Meeting the Sexual and Reproductive Health Needs of Women Living With HIV

Given that most HIV transmission occurs through sexual intercourse, it is critical to include a sexual and reproductive health lens in HIV programming. In fact, several European governments have recently revised their international policies, recognizing that HIV/AIDS is a sexual and reproductive health issue (Germain et al., 2009).

“All women have the right ‘to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights’ (CEDAW, 1979), including those living with HIV" (Wilcher and Cates, 2009: 833).The evidence and interventions in this section focus on the sexual and reproductive health (SRH) of women living with HIV. SRH includes availability and access to services that support healthy sexuality and reproduction such as services and support to help women plan their families, including pre-conception support and/or access to contraception as well as attention to infertility and cervical cancer screening and treatment. [See also Treating Sexually Transmitted Infections (STIs) and Staying Healthy and Reducing Transmission] Many women living with HIV have an unmet need for contraception, counseling on pregnancy planning, addressing infertility and information about sexuality, among other needs (Church and Lewin, 2010). However, because so many women do not know their HIV status, many of the interventions in this section are appropriate for all women irrespective of serostatus. Full coverage of sexual and reproductive health interventions for all women is beyond the scope of this review. [See Treatment as Prevention]

There are High Levels of Unintended Pregnancy and Unmet Need, Including Among Women Living with HIV

Globally, an estimated 80 million pregnancies each year are unintended (WHO et al., 2011b). Worldwide more than 215 million women say they would prefer to avoid a pregnancy, but are not using any form of contraception, or they are using traditional methods, which are less effective means of contraception (Singh et al., 2009b). Among these 215 million women with unmet need are women who may not know their HIV status. Countries with high burdens of HIV often also have high levels of unmet need for family planning (Wilcher et al., 2009). A study by the U.S. CDC in Uganda found that unwanted pregnancies may account for almost a quarter of all HIV-positive infants in Uganda (Hladik et al., 2008a).

HIV Affects Fertility Intentions and These Change Over Time

Women living with HIV can have similar reproductive patterns as women without HIV (Hoffman et al., 2008; Rochat et al., 2006 cited in Reynolds et al., 2008). Studies of women living with HIV suggest that their levels of unintended pregnancies are as high as for all women regardless of HIV status (Hoffman et al., 2008; Rochat et al., 2006 cited in Reynolds et al., 2008). Some women living with HIV want to start or continue having children and others do not, which may affect contraceptive use and other choices related to fertility.

Although many women living with HIV may desire (additional) children, some studies suggest that HIV-positive women may have lower fertility intentions than their HIV-negative counterparts (Hoffman et al., 2008; Taulo et al., 2009; Makumbi et al., 2010). However, this is not universal, and additionally, reported fertility intentions do not always translate to increased contraceptive use or to lower fertility rates (Smee et al., 2011). The impact of HIV on fertility intentions may depend on other factors, for example, number of living children, fertility norms in her community, or fears of stigma against reproduction by individuals living with HIV. Furthermore, “fertility desires change over time, especially in relation to health status and antiretroviral therapy” (King et al., 2011: 9; Todd et al., 2011b; Chen et al., 2001 cited in Myer et al., 2010), making regular access to contraceptive counseling and methods in integrated services important for women living with HIV. A cross-sectional study with 501 women living with HIV in Uganda found that although ART use was associated with increased fertility desire, it resulted in decreased odds of pregnancy and live birth (Maier et al., 2009). Studies assessing the desire for children by women living with HIV rarely stratify results by time of diagnosis. In addition, women’s choices may change over time irrespective of time elapsed since knowing their positive serostatus. The availability of drugs for prevention of mother-to-child transmission or regimens for long-term treatment may restore childbearing intentions among some HIV-positive women (Myer et al., 2007b; Maier et al., 2009; Cooper et al., 2009), but the evidence base remains mixed (Kaida et al., 2011; Kaida et al., 2010; Andia et al., 2009), and such associations may be contextually dependent.

