Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
Given that most HIV transmission occurs through sexual intercourse, it is critical to include a sexual and reproductive health lens in HIV programming. The evidence and interventions in this chapter focus on the sexual and reproductive health of women living with HIV. However, because so many women do not know their HIV status, many of the interventions in this chapter are appropriate for all women irrespective of serostatus.
Full coverage of sexual and reproductive health (SRH) interventions for all women is beyond the scope of this document, however, “[r]egardless of HIV status, increasing access to sexual and reproductive health services will not only offer women more control over their reproductive lives and help them safely achieve their desired fertility, but will also produce major public health benefits on maternal and infant morbidity and mortality. Voluntary contraceptive services, in particular, will benefit the health of women and infants in a variety of ways by delaying first births, lengthening birth intervals, reducing the total number of children born to one women, preventing high risk and unintended pregnancies and reducing the need for unsafe abortion” (Wilcher and Cates, 2009: 833). In addition, sexual and reproductive health (SRH) services may provide an important entry point for HIV prevention information and services—entry points that include contraception and family planning clinics, antenatal care clinics, STI clinics, and programs for adolescents (Interact Worldwide et al., 2007).
The sexual health of women is an important component of SRH services and is often overlooked, particularly for women living with HIV. Discussions of SRH services for women living with HIV often revolve around controlling fertility and ignore HIV-positive women’s needs for services that include attention to safe and healthy sexuality and a desire for children. Because women living with HIV are more vulnerable to rights abuses, for example forced contraception or coerced sterilization, ensuring that their sexual and reproductive health needs are met is critical (Wilcher and Cates, 2009). [See Chapter 13: Structuring Health Services to Meet Women’s Needs]
Fertility Planning is Important for All Women, Regardless of Serostatus
Women living with HIV have similar reproductive patterns as women without HIV (Stanwood et al., 2007; Hoffman et al., 2008a; Rochat et al., 2006 cited in Reynolds et al., 2008). Some women living with HIV want to start or continue having children and others do not. Worldwide more than 215 million women say they would prefer to avoid a pregnancy, but are not using any form of contraception, or they are using traditional methods, which are less effective means of contraception (Singh et al., 2009c). Among those 215 million women are women who may not know their HIV status.
Because many people still do not know their HIV status, and because negotiating condom use is not always possible, expanding access to contraceptives for all women who need and want them through rights-based, voluntary services, is an important component of HIV programming and is cost-effective (Adair, 2009; Halperin et al., 2009a). A 2008 modeling study in the 15 PEPFAR countries estimates that the annual number of unintended HIV-positive births currently averted by contraception use is over 220,000 (Reynolds et al., 2008). A study by the U.S. CDC in Uganda found that unwanted pregnancies may account for almost a quarter of all HIV-positive infants in Uganda (Hladik et al., 2008a; Hladik et al., 2009).
As for all women, a wide range of contraceptive options provided with quality counseling is required (WHO/RHR and CCP, 2007). “For women who do not currently desire pregnancy, the dual method approach—combining condoms for HIV/sexually transmitted disease (STD) prevention with longer-acting, more effective contraceptives for added protection against pregnancy—simultaneously prevents both heterosexual and perinatal HIV transmission. Prevention of unplanned pregnancies remains a cost-effective and economically feasible way to prevent pediatric HIV disease in most of Africa. This approach also reduces the number of AIDS orphans….” (Mark et al., 2007: 1201). The female condom also offers an important dual protection option for women (Welbourn, 2006). [See also Chapter 3. Prevention for Women and Chapter 9. Safe Motherhood and Prevention of Vertical Transmission] Women living with and without HIV report greater success in negotiating condom use if it is also presented to their partner as contraception.
