Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
Gaps in Research
- 1.
- Additional efforts are needed to provide information on contraceptive method use to women living with HIV (or whose serostatus is unknown) who do not desire to have a child or wish to space the next pregnancy.
- 2.
- Programs must adhere to the longstanding international agreement to voluntarism, informed consent, and ensuring the right of individuals and couples to decide freely and responsibly the number and spacing of their children.
- 3.
- Providers need training on contraception, including non-directive counseling and reducing stigma and discrimination for women living with HIV.
- 4.
- Interventions to increase dual protection and dual method use are needed.
- 5.
- Women living with HIV need information and access to services for emergency contraception; safe abortion, where legal; and post-abortion care (PAC) services where abortion is illegal. Research is also needed on the safest methods of abortion for HIV-positive women.
- 6.
- Efforts are needed to address barriers to ensure that women living with HIV can access and use contraceptives without the knowledge of their partner, if desired.
- 7.
- Potential drug interaction between contraceptive options and treatment for TB and HIV co-infection must be considered.
- 8.
- Efforts are needed to capitalize on opportunities to integrate family planning and HIV services.
- 9.
- Policy guidelines need to specify how family planning should be addressed in HIV prevention, treatment and care.
- 10.
- Additional efforts are needed to reduce the structural barriers, such as gender norms, that influence the behavior or decisions of people living with HIV to engage in unsafe sex.
- 11.
- Providers need additional skills and resources to provide non- judgmental, confidential safer sex counseling to people living with HIV.
- 12.
- Further interventions providing disclosure support are needed, particularly for women facing abandonment, violence, or other adverse events.
- 13.
- Interventions providing information on sero-sorting as a preventive strategy are needed.
- 14.
- Further interventions are needed to ensure that women, especially women living with HIV, are screened and treated for cervical cancer.
- 15.
- Screening and treating HIV-positive women and their partners for STIs may reduce HIV transmission and will improve health.
- 16.
- Adolescents who acquired HIV through perinatal transmission need information and treatment services through adolescent-friendly HIV and family planning services.
1. Additional efforts are needed to provide information on contraceptive method use to women living with HIV (or whose serostatus is unknown) who do not desire to have a child or wish to space the next pregnancy. Studies found that many women had significant numbers of unintended pregnancies.
Gap noted, for example, in South Africa (Cooper et al., 2009, Laher et al., 2008; Laher et al., 2009a, Rochat et al., 2008); Uganda (Homsy et al, 2009, Heys et al., 2009, Nakayiwa et al., 2009, Bunnell et al., 2008, Bajunirwe et al., 2008); Kenya (Okundi, 2009, Imbuki et al., 2009,); Kenya and Malawi (Anand et al., 2009); Argentina (Gogna et al., 2009); India (Suryavanashi et al., 2009); Benin (Gougounon et al., 2008); Botswana (ICW, 2006); Côte d’Ivoire (Desgrées-Du-Loû et al., 2002 cited in de Bruyn, 2003); general (Hoffman et al., 2008; Rochat et al., 2006 cited in Reynolds et al., 2008).
Cooper, D., J. Moodley, V. Zeigenthal, L. Bekker, I. Shah and L. Myer. 2009. “Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services.” AIDS Behavior 13: S38-S46.
2. Programs must adhere to the longstanding international agreement to voluntarism, informed consent, and ensuring the right of individuals and couples to decide freely and responsibly the number and spacing of their children. Studies found that women living with HIV had been sterilized against their will, were pressured by providers to terminate a pregnancy, or were stigmatized for becoming pregnant.
Gap noted, for example, in Namibia (ICW, 2009); Brazil (Oliveira et al., 2007, Nobrega et al., 2007 cited in Oliveira et al., 2007, Knauth et al., 2003); India (Batura et al., 2008); Chile (Araya, 2008); Mexico (Kendall and Perez-Vasquez, 2008); Ukraine (Yaremenko et al., 2004); Argentina, Mexico, Peru, Poland, Botswana, Kenya, Lesotho, Namibia, Nigeria, South Africa and Swaziland (de Bruyn, 2006a).
3. Providers need training on contraception, including non-directive counseling and reducing stigma and discrimination for women living with HIV. Studies found that HIV-positive women were required to wait in separate waiting rooms and that because provider bias limited contraceptive options, providers needed additional training on the full range of contraceptive options.