HIV impacts fertility rates when women do want to conceive. Biologically, women living with HIV have lower rates of conception and higher rates of miscarriage and stillbirth (Linas et al., 2011; Desgrees-du-Lou et al., 1999; Gray, 1997; Zaba and Gregson, 1998), particularly when viral load is high (Nguyen et al., 2006). However, when a woman does become pregnant, the use of HAART, along with high CD4 counts and/or undetectable or low viral loads provides the greatest likelihood to give birth to an HIV-negative infant. [See Safe Motherhood and Prevention of Vertical Transmission ] 

Women Need Access to Both Condoms and a Range of Contraceptive Options, as well as Accurate Information on HIV and Contraception

Access to contraception is a key need for women living with HIV as it is for those who are HIV-negative. Because many people still do not know their HIV status, and because negotiating condom use is often not possible, expanding access to contraceptives for all women who need and want them through rights-based, voluntary services is an important component of HIV programming and is cost-effective (Adair, 2009; Halperin et al., 2009a; Bianco et al., 2010). [See Transforming Gender Norms] “Contraceptive use has also been linked to social and economic benefits for women and their families” (Polis et al., 2011: 125). The impact of an HIV infection and awareness of infection status on fertility intentions, frequency of sexual intercourse, contraceptive use, and fertility is complex, and may also depend on factors such as access to antiretroviral therapy.

However, “limited data are available on the access and uptake of family planning services among women living with HIV at the population level” (WHO et al., 2011b: 149). In Uganda, a recently published survey found significantly greater unmet need for family planning among women living with HIV—75%—compared to those who are not—34% (Jhangri et al., 2011 cited in WHO et al., 2011b). In other countries, unmet need for family planning is lower among women living with HIV than among HIV-negative women (WHO et al., 2011b).

Health services should affirm a woman’s ability to make decisions about when and whether she wants children and forbid coercion in making family planning and reproductive health decisions (Eckman and Hersted, 2006). Numerous studies have found that women are not offered contraceptive choices, but simply told to use condoms or worse yet, as one Chilean woman living with HIV stated: “My doctor told me: 'You can’t have sex because you have AIDS or you have to make your husband use condoms'” (Marino and Alsina, 2011: 39).

Women with HIV often face challenges in accessing services and in the context of negative attitudes by providers (Hale and Vazquez, 2011). As a woman from the Argentinian Community of Women Living with HIV stated: “I don’t use the hospital or clinic services because every time that I have gone to ask for contraceptive pills, they interrogated me as if I were committing a crime” (Bianco et al., 2010: 20).

Many women living with HIV do not receive appropriate information from providers about contraceptive options, including dual protection, and lack access to contraceptives including emergency contraception (WHO, 2004a; Todd et al., 2011b). Clients should also know that while no method of contraception other than condoms has been proven to protect against STIs including HIV, condoms are not the most effective method to prevent pregnancy (WHO/RHR and CCP, 2007). Therefore dual method use – condoms plus additional contraceptive methods are the most effective in preventing HIV acquisition and transmission as well as preventing unintended pregnancies (Mark et al., 2007). The female condom also offers an important dual protection option for women (Welbourn, 2006). [See also Prevention for Women  and  Safe Motherhood and Prevention of Vertical Transmission ] Women living with and without HIV report greater success in negotiating condom use if it is also presented to their partner as contraception. [See Male and Female Condom Use]

