This article was co-authored by Heather Boonstra, a senior public policy associate at the Guttmacher Institute, and Laura Jacobson, a Master’s student at the Johns Hopkins Bloomberg School of Public Health and a Hopkins-Guttmacher Summer Fellow.

The ability to express oneself sexually and the desire to experience parenthood are, for many, central to what it means to be human. HIV-positive individuals are no different in that regard. They, too, have a right to sexual health and to decide if and when to have a child and to carry out their decisions voluntarily and safely.

But what challenges do they face in doing so? And how can we in the reproductive health community support their needs? To answer these questions, we need to look at three interrelated areas: how HIV status affects childbearing desires, which factors get in the way of HIV-positive women and men exercising their reproductive rights, and which steps should our community advocate.

HIV status and the desire to bear children

HIV status has less impact on the decision to have children than one might think. Research from both developed and developing countries suggests that it is one of many factors that women consider, but for most men HIV status does not appear to influence the decision much at all. For example, a recent study based on Demographic and Health Surveys in ten Sub-Saharan African countries found that HIV-positive women are less likely than HIV-negative women to want more children, while there is no difference in the desires of HIV-positive and HIV-negative men.

Most importantly, what these studies show is that being HIV-positive does not end the desire to bear and parent children, even in places where access to high-quality antiretroviral treatment is not always assured. Moreover, as the prognosis for people living with HIV (and their infants) improves over time, HIV status is likely to become an even less important factor in the decision to have children.

Current challenges

Clearly, there is a compelling need for specific services that address the sexual and reproductive health of people living with HIV. Of course, such services are not delivered in a vacuum. They are set against a backdrop of large-scale challenges that impede service delivery and people’s ability to access health care:

• Health systems that have been badly undermined by inadequate investment over decades and by the burden of AIDS itself. Virtually everywhere, there is a shortage of health care personnel. And where personnel are available, some have received no training or even basic information about HIV and sexual and reproductive health. Moreover, health care providers in low-resource settings often lack basic supplies that allow them to take universal precautions, making them all the more reluctant to provide services to patients known to have HIV.

• Sexual taboos, gender inequality, and stigma and discrimination towards those living with HIV. These factors, individually and together, make it difficult for people with HIV to disclose their status for fear of hostility or discrimination and to reach out and vindicate their legal and human right to obtain critical sexual and reproductive health services.

• Lack of access to and legal restrictions on sexual and reproductive health care, especially around abortion. The majority of women with HIV live in African countries where access to contraceptive services and supplies is inadequate and abortion is highly restricted by law, driving many to end a pregnancy clandestinely, with services provided by untrained personnel or using unsafe methods. Unsafe abortions, which are risky for all women, are particularly dangerous for women with HIV, whose compromised immune systems may make them more susceptible to infection and other complications. The World Health Organization estimates that, in Africa, 14 percent of maternal deaths result from unsafe abortion.

Supporting the sexual and reproductive health and rights of people living with HIV

The concept of sexual and reproductive rights is meaningless if it simply exists in the abstract—instead, it must be backed by real access to services. Here are some of the things we could do to benefit those living with HIV:

• Incorporate counseling about reproductive choices into HIV programs. Those who want to have children need information about when they can safely become pregnant. And those who want to delay having a child or avoid it entirely need access to effective modern methods of contraception.

• Increase access to services preventing mother-to-child transmission (MTCT). With antiretroviral treatment, safe delivery, and safe infant feeding, the risk of MTCT around the time of birth is only 2 percent. Without these critical interventions the risk increases at least tenfold (from 20 percent to 45 percent). Lack of health care infrastructure in many countries has hindered progress in this area.

• Make abortion legal and ensure that safe abortion services are accessible to all women who need them. Evidence from around the world shows that abortion legality and abortion safety are highly correlated.

Right now, sexual and reproductive choice is a privilege for those who have access to care, rather than a fundamental right for all. That’s why advocates must speak up for strong leadership and changes at the service-delivery level that allow HIV-positive people to pursue their sexual and reproductive health and rights. Reproductive rights—without the ability to access services and carry out meaningful decisions—is an empty promise.