Supporting the Reproductive Decisions of Women With HIV
With access to family planning services, supportive care, and the information needed to make good choices, women with human immunodeficiency virus (HIV), including women with acquired immune deficiency syndrome (AIDS), in many cases can lead healthy sexual and reproductive lives. Like all other women, women with HIV have the right to make their own decisions about their reproductive and sexual health.
Health care programs and providers can help women with HIV and their partners make and carry out informed reproductive health decisions (see Figure 1). Women with HIV who decide to prevent or delay pregnancy can safely use almost any family planning method. Preventing unintended pregnancies among women with HIV is an important and cost-effective way to avoid the birth of HIV-infected infants (see Box: Family Planning Is a Key Strategy to Reduce Mother-to-Child Transmission of HIV). For those who are considering having children, providers can help them weigh the risks and consider the responsibilities (see Box: When a Woman With HIV Decides About Pregnancy). For clients with HIV who want children now, providers can help them minimize the risk of transmitting the virus to their partners or to the infant.
In many countries hard-hit by HIV/AIDS, health care systems and resources that provide this important care and support are not widely available. Expanding such services should be a top priority at every level, from donor agencies to national governments to health care providers.
 |
|
Anna, a young Rwandan with HIV, is an orphan who lost her mother to AIDS and her father in the genocide. In much of the world, new HIV infections are concentrated among young people. Giving young people with HIV information about reproductive health and family planning is important to ensuring their health and longevity.
(Photo: © 2004 Eileen Dietrich, Courtesy of Photoshare)
|
Providers Should Focus on the Reproductive Health Needs of Women With HIV
Health care providers who understand the impact of HIV on women’s reproductive health, fertility desires, and family planning needs are better prepared to help clients with HIV make informed reproductive decisions.
Women account for nearly half of the world’s HIV cases. Women account for nearly half of the estimated 40 million cases of HIV infection worldwide. In 2006 an estimated 17.7 million women ages 15 and older, or about 13 in every 1,000 such women, were infected—approximately one million more than in 2004 (102). More than three-fourths of these women live in sub- Saharan Africa (see Web Figure 1), where there are three infected women for every two infected men (102). The numbers of women with HIV are increasing rapidly in many countries in this region (see Web Table 1). In South Africa, for example, prevalence of HIV among women attending public antenatal clinics was 35% higher in 2005 than it had been in 1999 (102).
In most places, unprotected vaginal intercourse with an HIV-infected partner causes most HIV infections in women (102, 221). In some regions of the world, such as Eastern Europe and Central Asia, use of injected drugs accounts for a growing number of infections among women, although accurate estimates are difficult (86).
Women are biologically vulnerable. Generally, studies have found that women are more susceptible to HIV infection than men when exposed to the virus during vaginal intercourse (130). U.S. and European studies of serodiscordant couples (that is, one partner is infected with HIV while the other is not) have found that male-to-female transmission is two to eight times more likely than female-to-male transmission (59, 157, 164). In general, women are more likely to become infected with STIs, including HIV, due to biological factors. Women have a greater area of exposed tissue (the cervix and the vagina) than men, and small tears may occur in the vaginal tissue during sex, making an easy pathway for infection (256).
As for men, it is thought that the presence of the foreskin on the penis makes them more susceptible to HIV infection. A number of recent studies have found that men who have been circumcised are at lower risk for HIV infection than men who have not been circumcised (8, 9, 78, 79, 234). In light of this recent compelling evidence, the World Health Organization (WHO) and other United Nations (UN) agencies recommend that programs recognize circumcision as an effective intervention for HIV prevention (103).