Integrating HIV and Contraceptive Services Can Meet the SRH Needs of Women
As women are living longer, healthier lives with HIV due to expanded access to treatment, there is an increased need for access to contraceptive methods suitable for women on antiretroviral therapy. “In studies of women with HIV infection approximately 70% are sexually active, effective contraceptive use is variable and unplanned pregnancy is frequently reported” (Desgrées-Du-Loû et al., 2002; Magalhaes et al., 2002 cited in Mitchell and Stephens, 2004: 167). A recent study in seven African countries found that within four years of initiating antiretroviral therapy, one-third of the women who initiated ARV therapy experienced a pregnancy. The treatment program did not include any contraceptive counseling or provision of contraceptives. “…[T]he design and operation of most HIV treatment services do not explicitly acknowledge the likelihood or the actual occurrence of pregnancy” (Myer et al., 2010). Integrating SRH, including provision of contraception, with other HIV services can increase contraceptive use and reduce unintended pregnancies (Duerr et al., 2005). Antiretroviral programs have regular contact with women living with HIV over long periods of time and as a result are a particularly important venue for meeting the reproductive health needs of women living with HIV (Myer et al., 2007a). Most clients would rather access contraceptive services at the same sites they receive HIV services (Asiimwe et al., 2005; Farrell and Rajani, 2007).
Many positive women do not receive appropriate information from providers about contraceptive options, including dual protection, and lack access to contraceptives and emergency contraception (WHO, 2004). This applies equally to positive women who wish to avoid pregnancy and to those who discover their HIV status during pregnancy. Providers and clients need to know that research on hormonal contraceptives has not resulted in any changes to family planning guidelines for women living with HIV (FHI, 2008). A 2009 systematic review of hormonal and intrauterine contraception for women living with HIV found that although one randomized trial raised concerns about enhanced disease progression, the evidence was “generally reassuring regarding adverse health effects, disease transmission to uninfected partners, and disease progression” (Curtis et al., 2009). Clients should also know that while no method of contraception other than male and female condoms has been proven to protect against STIs including HIV, condoms are not the most effective method to prevent pregnancy (WHO/RHR and CCP, 2007), so dual protection is warranted. More countries need guidelines and training regarding antiretroviral treatment and contraceptive options for women of reproductive age (Stevens, 2007) and guidelines on HAART regimens for women of reproductive age are being developed (Stevens, 2009).
ARV treatment programs should be part of a continuum of care that includes contraceptive and other integral health services from the onset (Shelton and Peterson, 2004; Farrell, 2007). Inclusion of contraceptive care in ARV treatment will take effort; in some cases, women living with HIV are denied information about safer sex because it is believed that they should not be having sex (Esplen, 2007). In fact, “sexual and reproductive health services need to provide [for women living with HIV]: improved information about, and access to…unbiased, legal, safe and confidential pregnancy, childbirth, and/or abortion services... [and] better training and awareness raising for health workers to reduce the frequency of forced abortion and forced sterilization of HIV-positive women” (ICW, 2008: 2). Based on the human rights underpinning of HIV and AIDS programming, “HIV-positive women should not be pressured not to have children, but should be given full information and be able to make their own informed decision” (Paxton et al., 2004a: 15). Health services should affirm a woman’s ability to make decisions about when and whether she wants children and forbid coercion in making family planning and reproductive health decisions (Eckman and Hersted, 2006). Women need to be asked on a regular basis: is pregnancy desired? If the answer is yes, preconception counseling is warranted along with support for a healthy and safe pregnancy. [See Chapter 9B. Safe Motherhood and Prevention of Vertical Transmission: Pre-Conception] If the answer is no, contraceptive options should be discussed and if an unintended pregnancy occurs, abortion, where legal, or, if necessary, post-abortion care services should be offered by providers (Wilcher and Cates, 2009).
Studies assessing the desire for children by women living with HIV rarely stratify results by time of diagnosis. Understanding how reproductive health choices change for women living with HIV is warranted. Studies have found that fertility desires of HIV-positive individuals changes over time (Chen et al., 2001 cited in Myer et al., 2010). The desire to limit births was higher among recently tested HIV-positive women in Zambia and Zimbabwe (Johnson et al., 2009). Some studies have found that knowing that one is HIV-positive may increase contraceptive use to prevent unintended pregnancies. A study of 227 women living with HIV in Malawi found that prior to receiving their HIV test results, 33 percent reported a desire to have future children; this declined to 15 percent one week later and remained constant for the following year. Contraceptive use increased from 38 percent prior to HIV testing to 46 percent after 12 months. The pregnancy incidence among women who reported that they did not want future children after HIV testing was less than half of the incidence among women who reported they did want future children (Hoffman et al., 2008b).