Gap noted, for example, in Namibia (ICW, 2009); Brazil (Malta et al., 2009); India (Batura et al., 2008); South Africa (Hatzell et al., 2008); Argentina (Gogna et al., 2008); Argentina, Mexico, Poland, Kenya, Lesotho, South Africa and Swaziland (de Bruyn, 2004 cited in Delvaux and Nöstlinger, 2007); Zambia (Mark et al, 2007); Uganda (Asiimwe et al., 2005); general (Richey and Shelton, 2007).
4. Interventions to increase dual protection and dual method use are needed. Studies found that couples are reluctant to use dual protection because it may symbolize distrust of a partner, particularly among adolescents.
Gap noted, for example, Ghana (Goparaju et al., 2003); general (Spieler, 2001 cited in Goparaju et al., 2003, Delvaux and Nöstlinger, 2007).
Goparaju, L., D. Afenyadu, A. Benton, V. Wells and G. Alema-Mensah. 2003. Gender, Power and Multi-partner Sex Implications for Dual Method Use in Ghana. Washington, DC: USAID.
5. Women living with HIV need information and access to services for emergency contraception; safe abortion, where legal; and post-abortion care (PAC) services where abortion is illegal. Research is also needed on the safest methods of abortion for HIV-positive women. Studies found that women did not have adequate knowledge of emergency contraception, nor access to services for post-abortion care or abortion, where legal. Abortion services are safe for HIV-positive women when performed by qualified professionals in sanitary conditions. However, unsafe abortion carries additional risks for HIV-positive women.
Gap noted, for example, in India (Sellers et al., 2008); Argentina, Mexico, Peru, Poland, Botswana, Kenya, Lesotho, Namibia, Nigeria, South Africa and Swaziland (de Bruyn, 2006a); global literature review (de Bruyn, 2003); general (Delvaux and Nöstlinger, 2007); globally (Guttmacher Institute, 2006 cited in Esplen, 2007).
Sellers, T., A. Saha, I. Khan and J. Omega. 2008. “Identifying HIV and SRH Service Integration Options to Increase Access to Family Planning and Safe Abortion for HIV Positive Women in India.” Abstract THPE0527. XVII International AIDS Conference. Mexico City, Mexico. August 3-8.
6. Efforts are needed to address barriers to ensure that women living with HIV can access and use contraceptives without the knowledge of their partner, if desired. Studies found that women would not always tell their partner about contraception use for a number of reasons, including the desire to avoid pregnancy.
Gap noted, for example, in South Africa.
Moodley, D., E. Smith, A. Groves and S. Maman. 2008b. “HIV-positive Women Describe their Control over Contraceptive Decision-making in Durban, South Africa” Abstract TUPE0846. XVII International AIDS Conference. Mexico City, Mexico. August 3-8.
7. Potential drug interaction between contraceptive options and treatment for TB and HIV co-infection must be considered. Articles noted a lack of data on potential interactions. Interactions between ARVs and oral contraceptives may alter the effectiveness or side effects of oral contraceptives.
Gap noted, for example, in Delvaux and Nöstlinger, 2007; Stuart, 2009: 412; Anderson et al, 2005; Chu et al., 2005; Aweeka et al., 2006 cited in Stuart, 2009.
8. Efforts are needed to capitalize on opportunities to integrate family planning and HIV services. Studies found that both men and women wanted greater integration of services.
Gap noted, for example, in Ethiopia (Wilson-Clark, 2008); South Africa (Mantell et al., 2008b); Mexico (Gonzalez, 2008).
Wilson-Clark, G. 2008. “Opportunities for Integrating HIV Prevention for Rural Adolescent Girls to the National Health Extension Programme in Ethiopia.” Abstract THPE0574. International AIDS Conference. Mexico City, Mexico. August 3-8.
9. Policy guidelines need to specify how contraception should be addressed in HIV prevention, treatment and care. Studies found that many guidelines did not explicitly address family planning in VCT and PMTCT guidelines and that providers and policymakers felt they had insufficient knowledge.
Gap noted, for example, in South Africa (Harries et al., 2007); 16 high- HIV prevalence countries (Strachan et al., 2004).