It is also critical that providers and women have access to accurate information on the menstrual cycle as well as on side effects of contraceptive methods so that methods are not rejected for invalid reasons. Women living with HIV may be concerned that some methods, such as the IUD, can tear condoms, and may have different or particular concerns about contraceptive side effects (Laher et al., 2010). Little research exists on menstruation and HIV and women living with HIV may have particular concerns about higher HIV transmission during menstruation (Laher et al., 2010; Royce et al., 1997). ICW, the International Community of Women with HIV/AIDS, has articulated the need for “better training and awareness raising for health workers to reduce the frequency of forced abortion and forced sterilization of HIV-positive women” (ICW, 2008: 2). Recognizing that women living with HIV are at particular risk of coerced sterilization (Nair, 2011; Vivo Positivo and Center for Reproductive Rights, 2010; de Bruyn, 2006a), the International Federation of Gynaecology and Obstetrics (FIGO) has stated that consent to sterilization must not “be made a condition of receipt of any other medical care, such as HIV/AIDS treatment (FIGO, 2011 cited in Arkin, 2011: 36). [See also Structuring Health Services to Meet Women’s Needs] 

Providers and women globally need to have the up to date information on interactions antiretroviral treatment and contraceptive options for women of reproductive age (Stevens, 2008), as concerns have been raised about interactions between ARVs and contraceptives. Women of reproductive age need HAART regimens tailored to their contraceptive needs as well as guidelines need to be updated and disseminated on a continuing basis, as new emerging evidence becomes available. WHO guidelines are available at: http://www.who.int/reproductive-health/publications/mec/mec.pdf (WHO, 2010e).

Does Hormonal Contraception Use Increase HIV Acquisition?

Questions regarding hormonal contraceptive use and HIV acquisition have been the subject of research for many years, however, uncertainty remains. Some biological and epidemiological studies have suggested that hormonal contraceptive use could influence HIV acquisition, but other studies have not reported this association. No randomized trials of hormonal contraceptive use and HIV acquisition have been completed, and associations between different hormonal contraceptive methods and risk of HIV acquisition have been examined in observational studies. To date, fifteen analyses have been published on fourteen longitudinal datasets to examine the relationship between injectable contraception and HIV acquisition. These studies have varied tremendously in methodological quality, size, and other factors. Six published analyses found a significantly increased HIV risk associated with injectable contraception (Ungchusak et al., 1996; Kumwenda et al., 2008b; Wand and Ramjee, 2012; Heffron et al., 2012a; Baeten et al., 2007b; Morrison et al., 2007). Nine published analyses have not found an association between hormonal contraception and HIV acquisition (Morrison et al., 2012; Reid et al., 2010; Feldblum et al., 2010; Myer et al., 2007b; Kiddugavu et al., 2003; Kleinschmidt et al., 2007; Morrison et al., 2007; Kilmarx et al., 1998; Kapiga et al., 1998). Three published analyses of longitudinal data have found no significant relationship between norethisterone enanthate (Net-En) – another injectable progestin in addition to depot medroxyprogesterone acetate (DMPA) – and HIV (Myer et al., 2007b; Kleinschmidt et al., 2007; Morrison et al., 2012). Two of sixteen prospective studies have found an increased risk of HIV acquisition associated with oral contraceptive use (Plummer et al., 1991; Baeten et al., 2007b).

In addition to HIV acquisition for women, studies have also been conducted to assess the role of hormonal contraception in the rate of disease progression to AIDS or death, as well as the role of hormonal contraception in the risk of HIV transmission from an HIV-positive woman to an HIV-negative man. The majority of evidence suggests that HIV-positive women can use hormonal contraception without concerns about faster progression of their HIV disease to AIDS or death. Evidence on the effect of hormonal contraception on HIV transmission to men is limited. The only available study that looked directly at new HIV infections in men suggested that injectable contraception increases the risk of female-to-male transmission, while studies assessing the impact of hormonal contraception on proxy measurements of infectivity have been mixed. Specifically, studies on the relationship between hormonal contraception and genital viral shedding have generated inconsistent findings, while studies assessing the impact of hormonal contraception on plasma viral load generally indicate no increase, and further analysis is needed (WHO, 2012a).

