Fulfilling the reproductive health rights of women living with HIV
Gaborone - In 2006 BONELA was alarmed by public comments made by an Honourable Member of Parliament who was quoted saying that he is concerned by HIV positive women who continue to fall pregnant and contribute to the spread of HIV/AIDS. This statement and its reference to HIV positive women as vectors and spreaders of HIV prompted BONELA to undertake a study to determine its validity and hopefully clear any misconceptions surrounding the matter.
In 2006 the Botswana Network on Ethics, Law and HIV/AIDS (BONELA) was alarmed by public comments made by an Honourable Member of Parliament who was quoted saying that he is concerned by HIV positive women who continue to fall pregnant and contribute to the spread of HIV/AIDS. This statement and its reference to HIV positive women as vectors and spreaders of HIV prompted BONELA to undertake a study to determine its validity and hopefully clear any misconceptions surrounding the matter.
Since the comment was made up till the beginning of 2007, BONELA has conducted and engaged in a series of community dialogues with women living with HIV to understand the challenges and difficulties that this particular group faces in exercising their sexual and reproductive health rights regarding pregnancy - planned and unplanned.
The first consultations with people living with HIV/AIDS took place in 2006 in Gaborone, Francistown and Maun. This was followed in 2007 by another set of community dialogues which took place in 15 areas within Botswana - Tsabong, Gantsi, Tlokweng, Selibe Phikwe, Bobonong, Jwaneng, Gabane, Mochudi, Kanye, Maun, Kasane, Gaborone, Ramotswa, Molepolole and Kopong. The participants comprised of 228 men and women living with HIV. The majority number of 213 were women from support groups of people living with HIV and 15 men from the same group.
The community dialogues were followed by a consultative meeting with health care workers from different hospitals in and around Gaborone, representatives from the Public Health Department and of the Ministry of Health and representatives of women’s groups and private/ NGO Sexual Reproductive Health (SRH) service providers such as the Botswana Family Welfare Association (BOFWA). The Health sector had a representation of 19 participants including nurses from the Infectious Disease Care Clinic (IDCC), Maternal Child Health Department, Ministry of Health Department - Sexual Reproductive Health Unit from Gaborone, Molepolole, Jwaneng and Ramotswa.
From the onset it needs to be recognized that various factors influence people’s decisions regarding pregnancy and collectively, the reasons given by women living with HIV that characterize their decisions of pregnancy and child bearing do not differ from the reasons that HIV negative women give for falling pregnant and having children. Participants reported social pressures from family members to have children. Another reason given was the fulfillment one feels once they have a child and also to prove that one is fertile, lastly the need to continue the bloodline and family name.
For women living with HIV, an HIV diagnosis may have come before they had children and in such cases child bearing may still remain very central to them. With that in mind it seems, however, that women living with HIV are experiencing challenges fulfilling their sexual and reproductive health rights in the context of; family planning and contraceptive choice and use, prevention and treatment for HIV-AIDS related infections and Pap smears.
Family planning and Contraceptive choice and use
When asked whether they discuss family planning with their clients, health workers reported that family planning is not part of the overall HIV treatment and care program, that they refer such clients to the family planning clinics. Continued discussions with health workers also revealed that women living with HIV increasingly spend more time in Infectious Disease Care Clinics (IDCC) accessing treatment and bringing forth all their health needs and are therefore not fully utilizing the family planning clinics.
Despite extensive literature that showcases the inconsistent use of the condom by women due to various factors such as: male partners’ refusal to use condoms and the inability by many women to negotiate condom use - health workers in the IDCC reported promoting and encouraging condom use for their clients as it prevents both infections or re-infections and pregnancies. Participants reiterated this point by acknowledging the availability of contraceptives in clinics, other than IDCC’s, but also highlighting the limited access women living with HIV have to these contraceptives. Another point raised indicated that although there are other contraceptive methods apart from the condom, including the injection, IUD and the diaphragm – these are only offered to HIV positive women if they are insistent on an alternative method.
Child bearing among people living with HIV
Health workers reported that they generally do not encourage pregnancies for women living with HIV, however, if a couple wishes to have children; they provide proper counseling and encourage the couple to monitor the woman’s health to ensure that there will be no risks to the health of the pregnant woman and the unborn child. This view was also shared by women living with HIV who felt that women living with HIV should not become pregnant mainly because ‘the woman will die and leave their child behind’ and also the risks of transmission to the child. The group also acknowledged that there are high incidences of unplanned pregnancies and that women need to be adequately informed to assist them to make informed decisions about pregnancy.
There is reluctance to discuss with health workers the plan to be pregnant by HIV positive people largely due to negative judgmental attitudes towards women living with HIV who may want to conceive. These attitudes have led to some women who are on HIV treatment to conceive without proper consultations with their health providers. Women who participated in the prevention of mother to child transmission (PMTCT) program were asked whether they had discussed their plans of a pregnancy with a health worker and they all said no.
The focus of childbearing among women living with HIV is mainly the prevention of mother to child transmission. Minimal attention is given to other methods of parenting like adoption and availability of assisted conception, as noted by the women during the dialogues. The issue of assisted conception was raised as a concern for discordant couples; where one partner is HIV positive and the other is HIV negative. The options mentioned were in vitro fertilization and sperm washing. However respondents noted that these services are not available in the public health system and were expensive in private hospitals.
Providing sexual and reproductive health to HIV positive women
In regard to providing sexual and reproductive health services to women living with HIV health workers expressed challenges in discussing the matter with clients reporting that they find it difficult to openly discuss sexuality with their clients due to; lack of skills on the topic, time constraints and too many patients to allow for in depth discussions.
It is commonly known that women living with HIV are at a greater risk of developing cervical cancer. Despite this and the fact that Pap smear screenings – tests that are carried out to detect signs of cervical cancer- are available in most hospitals in Botswana, most of the women (an alarming 70% interviewed) were not aware of Pap smears and had never undergone a screening. From the mere 21% who knew of such a service and had actually undergone a screening only a handful (38.9%) had received the results and a disturbing 61.1% who underwent the screening had not received the results. The saddest revelation was the woman who thought that a Pap smear was a disease. Health care workers reported that they refer their clients for Pap smears even though there are challenges in the health system regarding the adequate provision of this service to women; some women never benefit at all from the service or never receive their test results.
Health workers and women living with HIV recognized the need for:
- Adequate referral and provision of family planning for people living with HIV. Consideration should be made towards the integration of sexual and reproductive health into the overall HIV care and treatment program.
- Aggressive education and provision of Pap smears and cervical cancer awareness especially for women living with HIV.
- Intensifying training for health care workers on addressing sexuality with clients.
- Male involvement in sexual and reproductive health services should be promoted, both as individuals and/or partners in a relationship.
- Consultations with women living with HIV which will allow them to make informed choices about their sexual and reproductive health needs, including choosing contraceptives that are most suited to their needs.
- To connect women who are considering child bearing with other women who have fallen pregnant whilst HIV positive as a way of peer mentoring to learn from their experiences.
- Availing assisted conception methods for discordant couples.