Harries, J., D. Cooper, L. Myer, H. Bracken, V. Zeigenthal and P. Orner. 2007. “Policy Maker and Health Care Provider Perspectives on Reproductive Decision-Making amongst HIV-Infected Individuals in Low Resource Settings.” BMC Public Health7 (282).
10. Additional efforts are needed to reduce the contextual barriers that influence the behavior or decisions of people living with HIV to engage in unsafe sex. Studies found that factors such as difficulties negotiating condoms, partner refusal, high unemployment, alcohol use, financial dependency, expectations of childbearing, fear of disclosure, etc., influenced protective behavior.
Gap noted, for example, in South Africa (MacDonald et al., 2008, Eisele et al., 2008); Uganda (King et al., 2009; Bakeera-Kitaka et al., 2008); Cameroon (Abega et al., 2008).
MacDonald, S., S. Pillay, D. Cornman, W. Fisher, S. Christie, G. Mahlase, P. Shuper, S. Kene, M. Kistnasamy, L. Sheperd, A. Adelaja, g. Griedland, U. Lallo and J. Fisher. 2008. “Factors Contributing to High-Risk Sexual Behavior among HIV Positive Adults Enrolled on the National ARV Program in KwaZulu-Natal (KZN), South Africa.” Abstract WEPE0291. International AIDS Confeerence. Mexico City, Mexico. August 3-8.
11. Providers need additional skills and resources to provide non-judgmental, confidential safer sex counseling to people living with HIV. Studies found that providers faced barriers in providing effective counseling including too few staff, limited time, discomfort discussing sex, etc.
Gap noted, for example, in South Africa (Cornman et al., 2008); Russian Federation (Davidson et al., 2008).
Cornman, D., S. Christie, L. Shepherd, S. MacDonald, P. Shuper, G. Mahlase, S. Pillay, W. Fisher, S. Kiene, M. Kristnasamy, U. Lailoo and J. Fisher. 2008. “Challenges of Providing HIV Risk Reduction Counselling to PLHIV in Clinical Care in KwaZulu-Natal (KZN), South Africa.” Abstract WEPE0293. XVII International AIDS Conference. Mexico City, Mexico. August 3-8.
12. Further interventions providing disclosure support are needed, particularly for women facing abandonment, violence, or other adverse events. Studies found many women faced abuse and abandonment upon disclosing their status.
Gap noted, for example, in Malawi (Chinkonde et al., 2009); South Africa, Malawi, Swaziland, Lesotho and Tanzania (Greeff et al., 2008).
Chinkonde, J., J. Sundby and F. Martinson. 2009. “The Prevention of Mother-to-Child HIV Transmission Programme in Lilongwe, Malawi: Why Do So Many Women Drop Out?” Reproductive Health Matters 17 (33): 143-151.
13. Interventions providing information on sero-sorting as a preventive strategy are needed. Studies found that sero-sorting emerged as a strategy to reduce transmission risk.
Gap noted, for example, in Uganda.
Seely, J., S. Russell, K. Khana, R. King and R. Bunnell. 2008. “Sex after ART: The Nature of Sexual Partnerships Established by HIV-infected Persons Taking Anti-retroviral Therapy in Eastern Uganda.” Abstract THPE0819. XVII International AIDS Conference. Mexico City, Mexico. August 3-8.
14. Further interventions are needed to ensure that women, especially women living with HIV, are screened and treated for cervical cancer. Studies found that women were not aware of and/or did not receive regular screening and treatment of cervical cancer, despite higher risk of developing cervical cancer.
Gap noted, for example, in Bahamas (Dames et al., 2009); Nigeria (Dim et al., 2009); South Africa (Wake et al., 2009, Denny et al., 2008, Myer et al., 2007a, Gaym et al., 2007); United States (Massad et al., 2008); Kenya (Yamada et al., 2008); Uganda (Safaeian et al., 2008); Tanzania (Kahesa et al., 2008); France (Heard et al., 2006); general (Goldie et al., 1999).
Dames, D., C. Ragin, A. Griffith-Bowe, P. Gomez and R. Butler. 2009. “The Prevalence of Cervical Cytology Abnormalities and Human Papillomavirus in Women Infected with Human Immunodeficiency Virus.” Infectious Agents and Cancer4 (Supplement 1): S8.