“Foundations” is an occasional series of informal question-and-answer sessions with employees and others affiliated with The William and Flora Hewlett Foundation to give them an opportunity to explain their work.

Nicole Gray, an officer with the Foundation’s Population Program, manages a broad range of grants in the United States and internationally that pertain to reproductive health. Here she discusses her work to support the integration of family planning and reproductive health services into HIV/AIDS programs in sub-Saharan Africa.

Gray joined the Foundation in 2002 after working in the Population Program at the David and Lucile Packard Foundation. She has B.A. and M.A. degrees in African Studies from Yale University and M.P.H. and M.P.P. degrees from the University of California, Berkeley.

Can you remind us of the dimensions of HIV/AIDS in sub-Saharan Africa?

The U.N. estimates that 33 million people worldwide are living with HIV/AIDS, and in sub-Saharan Africa-the most seriously affected region-the disease is the leading cause of death. The prevalence of AIDS within this population is approximately 5 percent, compared with less than 1 percent globally.

Even though the rate of new cases is declining, the number of people with the disease is still huge. And the number of people affected reaches far beyond just those who have the disease. The impact on the economy alone is great. HIV/AIDS is striking relatively young people who, if healthy, would be in their peak productive years.

The other issue is that women are disproportionately affected in this region. Globally, infection rates are about equal between the sexes, but in sub-Saharan Africa 60 percent of those infected are women, and that percentage has been growing. It’s referred to as the “feminization” of the disease. There are some biological reasons for this, but there are also cultural and economic reasons why women are more at risk.

The good news is that now more people have access to drugs that make this disease chronic rather than fatal. That brings lots of great benefits, allowing people to maintain a higher quality of life. Of course, it’s a massive, massive undertaking to provide these drugs to everyone who needs them for an entire lifetime, and they still don’t reach everyone.

Why haven’t family planning and reproductive health care been integrated with AIDS care before now?

That’s a good question. There are a couple of reasons. First of all, it’s very common to have vertical programs that deal with one kind of problem from top to bottom. A program that addresses a single health care issue, from policy and fundraising to service delivery, makes training and organization much easier. And there has always been a tension in global public health planning between this approach and a much broader, horizontal, primary-care-for-all approach. The current thinking is that you need some of both.

Also, organizations that work on issues of sexually transmitted diseases typically are run by different people with different training from those who work on family planning and reproductive health issues.

A final reason is that the movement to prevent and treat HIV/AIDS has been characterized by a sense that this crisis of epic proportions must sometimes be addressed to the exclusion of other health issues. Advocates were driven by activism, and that’s different from the typical motivation of people who work on delivering family planning services.

And the politics around all this, from debate about U.S. reproductive rights to cultural attitudes surrounding sexually transmitted diseases, makes everything harder.

Why is it important to integrate these programs?

HIV/AIDS programs are trying to reach millions of people to help them understand how to avoid infection, as well to care for people who already have the disease. That’s a big population and very similar to the one we’re trying to reach with family planning programs.

It’s not as unusual for family planning organizations to have HIV prevention as one of their mandates as it is for HIV/AIDS programs to address family planning. That’s where more of the missed opportunities are. HIV/AIDS programs reach a vast new population.

In concrete terms, what is Hewlett funding in which countries to make this happen?

It’s a fascinating problem. We’re building this plane while we’re flying it, and we need to focus on different issues at once. One part of it is to encourage people who run HIV/AIDS programs who see the virtue of incorporating the additional services to talk to their colleagues about how this is their issue, too. And we’re investing in encouraging major sources of funding for HIV services, like the Global Fund to Fight AIDS, Tuberculosis and Malaria, to support the integration of reproductive health into HIV/AIDS programs.

We also fund programs on the ground in Mozambique and South Africa to help clarify what an integrated program should look like. One site is urban and one is rural; one has a high prevalence of infection and the other a lower prevalence. It’s a way for everyone to figure out what the important factors are if you want to do this.

The final piece is to find ways to share this knowledge and connect people who are working on integrating programs. So we fund a Web site that is a resource hub for them: Resources of HIV/AIDS & Sexual and Reproductive Health Integration (http://www.hivandsrh.org/index.php).

What are the biggest obstacles to integration?

It’s a problem that has no simple solution. This is about crossing disciplinary boundaries and crossing organizational boundaries between different kinds of health delivery services. And our approach is going to vary by the cultural context and by the different actors. That makes the work exciting. There’s so much opportunity to reach new people. But it’s complicated.

What are our short- and medium-term goals for this work?

I think that ultimately what we want to see is an increase in sexual and reproductive health services delivered to people who need them. And that’s a long-term objective; I don’t think it will be reached in two years. We’re talking about changing massive systems shaped by forces over which we have little control in many cases.

In the interim, we can measure progress by asking: How many of the programs we supported were integrated, and what percentage of all programs was that? What knowledge did we glean from this effort and share with others? And how much more of the money allocated for HIV/AIDS programs also included money for sexual and reproductive health?