Government's commitment to voluntary and free-choice family planning practices comes to question as Kenyan HIV infected women continue being coerced to use specific family planning methods. The Citizen TV on November 22, 2011 ran a story about a widow in Mbita who had benefited from a fish farming venture supported by a grant from an American based non-governmental organisation.
The sole qualification she needed to merit the grant was to be HIV positive and willing to be fitted with an intrauterine contraceptive device (IUCD). It is probable that this poor widow had no choice but to accept the condition- she needed help to support her family and, to that end, would take considerable risk. The question here is whether she had any choice in embarking on this method of family planning? Is it fair to assume she was in fact coerced to accept an IUCD by the grant of much needed cash?
In the last few days the same TV network has run stories of HIV positive women who reported having been sterilized in government hospitals simply because they happened to be HIV positive. What is the position of the Kenya Government on the matter? According to the Minister for Medical Services, Prof Peter Anyang' Nyong'o, family planning practice should be voluntary. Service providers must educate clients on the range of choices available, and let them choose that which suits them best. "But to flash money and say take this - no, that is not how to do it!" he added.
However, it remains unclear what the Minister has done or intends to do to arrest any coercive practices there may be. Kenya's National Reproductive Health Policy (2007) recognizes reproductive and sexual rights as components of human rights which must be respected by all, regardless of religion, culture and socio-economic status. All couples and individuals have the basic right to decide freely and responsibly on all aspects of their sexuality, the timing, number and spacing of their children, have access to information and education in order to ensure optimal health and informed decision-making.
Concerns regarding coerced sterilization of HIV-positive women came to light in 2007 when 13 cases were documented in Namibia. Shortly afterwards there were reports of HIV-positive women in Kenya being paid money to accept long-term contraceptive methods, particularly the IUCD. These activities in Kenya (which include the case in point) were supported by Project Prevention, an American NGO founded in 1997 which also pays female drug users in the U.S. and UK to be sterilized.
Whereas HIV-positive women do have a legitimate need for family planning services, like every other woman they are entitled to exercise choice free of coercion or manipulation through incentives. Use of incentives and disincentives to pressure poor people to be sterilized was roundly rejected at both the 1994 International Conference on Population and Development (ICPD) in Cairo, and the 1995 Fourth World Conference on Women in Beijing. In particular, the Beijing Platform for Action states clearly that "The human rights of women include their right to ....decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence".
The current reports of coercive sterilisation also bring to mind the excesses in India during the rule of Prime Minister Indira Gandhi, who during a 21-month period (1976-1977) netted 8.3 million sterilizations, mainly vasectomies, compensating each victim with a transistor radio! Apparently, payment for sterilisation continues in India to this very day; for example, a medical college was recently reported to pay men that opted for non-scalpel vasectomy 1,100 Indian Rupees, while in Uttar Pradesh vasectomy facilitates issuance of a gun licence.
Proponents of coerced contraception for HIV infected women are usually driven by the wish to create an HIV-free tomorrow by preventing births of children infected by their mothers. In Africa before the advent of antiretroviral drugs up to 40 percent of children born to HIV infected mothers were also infected. However, in Kenya, there has been an increasing access to services for prevention of mother-to-child HIV transmission (PMTCT), most often offered at antenatal clinics and at delivery. According to the Kenya Service Provision Assessment Survey of 2010, 58% of all health facilities nationwide offered some component of PMTCT services.
This is increasingly reducing the incidence of perinatal transmission as well as rates of mortality among infected children. Accumulated evidence to date shows that administration of antiretroviral therapy to the mother during pregnancy, labour and delivery, and then to the newborn, as well as delivery by Caesarean section for women with high viral loads, can reduce the rate of perinatal HIV transmission to well below 10 percent.
What this means is that despite the many challenges not addressed here, it is possible to dream of an HIV-free generation without having to resort to cruel acts of forced contraception for HIV infected persons. Indeed this was the view expressed by UNAIDS Executive Director Michel Sidibe during a recent visit to Millennium Villages Projects (MVP) in Kenya: "We have seen that it is possible to virtually eliminate infant HIV infections in high-income countries ....Now we must apply the knowledge and tools to create an AIDS-free generation in Africa and the rest of the world." These 'tools' do not include coerced contraception!
The writer is a former Professor and Chairman of the Department of Obstetrics and Gynaecology University of Nairobi.