One of the above studies has received a great deal of attention due to its striking results demonstrating increased risk of HIV acquisition among injectable hormonal contraception users. This study promulgated a renewed review and clarification of international guidance on hormonal contraception and thus warrants a deeper look. The analysis by Heffron et al. regarding the role of hormonal contraception and transmission looked at both acquisition and transmission and found an increased risk for both. An observational analysis of 1,314 HIV-negative women in serodiscordant partnerships measuring HIV acquisition and subsequent viral load found an increased risk of HIV acquisition with use of hormonal contraception, particularly injectable progestin methods (Heffron et al., 2012a). However, the study was not designed to examine hormonal contraceptives and HIV risk, but rather was a secondary analysis of an HIV prevention trial; contraceptive use and unprotected sex was not randomly assigned and was self-reported (Morrison and Nanda, 2011). Other study limitations included a lack of precision as to when HIV seroconversion occurred and the limited number of HIV seroconversions overall (Yacobson, 2012). “Some studies suggest that women using progestogen-only injectable contraceptives may be at increased risk of HIV acquisition, other studies do not show this association” (WHO, 2012a). Myer et al. contend that “any true association is likely to be small… In the case of hormonal contraception and HIV infection, it is unclear whether more definitive evidence is likely to emerge from observational epidemiological studies…” (Myer et al., 2007b: 173). Further, “little evidence is available on the potential relationship between HIV risks and other hormonal contraceptive methods such as implants, vaginal rings, patches or intrauterine devices” (WHO, 2012a: 3) but limited data suggest no increased risk of HIV among copper IUD users (Morrison et al., 2009). A randomized controlled trial is typically the gold standard to assess this type of risk, but randomizing women’s contraceptive choice could entail numerous methodological and ethical challenges.

Experts have proposed several biological mechanisms by which hormonal contraception could theoretically increase HIV risk, but it remains unknown which of these mechanisms, if any, play a role (Shelton, 2011a; Morrison, 2012). Experts note that “care should be taken…to avoid inducing unwarranted concern about risks associated with contraceptive use” (Morrison et al., 2009: 280). Although the evidence on the relationship between pregnancy and various HIV-related risks is also mixed, some studies suggest that pregnancy may increase the risk of acquiring and/or transmitting HIV (Mugo et al., 2011; Gray et al., 2005; Reid et al., 2010; Morrison et al., 2007). In addition, preventing unintended pregnancies with effective contraception is critical to reducing maternal and infant morbidity and mortality, and in reducing perinatal HIV. A modeling study that assumed an increased risk for HIV acquisition showed that if injectables were removed from use without 70%–100% of women switching to an IUD or a combined oral contraceptive, as many as nine additional maternal deaths would occur for every case of HIV avoided (Rodriguez et al., 2012). An analysis of data from Kenya, South Africa and Zimbabwe found that a shift from DMPA to an oral contraceptive or male condom by an individual could result in 600 additional unintended pregnancies; a shift from DMPA to no method could result in an additional 5,400 unintended pregnancies per 100 HIV infections averted. “At the macro level, [a] decision to withdraw DMPA from family planning programs in sub-Saharan Africa is not warranted” (Jain, 2012: 645). Injectable contraception is the most commonly used method of hormonal contraception in sub-Saharan Africa and is an effective, easy-to-use method that women can use without the knowledge of their sexual partner, if necessary. The method involves an injection every few months, rather than a daily pill, and is considered easy for providers (Rees, 2012). For women who are HIV-positive and using antiretroviral therapy, injectables also offer a highly effective method of contraception that is not expected to cause adverse drug interactions with antiretroviral medications.

Advice for Women About the Known and Potential Risks and Benefits of Hormonal Contraception Must Be Clear

Given the mixed evidence about the role of hormonal contraception and HIV risk, a statement by the International Community of Women Living with HIV/AIDS (ICW) noted that guidance about the potential risk of increased HIV acquisition by women using progestin-only injections for contraception should be “translated into clear, simple language that allows women to make genuinely informed decisions about family planning and HIV risk reduction. This means explaining what is known and unknown based on today’s data” (Mworenko, 2012). Women’s groups have also requested that women and their providers be given a range of contraceptive options with complete information as to potential risks or uncertainty regarding various contraceptive methods and their role in HIV acquisition and/or transmission.