A number of additional factors affect infectivity including stage of disease and viral load (the amount of virus in a person’s blood). A study in Rakai, Uganda, found the overall transmission rate of HIV among serodiscordant couples to be 12 in every 10,000 acts of vaginal intercourse but as high as 82 per 10,000 coital acts in the period immediately after one partner became infected, when the viral load is high (233) (see From Exposure to AIDS: The HIV Disease Continuum). Factors that may increase women’s susceptibility to HIV include the presence of sexually transmitted infections (STIs), particularly infection with the herpes simplex virus (HSV) (106), as well as bacterial vaginosis and candidiasis—infections that are not sexually transmitted (129, 212)—and very frequent use of spermicides (26, 11) (see 'Avoid spermicides').
It is not certain whether pregnancy increases a woman’s susceptibility to HIV infection. A large study in Uganda found that pregnant women were more than twice as likely to become infected with HIV as women who were not pregnant (80). Another large study, in Uganda and Zimbabwe, did not find any difference (145).
|
Despite the desire to avoid having children, many women with HIV experience unintended pregnancies.
|
|
Young women are particularly at risk. In much of the world new HIV infections are concentrated among young people, ages 15 to 24. In 2006 this population accounted for as many as 40% of new adult infections (102). Young women may be more vulnerable to HIV infection than are older women because of the physiological properties of an immature genital tract (174). Young women also may find it more difficult to negotiate condom use (113) (see Box: Helping Women Talk With Their Partners About Contraception and Safer Sex). They may have older partners, who for that reason alone are more likely to be infected (122). In South Africa, for example, young women are four times more likely to be infected with HIV than are young men (102).
Because many women with HIV are diagnosed during their reproductive years, they inevitably face decisions about their reproductive future. Addressing the sexual and reproductive health needs of all young people, including those with HIV, is important to ensure their health and longevity.
|
Figure 1. Basic Family Planning Choices and Care for Women With HIV
Adapted from Cates 2001 (21) and World Health Organization 2006 (251)
|
Many Women With HIV Are Sexually Active and Want Family Planning
Regardless of their fertility desires, many women with HIV are sexually active after learning of their infection (3, 42, 155, 188). In studies in developed and developing countries two to four of every five women with HIV report sexual activity (44, 49, 87, 138, 148, 241).
Women may resume or increase sexual activity as their health improves with the use of antiretroviral (ARV) medications (240). A study of 179 people in Kenya found that nearly 70% of those who had been receiving ARVs for 18 to 24 months were sexually active, compared with 50% of those who had been receiving ARVs for less than 6 months (190). Similarly, a study in Brazil found that, among 103 people with HIV, the percentage reporting at least one sexual encounter per month had increased from 60% initially to 78% by 24 months after starting ARVs (12).
Many women with HIV who are sexually active want to prevent pregnancy. Some may decide not to have children to avoid the risks of transmission to a newborn and the potential health risks of pregnancy (see 'HIV Infection Increases Risk of Poor Pregnancy Outcomes') (27). Others may worry about caring for children and leaving orphans behind (14).
Despite the desire to avoid having children, many women with HIV experience unintended pregnancies. For example, a study of three South African programs for preventing mother-to-child transmission (PMTCT) of HIV found that 84% of the pregnancies among the 242 participants with HIV were unplanned (183). In a Ugandan study 82 of 85 women on ARVs who became pregnant had not wanted more children. Many of these women were surprised that they became pregnant because they had not conceived before they started ARVs (200). Unplanned pregnancy can be a special concern for women taking some ARVs—in particular, the ARV medication efavirenz, as it may cause birth defects (70).
Unmet need for family planning is high among women with HIV. Many women with HIV want to avoid pregnancy but have an unmet need for family planning—that is, they are not using family planning despite wanting to avoid pregnancy, and thus they risk unintended pregnancy (42, 47, 49, 179, 196).
