Neglected Realities: Pregnancy, Childbirth, and Abortion in the Context of HIV

The majority of women living with HIV are in their reproductive years. The need to promote and protect their reproductive and sexual rights has never been greater.

Women around the world have been disproportionately affected by HIV and AIDS, particularly in the regions hardest hit by the pandemic, such as sub-Saharan Africa. But with increased global access to antiretroviral therapy (ART), greater numbers of HIV-positive women are living longer healthier lives. And since the majority of women living with HIV are in their reproductive years, the need to promote and protect their reproductive and sexual rights has never been greater.

This was a recurring theme at AIDS 2010 in Vienna, and the subject of a three-day conference convened earlier in the year at the Harvard School of Public Health. The resulting report, The Pregnancy Intentions of HIV-Positive Women: Forwarding the Research Agenda was one of the first to collect perspectives from across disciplines and experience about pregnancy, delivery, childbearing, and abortion in the context of HIV.

For all women, the ability to terminate a pregnancy safely is affected by the legal status of abortion where they live, including the existence or not of clandestine and potentially unsafe services. This is well known and well documented.

For HIV-positive women, however, the risks of unsafe abortion are not only high but insufficiently discussed. Whether abortion is legal or not has been shown to have direct impacts on the lives of HIV-positive women.  In Pretoria, South Africa, for example, the number of women presenting with incomplete abortions was found to decrease by half upon legalization of abortion.

For women who experience spontaneous abortions or whose only option is unsafe abortion, post-abortion care (PAC) can be life-saving. But accessing PAC can pose significant problems for women in countries where abortion is criminalized. And criminalization has been shown to make existing problems, such as maternal morbidity and mortality, worse for HIV-positive women by delaying or inhibiting women from seeking PAC even where it is available.

Desired pregnancy for HIV-positive women also receives insufficient attention from policy makers, researchers, and programmers. And new issues continue to pop up which require consideration – ranging from the availability of ART to assisted reproductive technologies – as these influence the pregnancy intentions of HIV-positive women.

Pregnancy prevention also remains critically important to the lives of HIV-positive women. But how service delivery models can most effectively and safely meet women’s sexual and reproductive health needs and rights – including in relation to family planning counseling and contraception as well as HIV treatment, care, and prevention – is still not clear. Bringing together human rights and public health considerations to assess and address the availability, accessibility, acceptability, quality, continuity, and constellation of services on offer could be an important step in this direction.

Though some aspects of safer pregnancy and delivery for HIV-positive women have received substantial attention, a more comprehensive view is still needed – and one which truly engages both the range of service delivery concerns and the human rights issues affecting HIV-positive women. Open discussion with HIV-positive women is critical. Promise Mthembu offers an important example of a woman willing to share her story so that progress can be made.

The Harvard conference proposed a number of targeted recommendations for further research, in the context of women living with HIV, their communities, their health systems, and the broader legal and policy frameworks under which they live.

A stronger evidence base from each of these areas will help provide more comprehensive information relevant to the lives of women living with HIV, and create demand for appropriate services and policy.