access to a health facility is not possible or is unreliable).

MISP Objective 5 – At the onset of an emergency, it is important to ensure contraceptives are available to prevent unintended pregnancy. The SRH Coordinator, health program managers, and service providers must work to: ensure availability of a range of long-acting reversible and short-acting contraceptive methods (including male and female condoms and emergency contraception) at primary health care facilities to meet demand; provide information, including information, education, and communication (IEC) materials, and, as soon as possible, ensure contraceptive counseling that emphasizes informed choice, effectiveness, and supports client privacy and confidentiality; and ensure the community is aware of the availability of contraceptives for women, adolescents, and men.

Post emergency phase

Longer-term standard (post-emergency phase)

The MISP not only entails coordination to make lifesaving SRH services available, but it also aims to address comprehensive SRH needs and demands as soon as possible. This requires a sound understanding of the local situation and opportunities related to health system functioning.

MISP Objective 6 – Plan the transition to comprehensive SRH, integrated into primary health care

SRH is a lifetime concern for both women and men, from infancy to older ages. UNHCR recognizes that how SRH needs are met at one stage in life has implications for SRH outcomes and needs during other stages of life. Therefore, to adequately meet the health needs of refugees throughout their life course, UNHCR works to build on the MISP and provide a more comprehensive package of SRH services. This includes:

A choice of safe and effective contraceptive methods.
Safe and effective antenatal, childbirth, and postnatal care.
Safe and effective abortion services and care, to the full extent of the law.
Prevention, management, and treatment of infertility.
Prevention, detection, and treatment of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), and of reproductive tract infections.
Prevention, detection, and treatment of reproductive morbidities (e.g., cervical cancer, obstetric fistula, female genital mutilation, etc.).
Health promotion and education, counseling services, community outreach
Adolescent friendly services and tailored services that are accessible and acceptable, culturally appropriate, and responsive to gender and life course requirements.