In response to the conflicting evidence about the possible increase in HIV risk due to hormonal contraception, the WHO convened a technical consultation in late January 2012 to review the evidence and released a technical statement concluding that there should be no restriction on the use of any hormonal contraceptive method for women living with HIV or at high risk of acquiring HIV and noted: “Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not show this association… Because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms” (WHO, 2012a: 1). The U.S. Department of Health and Human Services (HHS) noted: “Further research is needed to definitively determine if hormonal contraceptive use is an independent risk factor for acquisition and transmission of HIV” (USHHS, 2011: 135). U.S. Centers for Disease Control and Prevention (CDC) issued guidance for women in the United States on this topic and stated: “... A clarification is added to the recommendation for women at high risk for HIV infection who use progestin-only injectables to acknowledge the inconclusive nature of the body of the evidence regarding association between progestin-only injectable use and HIV acquisition. The clarification also notes the importance of condom use and other HIV preventive measures, expansion of the variety of contraceptive methods available (i.e., contraceptive method mix) and the need for further research on these issues” (CDC, 2012a: 449). USAID further noted that “All individuals, whether at risk of HIV or living with HIV, should take all possible precautions to prevent the acquisition and transmission of HIV, including correct and consistent condom use” (USAID, 2012a), while continuing the commitment to “diversifying contraceptive method choice” (USAID, 2012a). Others agree that expanding contraceptive choice is critical by broadening access to a wide range of contraceptive methods available (Rees, 2012; Abdool Karim, 2012; Welbourn, 2012). But it must be noted that many women have difficulty negotiating condom use. [See Male and Female Condom Use]

Just as importantly, the mixed evidence on the relationship between progestin-only injectables and HIV acquisition and transmission presents a communications challenge. For women who are HIV-negative, there are challenges to countering the myths in many countries that perpetuate the idea that HIV is acquired from contraceptive programs promoted by the government (Peters et al., 2010b). Without clear explanations of the conflicting nature of the evidence, those myths may be further perpetuated and/or women may stop using hormonal contraception altogether. In addition, for women who are living with HIV, there is a danger that health personnel will discriminate against them, denying them access to effective hormonal contraception. Not providing women with effective contraception exposes them to high risk of pregnancy in addition to HIV and increases overall health risks for women.

Dr. Charles Morrison, long involved in research on this topic, summed up the dilemma: “Active promotion of DMPA in areas with high HIV incidence could be contributing to the HIV epidemic in sub-Saharan Africa, which would be tragic. Conversely, limiting one of the most highly used, effective methods of contraception in sub-Saharan Africa would probably contribute to increased maternal mortality and morbidity and more low birth weight babies and orphans – an equally tragic result. The time to provide a more definitive answer to this crucial public health question is now” (Morrison and Nanda, 2011: 2).

 

Integrating HIV and Comprehensive Sexual and Reproductive Health Services Can Meet the Needs of Women

Increasing access to family planning for women living with HIV can be achieved both by integrating family planning services and HIV services as well as strengthening existing vertical family planning programs, which will reduce the number of unintended pregnancies among the many HIV-positive women who do not know their serostatus (Wilcher and Cates, 2010). Integrating SRH, including provision of contraception, with other HIV services has the potential to increase contraceptive use and reduce unintended pregnancies (Duerr et al., 2005). A recent study in seven African countries shows why integration is important. The study found that within four years of initiating antiretroviral therapy, one-third of the women who initiated ARV therapy experienced a pregnancy. The treatment program did not include any contraceptive counseling or provision of contraceptives. “…[T]he design and operation of most HIV treatment services do not explicitly acknowledge the likelihood or the actual occurrence of pregnancy” (Myer et al., 2010).