In almost all places with a generalized heterosexual epidemic and high HIV prevalence, unmet need for family planning is high. For example, in sub-Saharan African countries available survey data indicate that 13% to 41% of currently married women have unmet need (222, 236). Overall estimates for unmet need among women with HIV are not available, but a few small studies indicate that their rates may be higher than rates for women in general. For example, among clients of counseling and testing facilities in Zimbabwe in 2005, 39% did not wish to get pregnant but did not use a family planning method (88). The Zimbabwe Demographic and Health Survey from the same year indicated that the level of unmet need among married women in the general population was 13% (25). Similarly, a Ugandan study found that nearly three-fourths of sexually active men and women with HIV who did not use condoms or another contraceptive method did not want any more children (152). The Uganda Demographic and Health Survey from the same year indicated that the level of unmet need among married women in the general population was 41% (222).
|
A Ugandan study found that nearly three-fourths of sexually active men and women with HIV who did not use condoms or another contraceptive method did not want any more children.
|
|
Unmet need for family planning may be common among women with HIV who have recently had children. In a study evaluating a PMTCT program in Rwanda, 92% of women with HIV interviewed in the postpartum period reported not wanting additional children, yet only 54% were using any contraceptive method (187). This finding highlights the importance of helping pregnant women with HIV think about their postpartum family planning options early in pregnancy.
Many of the factors contributing to unmet need among women with HIV are similar to those for other women, including having little or incorrect knowledge of contraceptive options and limited access to family planning services (20, 42). In addition, some women with HIV may feel reluctant to seek family planning services, fearing stigma and discrimination (40). (See Web tool, “Assess Your Attitudes and Beliefs About People With HIV,” to identify how a health care provider’s attitudes and beliefs may affect service provision.)
Many Women With HIV Want to Have Children in the Future
Women with HIV have much the same desires to have children as do other women (84, 155, 199). Surveys in developed and developing countries have found that 18% to 43% of women with HIV wanted children in the future (27, 152, 161, 165, 205). In general, people with HIV want children for reasons common to many other people who desire parenthood. For example, in Uganda people with HIV expressed a desire for children to continue the family lineage, to have a child of a specific sex, or because they did not yet have any children (152). In Mumbai, India, people with HIV said that they wanted children for security later in life, to prove they are fertile, and to leave something of themselves behind after death (199).
Often, however, women with HIV who would like to have children in the future do not expect that they will have them. For example, a U.S. study found that 3 of every 10 women with HIV who desired children did not expect to have any (27). Those who both desired and expected to have children were more likely to be younger, to have fewer or no children, and to know their partners’ HIV status (27). The discrepancy between fertility desires and expectations most likely reflects a range of considerations, including health status, infertility, the partner’s desire for children, or fear that the pregnancy would be dangerous or that the child will be born infected with HIV (see Box: When a Woman With HIV Decides About Pregnancy). Discussing family planning options with women with HIV who are unsure about pregnancy can help them to avoid unintended pregnancy.
When Services Are Made Available and Accessible, Many Women With HIV Use Family Planning
As with women generally, women with HIV are more likely to use family planning if information and services are easily accessible. Recent examples of the use of information communication technology (ICT) have proven effective in expanding the reach of information about reproductive health, family planning, and HIV (see Box: When a Woman With HIV Decides About Pregnancy).
For women with HIV, integrating family planning services into HIV care can also help improve access to information and services. For example, in Zimbabwe about three-fourths of clients at HIV counseling and testing services said they would be more likely to seek out family planning services if they were offered in the same facility (88). Many women with HIV prefer to obtain family planning from their HIV care provider rather than disclose their HIV status to another health care provider (35). Providing both HIV and family planning services at the same facility enables providers to offer more convenient, more comprehensive services (61).
Family planning services meet an important need for women with HIV. At the same time, they serve a major public health purpose: Preventing unwanted pregnancy among women with HIV is an important and cost effective way to reduce the number of infants who become infected with HIV (see Box: Family Planning Is a Key Strategy to Reduce Mother-to-Child Transmission of HIV).
|
Order this report
Download PDF
E-mail this page 
See Companion INFO Report: “Women and HIV: Questions Answered”