Nairobi — In the rush to save babies from HIV infection and treat their mothers, experts warn that a key element of HIV prevention is being neglected in Africa - contraceptives for HIV positive women.
Yet contraception is the second pillar of successful prevention of HIV transmission from mother to child (PMTCT), along with preventing infection among women and babies, and caring for those infected.
"The contraceptive needs of HIV positive women are often put on the background, the main focus is on keeping mother and child healthy," Florence Ngobeni-Allen, a spokesperson with the Elizabeth Glaser Paediatric AIDS Foundation, told IPS. A South African, she was diagnosed with HIV in 1996, lost a baby to AIDS and now has two healthy boys.
Contraception is crucial in East and Southern Africa, where high HIV prevalence combines with high unmet needs for family planning, and where eight in ten HIV positive women are within their reproductive years, according to the United Nations Population Fund (UNFPA). Fast Facts about Contraception and HIV
Most modern methods of hormonal contraception are safe for women with HIV.
Some hormonal methods not recommended for women on ARV therapy due to potential for drug interactions.
IUD insertion is not recommended for a woman with AIDS, due to weakened immune system.
Spermicides and diaphragms are not suitable for HIV positive women.
Source: World Health Organisation
Studies suggest that women living with HIV have equal "if not more desire to limit childbearing compared with HIV negative women. Reducing unmet need for family planning among these women is critical for meeting the target of reducing new child HIV infections by 90 percent," says the United Nations report Women Out Loud.
Surveys of HIV positive women in Kenya and Malawi show that nearly three-quarters did not want more children within the next two years or ever, but only a quarter used modern contraceptives.
Weakness in programmes
A study by Family Health International among HIV positive women in Rwanda, Kenya and South Africa showed that more than half did not plan their most recent pregnancy.
Although the women wanted family planning, access was difficult. One barrier was health staff: they were not trained on contraceptive options for women living with HIV; had misconceptions about contraceptive safety; most only offered male condoms, although women preferred long-acting implants and injections, and many were judgmental about the women's sex lives
"Sometimes nurses forget that women are still sexual when they find out you are HIV positive," says Ngobeni-Allen.
Kenya's unmet need for contraceptives is 25 percent nationwide but 60 percent among HIV positive women, Dr John Ong'ech, assistant director at Kenyatta National Hospital, told IPS.
Low access to family planning for HIV positive women, who are six to eight times more likely to die from pregnancy-related complications compared to HIV negative women, "is a weakness in health programmes," he told IPS, although it is cheaper and more effective to provide contraceptives than PMTCT.
Husbands and mothers-in-law
Mary Naliaka, who works in paediatric AIDS in Kenya's health ministry, told IPS that family planning should be part of the HIV treatment package and offer a variety of contraceptive options.
But the health systems in East and Southern Africa often suffer commodity stock outs and many clinics lack adequate infrastructure.
"To insert an intrauterine device you need a sterile environment," Ong'ech says.
Injection is the most popular method because women can use it without telling the husband, he adds.
Unequal gender relationships and weak negotiating power influence contraceptive use. Naliaka observes that in African culture, "the mother-in-law can engineer the end of a marriage if a baby is not forthcoming."
Dorothy Namutamba, of the International Community of Women Living with HIV in East Africa (ICWEA), who is based in Kampala, Uganda, told IPS that women are raised to please husbands.
"If a man demands that you should have ten children [you must] and if you're not able, he'll look somewhere else," she says. "Most men do not encourage women to go on family planning, it's a big problem."
Stigma and domestic violence compound the problem. "Women fear to declare their HIV status because they may face gender violence, and this limits their access to family planning," Anthony Mbonye, Commissioner of Health Services in Uganda, told IPS.
Given men's power over decisions about pregnancy, couple-oriented reproductive health services are crucial, but "health facilities are too overcrowded to absorb the male partner," Naliaka told IPS.
The coerced sterilisations of HIV positive women in Kenya, Malawi, Namibia, South Africa and Zambia, with lawsuits pending, further cloud the issue of reproductive rights and needs and HIV.
"This shamed the health sector," says Naliaka. However, she adds, "through these publicized cases, the health sector and the public have understood that these women have reproductive health needs similar to those of HIV negative women."
Moving forward, experts recommend integrating HIV, family planning and maternal and child health care services, saving time for both users and health staff.
Seven Southern African countries have set up such "one-stop shops" for reproductive health, where a woman can get ARVs, cervical cancer screening, breastfeeding advice and family planning in one visit, under one roof, sometimes in one room with one health worker.
Linking services is cost effective and efficient, says UNFPA. It makes "people sense".
Edited by: Mercedes Sayagues