ARV treatment programs should be part of a continuum of care that includes contraceptive and other integral health services from the onset (Shelton and Peterson, 2004; Farrell, 2007). Antiretroviral programs have regular contact with women living with HIV over long periods of time and as a result are a particularly important venue for meeting the reproductive health needs of women living with HIV (Myer et al., 2007a). Most clients would rather access contraceptive services at the same sites they receive HIV services (Asiimwe et al., 2005; Farrell and Rajani, 2007). Studies have shown that health care workers can provide counseling on sexuality, family planning, HIV/AIDS, and STIs, if they receive adequate training (IPPF/WHR, 2000). Yet integration is not always advantageous to women, particularly if additional services increase wait times and the quality of care. And many studies found the need to train providers not to discriminate against women living with HIV. [See Gaps]

Inclusion of contraceptive care in ARV treatment will take effort; in some cases, women living with HIV are denied information about safer sex because it is believed that they should not be having sex (Esplen, 2007). A growing amount of evidence exists on integrating sexual and reproductive health programs and services with HIV prevention, treatment and care, but more evaluation studies to demonstrate what works for women are needed (Wilcher and Cates, 2009; Spaulding et al., 2009). [See Structuring Health Services to Meet Women’s Needs] Where HIV and contraceptive services are combined, women report greater use of both services. An analysis of VCT clients in Ethiopia suggests that various levels of service integration may attract different types of clients, including services provided in the same facility, the same room and by the same provider. More atypical family planning clients (younger women and males) were likely to increase use of HIV and SRH services provided in the same room. Facilities where counselors jointly offered HIV and family planning services and served many repeat family planning clients were most likely to serve older, married women who still had significant rates of HIV. Integrating VCT with family planning and vice versa is an effective strategy for expanding both services and reaching a wider range of clients (Bradley et al., 2008a).

While there have been some successes in integration, including a more favorable policy environment both at the global and national levels, “widespread integration remains an unrealized goal” (Ringheim, 2009: 1). Largely separate funding for family planning and HIV/AIDS may be a key barrier to integrating contraception in HIV/AIDS programs (Petruney et al., 2010). In most countries, family planning and HIV/AIDS programs are run in parallel fashion by separate departments within ministries of health, each of which has its own policies, guidelines, training, monitoring and service delivery structures, with limited coordination (Wilcher and Cates, 2010; Bianco, 2011). In instances where programs have been integrated or linked, women have greatly increased access to testing, treatment and other sexual and reproductive health services, including increased condom and contraceptive use. [See Structuring Health Services to Meet Women’s Needs]

Sexual Health and Infertility for Women Living with HIV is Often Ignored

Most research on women’s sexual and reproductive health has had the objective of increasing condom use, reducing unintended pregnancies and assessing HIV transmission. “Issues related to other aspects of sexual health, including satisfaction with sexual relationships among women living with HIV infection, have received relatively little attention” (Wilson et al., 2010b: 360). The sexual health of women is an important component of SRH services, particularly for women living with HIV. Discussions of SRH services for women living with HIV often revolve around controlling fertility and ignore HIV-positive women’s needs for services that include attention to safe and healthy sexuality and a desire for children. Because women living with HIV are more vulnerable to rights abuses, for example forced contraception or coerced sterilization, ensuring that their sexual and reproductive health needs are met is critical (Wilcher and Cates, 2009).

“My HIV status does not take away my sexuality.” —Grace Sedio, ICW Representative from Botswana (Sedio, 2008b)

HIV and AIDS can have specific impacts on sexuality. One study in Brazil found that women with HIV experienced a lack of sexual arousal and that men with AIDS, needed more time to ejaculate than they wished (Tubino Scavino and Abdo, 2010). These may become issues that both men and women may want to discuss in reproductive health services. A U.S. study found that women with HIV reported greater sexual problems than did those without HIV (Wilson et al., 2010b). “Very little has been published on sexual dysfunction in women, and even less in the context of HIV infection” (Fakoya et al., 2008: 697), although work is forthcoming (Welbourn, 2012). “Most women with HIV are sexually active following their diagnosis” (Wilson et al., 2010b: 360), yet many providers do not acknowledge the sexuality of women living with HIV (Sedio, 2008b; Bianco et al., 2010). 

