By Heather Boonstra, Kevin Moody, and Fiona Pettitt

Despite the enormous challenge that AIDS still poses to global health, international efforts to reach those who urgently need HIV treatment have made significant progress in recent years. For a growing number of people with access to antiretroviral treatment, HIV is now a chronic disease rather than an imminent death sentence. And yet, the very success of international efforts in getting people access to life-saving drugs is also posing an entirely new set of challenges.

Consider this example from South Africa: When Christo and Liesel married 17 years ago, becoming a father was not something Christo thought was possible, even though he very much wanted to be a parent. The reason: Christo, 41, is HIV-positive. But thanks to life-saving antiretroviral treatment, his focus has turned to the future. "Now I dare to dream," says Christo, whose personal story is included in a recent report on HIV-positive fathers. "I have always lived positively since I knew my status, but now I can think beyond two years and where I will be in 10 years."

As the example of Christo and Liesal illustrates, many HIV-positive men and women want to have a child. But they worry about the health risks for the parents and the baby, and whether or not they will have a long, healthy life to love and support the child. Other HIV-positive couples want to prevent pregnancy, either to wait to have a child or to avoid childbearing entirely, but do not know about the full range of birth control methods that may be appropriate for them. And still others want to pursue a satisfying sex life and need health care providers who are comfortable talking with them about sexual intimacy, risky behaviors and other sensitive issues.

Increasingly, there is a compelling need for specific services that address the sexual and reproductive health of people living with HIV—but this need is set against a backdrop of large-scale challenges. Among the many impediments to proper care are weak health care systems, where staff may not have been trained about HIV and sexual and reproductive health, and where supplies are often lacking. Parallel programs often separately focus on HIV services and on sexual and reproductive health services, instead of integrating or making effective linkages between the two.

Worse, societal norms and traditions often get in the way. Taboos abound around sex, and HIV-related stigma and discrimination are widespread. Far too often, health care professionals refuse to care for HIV patients; disclose clients' HIV status without consent; let their own biases influence their advice on contraceptive methods; and pressure women to undergo abortion or sterilization.

Despite the fact that the risk of mother-to-child transmission of HIV is below 2% with antiretroviral treatments, safe delivery and safe infant-feeding, some HIV-positive men and women report strong pressure from family members, people in their community and health care providers to give up the idea of having children. Rolake, a woman in her mid-30s living in Nigeria, has experienced such discrimination firsthand. "When you are positive, doctors make you feel guilty for wanting a child," says Rolake, one of 13 women highlighted in a recent report on the sexual and reproductive health experiences of HIV-positive women. "As a positive woman, people say you have no business becoming pregnant."

In many countries, women also have little or no say in when sex occurs, which often prevents them from taking steps to protect themselves—and also undermines their ability to cope with the social, economic and physical impacts of HIV. Rosa, an HIV-positive woman from Honduras featured in the same report, puts it bluntly: "Men are the ones who decide when and how to have sexual relations."

Despite these challenges, the evidence clearly shows that HIV infection need not prevent men and women from having sex, bearing children, using contraceptives or accessing abortion services in relative safety. Because sexual intimacy and childbearing are central to the lives of almost everyone—including those living with HIV—true progress can only be achieved by fully accepting the human rights of HIV-positive men and women to decide whether and when to have children and to pursue a safe and satisfying sex life.

HIV prevention programs must actively involve people living with HIV in designing sexual and reproductive health services, including in decisions about how and which services should be made available. At the individual level, this will boost the health and well-being of HIV-positive people, while greatly strengthening efforts to prevent new infections at the global level.

Heather Boonstra is a senior public policy associate at the Guttmacher Institute, a reproductive health think tank;
Kevin Moody is the international coordinator and CEO at the Global Network of People Living with HIV (GNP+); and
Fiona Pettitt is the international network manager at the International Community of Women Living with HIV/AIDS (ICW).