A growing amount of evidence exists on integrating sexual and reproductive health programs and services with HIV prevention, treatment and care, but more evaluated studies to demonstrate what works for women are needed (Wilcher and Cates, 2009; Spaulding et al., 2009). [See Chapter 13. Structuring Health Services to Meet Women’s Needs] Combining family planning information with HIV prevention messages may be a good way to prevent HIV among women but is often a missed opportunity. For example, in Ethiopia, community health workers have visited more than 42% of women aged 15-19 years old throughout the country with family planning information, referral and services, but not HIV prevention (Wilson-Clark, 2008). Studies have shown that health care workers can provide counseling on sexuality, family planning, HIV/AIDS, and STIs, if they receive adequate training (IPPF/WHR, 2000). To date, however, in most settings HIV and family planning services have been offered separately (Delvaux and Nöstlinger, 2007). Given the frequency of new information on HIV and SRH, it is important that providers receive ongoing training (Asiimwe et al., 2005; Farrell 2007).
Where HIV and contraceptive services are combined, women report greater use of both services. An analysis of VCT clients in Ethiopia suggests that various levels of service integration may attract different types of clients, including services provided in the same facility, the same room and by the same provider. More atypical family planning clients (younger women and males) were likely to increase use of HIV and SRH services provided in the same room. Facilities where counselors jointly offered HIV and family planning services and served many repeat family planning clients were most likely to serve older, married women who still had significant rates of HIV. Integrating VCT with family planning and vise versa is an effective strategy for expanding both services and reaching a wider range of clients (Bradley et al., 2008a).
Women Living With HIV Need Screening and Treatment for Cervical Cancer
Cervical cancer is another sexual and reproductive health issue of particular concern for HIV-positive women. Cervical cancer is preventable and treatable (WHO, 2009c; Hale, 2009). Women living with HIV are at a high risk for developing cervical cancer (Agaba et al., 2009; Chaturvedi et al., 2009; and Singh et al., 2009a). Despite the fact that HIV infection increases the risk of cervical cancer as well as a range of vaginal and cervical infections (Levine, 2002; Cejtin, 2003 cited in Myer et al., 2007a; Franceschi and Jaffe, 2007; Banura et al., 2008), “coverage of cervical cancer screening in developing countries is on average 19%, compared to 63% in developed countries, and ranges from 1% in Bangladesh to 73% in Brazil (Gakidou et al., 2008: 0863). “We are getting HAART, but we still die of cervical cancer,” noted Grace Sedio, ICW representative in Botswana (Sedio, 2009). The impact of antiretroviral therapy on cervical cancer is unclear (Massad et al., 2009; Massad et al., 2008; Asheber et al., 2007 cited in Stevens, 2008; de Vuyst et al., 2008; Bernal et al., 2008), but ARV therapy improves immunity and increases lifespan, which increases likelihood of persistent HPV infection developing into cervical cancer. What works best to detect cervical cancer in HIV-positive women in places without sophisticated lab equipment is unclear and no test is optimal. PATH is currently testing different screening options for cervical cancer in HIV-positive women (Jeronimo, 2010).
Available Guidelines
A number of sexual and reproductive health guidelines are available to program managers and policymakers. Guidance regarding which contraceptive options are best for women living with HIV is available from WHO, 2008a: http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/A counseling tool is also available at: http://www.engenderhealth.org/pubs/hiv-aids-sti/srh-hiv-positive-women-girls.php. Strategic considerations on linking family planning and HIV services can be found at http://www.fhi.org/en/RH/Pubs/booksReports/FP-HIV_Strategic_Considerations.htm. EngenderHealth also has training guidelines for program managers and health workers to provide comprehensive SRH care for women and girls living with HIV: http://www.engenderhealth.org/pubs/hiv-aids-sti/index.php. Recent Global Fund guidelines have called for integration of the sexual and reproductive health needs of HIV-positive women into national AIDS plans, with successful examples of Global Fund proposals (Hardee et al. 2009a, http://www.populationaction.org/Publications/Reports/A_Practical_Guide_to_IntegratingReproductive_Health_HIV-AIDS/Summary.shtml).
[See also Prevention for Women: Treating Sexually Transmitted Infections]