“Many people have HIV, there are many treatments for HIV, there are educational programs for HIV, but none of that exists for infertility, so that [infertility] seems worse…there is no UN program for infertility treatment here, nobody cares like they do about AIDS…” —Woman from Botswana, who described herself as struggling with infertility (Upton and Dolan, 2011: 101)

Estimates of infertility range from between 8% in high-income countries (Upton and Dolan, 2011) to 25% of ever-married women in low- and middle-income countries, excluding China (Hardee et al., 2012). Risk factors for infertility include HIV and STIs such as herpes simplex virus type 2 (HSV-2), bacterial vaginosis, syphilis and gonorrhea (Sneeringer and Logan, 2009), as well as chlamydia (Bianco, 2012). Especially in many countries in the Global South, “if a woman cannot produce a living child in a formal union with a man, she will often be told to leave and is isolated and stigmatized in the wider community” (Dhont et al., 2011: 2). A study of infertile men and women in Botswana found that “fears of sterility overshadow fears of HIV/AIDS…” (Upton and Dolan, 2011: 97).

Numerous studies have reported the desire by both men and women living with HIV to have children, with the least risk possible to their sexual partner and their infant (Beyeza-Kashesya et al., 2010; Matthews et al., 2011). Yet, infertility receives insufficient attention in either reproductive health or safe motherhood programming (Hardee et al., 2012; Bianco, 2011) [See also Pre-Conception]

Women Living with HIV Also Need Screening and Treatment for Cervical Cancer

Cervical cancer is preventable and treatable (WHO, 2009c; Hale, 2009), yet in 2010, cervical cancer killed more than 200,000 women globally, of whom 85% live in low- or middle-income countries (Forouzanfar et al., 2011; Jeronimo, 2012). Women living with HIV are at a high risk for developing cervical cancer (Agaba et al., 2009; Chaturvedi et al., 2009; Singh et al., 2009a; Oliveira et al., 2010c; Kuhn et al., 2010d; Anastos et al., 2010; Peedicayil et al., 2009; Zhang et al., 2011a; Adjorlolo-Johnson et al., 2010; Coelho Lima et al., 2009; Holmes et al., 2009; Kiatiyosnusorn et al., 2010) and it has been noted as an “AIDS-defining cancer” (Pantanowitz and Michelow, 2010: 66). Despite the fact that HIV increases the risk of cervical cancer as well as a range of vaginal and cervical infections (Levine, 2002; Cejtin, 2003 cited in Myer et al., 2007a; Franceschi and Jaffe, 2007; Banura et al., 2008), "coverage of cervical cancer screening in developing countries is on average 19%, compared to 63% in developed countries, and ranges from 1% in Bangladesh to 73% in Brazil" (Gakidou et al., 2008: 0863). Cervical cancer screening coverage in sub-Saharan Africa ranges from 2% to 20.2% in urban areas and 0.4% to 14% in rural areas, with only six countries with nationwide screening programs and the remaining countries with only research or pilot programs (Louie et al., 2009).

Much remains unclear when it comes to cervical cancer and HIV. Even in resource-rich settings, experts and guidelines disagree at what intervals to screen women with HIV for cervical cancer. “There is no simple, agreed upon guideline for cervical screening in HIV-positive women” (Pantanowitz and Michelow, 2010: 68). In South Africa, current guidelines call for screening every ten years but a recent study suggested that screening at longer intervals than one year but shorter intervals than ten years is warranted, as “annual screening may…use scarce screening and colposcopic resources for the diagnosis of transient cervical abnormalities destined to resolve with time” (Omar et al., 2011: 93). A study in Thailand concluded that more than two Pap smears per year may be warranted for HIV-positive women (Chalermchockcharoenkit et al., 2011). “Unfortunately, cervical cancer prevention in HIV-infected women is lagging behind even in the highest resource countries” (Franceschi and Ronco, 2010: 2579).

