Reproductive Health Choices for People Living with HIV/AIDS in Developing Countries
July 27, 2010
Senior Associate, Global Health Policy Center, CSIS
Since the early 1990s, many Americans have learned a lot about the cultures and health problems of various developing countries through reading and hearing about the spread and consequences of HIV/AIDS in those countries. However, one particular developing country HIV/AIDS dilemma that requires more attention in global AIDS policy and that has not been highlighted at the 18th International AIDS Conference in Vienna is the set of complex reproductive health decisions faced by HIV-infected women or by couples, at least one of whom is infected by HIV.
HIV-infected and wanting to become pregnant
A subgroup of people living with HIV/AIDS (PLWHA) is those people who are not yet pregnant, but who want to have a child. In industrialized countries, with relatively easy access to anti-retroviral drugs and to various kinds of assisted reproductive technologies, the odds of such PLWHA completing a pregnancy that results in an uninfected child are very good.
In contrast, pregnancy planning among HIV-infected women living in developing countries present a far more complex set of issues.
While there is considerable societal pressure on women in most developing countries to have children, some non-pregnant women who know that they are infected with HIV but still want to bear a child are subjected to strong social pressures not to do so - by families, by communities, and by health care providers. In some cases, women face even more extreme forms of resistance such as the coerced sterilization recently documented among a group of HIV-infected women in Namibia. Still other HIV-infected women desiring to have a child may be lucky enough to have access to a specialized antenatal program that can provide them and their newborns with the kind of care and anti-retroviral medicines that can markedly reduce their children’s risk of becoming infected with HIV, while also ensuring that the mothers have access to HIV treatment for themselves. The coverage and effectiveness of such specialized programs for the prevention of mother-to-child transmission (PMTCT) – and their linkage to routine family planning, antenatal programs, and HIV treatment – is still sporadic but growing, and these programs deserve targeted support.
HIV-infected and not wanting to become pregnant
For non-pregnant HIV-infected women who do not want to become pregnant or who want to space their pregnancies, their ability to make that kind of planning decision in most developing countries depends on their relationships with their spouses or other sexual partners and on their access to – and ability to use - adequate forms of contraception.
Already pregnant and HIV-infected
Because the frequency of HIV testing and counseling is still low in many developing countries, a far more common scenario in those countries is for women to find out that they are HIV-infected only after they are pregnant, when they are tested for HIV as a component of their routine antenatal care.
That situation – HIV diagnosis after becoming pregnant – presents an even more complex and more difficult set of choices. First, the shock of finding out that they are infected with an ultimately fatal and highly stigmatized disease presents each one with an almost overwhelming set of concerns, e.g., How did they become infected? What will happen to them if they disclose their status to their partner? Will they be blamed for bringing the virus into the household, even if they were infected by their partner? What does it mean for their future? Can their baby be protected? What does it mean for their baby’s future? How can their disease be treated? Will their family support them? Some of these women may have access to the kind of PMTCT program described earlier and can hope to have an uninfected child. Many will not have such access.
Even with access to adequate counseling and PMTCT services, the reality is that, fearing for their own future and their children’s future, many such women will not want to continue their pregnancies and will seek pregnancy termination. Many of these women will put themselves at risk of death or other severe sequelae because their only choice is an unsafe abortion.
Although presented only in abbreviated form, these various HIV and pregnancy scenarios obviously raise a set of complex and partially overlapping public policy issues for any individuals and organizations concerned with HIV prevention and with maternal and child health in developing countries. For example: (1) How can overall HIV prevention efforts be accelerated so as to minimize the number of people in developing countries who find an HIV infection complicating their childbearing decisions? (2) How can the HIV testing and counseling process be improved so that more people know their own and their sex partner’s HIV status before pregnancy becomes an issue? (3) How can HIV-related stigma be best addressed? (4) How can the access of HIV-infected women to effective contraceptive be improved as part of HIV treatment programs? (5) How can the coverage and effectiveness of PMTCT programs be improved? (6) How can the exposure of women to unsafe abortion be reduced so as to further decrease maternal mortality?
Policy decisions made both in developing countries themselves and in the United States and other donor nations will help answer these questions.