“We are getting HAART, but we still die of cervical cancer.” —Grace Sedio, ICW Representative from Botswana (Sedio, 2008b)

The impact of antiretroviral therapy on cervical cancer is also unclear (Pantanowitz and Michelow, 2010; Kuhn et al., 2010d; Firnhaber et al., 2010; Massad et al., 2009; Massad et al., 2008; Asheber et al., 2007 cited in Stevens, 2008; de Vuyst et al., 2008; Bernal et al., 2008), but ARV therapy improves immunity and increases lifespan, which increases the length of time during which persistent human papillomavirus (HPV) may develop into cervical cancer. “No recommendations exist for the use of HPV testing for primary screening or triage in HIV-infected women” (Franceschi and Ronco, 2010: 2579). In 2011, PEPFAR committed additional funds to screening and treatment for cervical cancer for women living with HIV, along with the George W. Bush Institute. What works best to detect cervical cancer in women with HIV in places without sophisticated lab equipment is unclear and no test is optimal (Woo et al., 2012; Firnhaber et al., 2012a). PATH is currently testing different cervical cancer screening options for women living with HIV (Jeronimo, 2012) and has recently conducted a feasibility study of an E6 test which can detect a protein expressed only when pre-cancer changes occur. This may significantly reduce the numbers of women who need referral as this test can distinguish between HPV that does not yet need treatment and the development of cancerous lesions that do (Schweizer et al., 2010).

Greater Efforts are Needed to Involve Men in Sexual and Reproductive Health

Further efforts are also needed to educate men in gender-equitable ways about contraception and the general safety of contraceptive methods. At the same time, it is critical for women to have autonomy over their bodies. In many cases, "women traditionally ask their husbands about family planning because if the man finds out that the woman has accessed contraception without consultation, he may conclude that the woman is unfaithful" (Imbuki et al., 2010: 112). Some women living with HIV may need to use contraception covertly and this may influence method choice (Wanyenze et al., 2011a). A recent review of 63 studies from 1995 to 2008, using experimental or quasi-experimental design found that making services available to couples in villages and homes was among the successful approaches to reducing unintended pregnancy. In addition, using mass media, peer-led, community-based, or instructor-led outreach as well as increased conditional cash transfers, access, quality of care and lower costs for users resulted in prevention of unintended pregnancies (Mwaikambo et al., 2011). However, use of cash transfers to encourage contraceptive use can raise ethical questions related to voluntarism.

Available Guidelines

A number of sexual and reproductive health guidelines are available to health program managers and policymakers. Guidance regarding which contraceptive options are best for women living with HIV is available from WHO: http://www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/ (WHO, 2010e; see also the Technical Statement, above). Linkages between SRH and HIV are available at: SRH & HIV Linkages Resource Pack (2010). A counseling tool is also available at: http://www.engenderhealth.org/pubs/hiv-aids-sti/srh-hiv-positive-women-girls.php. Strategic considerations on linking family planning and HIV services can be found at: (PAHO, 2010); Strategic considerations for linking family planning and HIV (WHO, 2009l) are available at: http://www.fhi.org/en/RH/Pubs/booksReports/FP-HIV_Strategic_Considerations.htm. EngenderHealth also has training guidelines for program managers and health workers to provide comprehensive SRH care for women and girls living with HIV: http://www.engenderhealth.org/pubs/hiv-aids-sti/index.php. Recent Global Fund guidelines have called for integration of the sexual and reproductive health needs of HIV-positive women into national AIDS plans, with successful examples of Global Fund proposals (Hardee et al., 2009a).

The following represents recent evidence as to what works in meeting the sexual and reproductive health needs of women living with HIV. [See also Treating Sexually Transmitted Infections (STIs)]