Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
Gaps in Research
- 1.
- Additional efforts are needed to provide information and more contraceptive options for women living with HIV (or whose serostatus is unknown) who do not desire to have a child or wish to space the next pregnancy. The 2012 WHO guidelines on hormonal contraceptives and HIV should be widely disseminated to programs and providers.
- 2.
- Providers need training on meeting the contraceptive needs of women and couples with HIV, including providing non-directive, informed choice counseling and reducing stigma and discrimination for women living with HIV.
- 3.
- Efforts are needed to capitalize on opportunities to integrate family planning and HIV services.
- 4.
- Programs must adhere to the longstanding international agreement to voluntarism, informed consent, and ensuring the right of individuals and couples to decide freely and responsibly the number and spacing of their children.
- 5.
- Interventions to increase dual protection and dual method use are needed.
- 6.
- Women living with HIV need information and access to services for emergency contraception and post-abortion care (PAC) services.
- 7.
- Policy guidelines, including service delivery guidelines, need to specify how contraception should be addressed in HIV prevention, treatment and care.
- 8.
- Additional strategies are needed to address the cultural, gender and other contextual barriers that influence the behavior or decisions of people living with HIV to engage in unsafe sex.
- 9.
- Further interventions providing HIV disclosure support are needed, particularly for women facing abandonment, violence, or other adverse events.
- 10.
- Further interventions are needed to ensure that women, especially women living with HIV, are screened and treated for cervical pre-cancer and cancer.
- 11.
- Improved screening technologies to distinguish transient HPV infections from longer duration cancer-inducing infections to improve HPV test-based screening is needed.
- 12.
- Interventions are needed to meet the contraceptive needs of different groups of women who are living with HIV, such as sex workers, migrants, young women, etc.
- 13.
- Additional programming, including access to antiretroviral therapy, is needed to reduce sexual transmission within stable heterosexual serodiscordant couples.
- 14.
- Policies that demonstrate prejudice to women living with HIV—such as those that initiate family planning only on the first day of a woman’s menstrual cycle and women with HIV are more likely to have amenorrhea—must be changed.
- 15.
- Adolescents living with HIV need information and treatment services through adolescent-friendly HIV and family planning services.
- 16.
- Screening and treating HIV-positive women and their partners for STIs may reduce HIV transmission and will improve health.
- 17.
- Services to provide sex workers with access to antiretroviral therapy in the same clinics that provide them with condoms, contraceptives, HIV testing and STI services are needed.
- 18.
- Women living with HIV need access to information and services to address infertility.
- 19.
- Greater efforts are needed to involve men in sexual and reproductive health.
1. Additional efforts are needed to provide information and more contraceptive options for women living with HIV (or whose serostatus is unknown) who do not desire to have a child or wish to space the next pregnancy. The 2012 WHO guidelines on hormonal contraceptives and HIV should be widely disseminated to programs and providers. Studies found that many HIV-positive women had significant numbers of unintended pregnancies and that preferred contraceptive methods were not available.
Gap noted, for example, in Kenya (Kiarie et al., 2012; Imbuki et al., 2010); South Africa, Brazil and Kenya (Todd et al., 2011b); Kenya, Zambia, Tanzania, Uganda, Rwanda and Namibia (Johnson, 2011); South Africa (Hoffman et al., 2010a; Cooper et al., 2009; Laher et al., 2009a); Ukraine (Saxton et al., 2010); Tanzania (Nielsen-Bobbit et al., 2011); Uganda (King et al., 2011; Wanyenze et al., 2011a; Makumbi et al., 2010; Homsy et al., 2009; Heys et al., 2009; Nakayiwa et al., 2006; Bunnell et al., 2008); Nigeria (Iliyasu et al., 2009); Kenya and Malawi (Anand et al., 2009); Argentina (Gogna et al., 2009); India (Chakrapani et al., 2011a; Suryavanashi et al., 2009); Botswana (ICW, 2006a); Côte d’Ivoire (Desgrees-du-Lou et al., 2002 cited in de Bruyn, 2003); general (Hoffman et al., 2008; Rochat et al., 2006 cited in Reynolds et al., 2008). Argentina, Brazil, Chile and Uruguay (Bianco et al., 2010).
2. Providers need training on meeting the contraceptive needs of women and couples with HIV, including providing non-directive, informed choice counseling and reducing stigma and discrimination for women living with HIV. [See also Reducing Stigma and Discrimination] Studies found that HIV-positive women were required to wait in separate waiting rooms and that because provider bias limited contraceptive options, providers needed additional training on the full range of contraceptive options. Other studies showed that providers have inaccurate knowledge concerning HIV and contraception.
Gap noted, for example, in Uganda (King et al., 2011; Asiimwe et al., 2005); Namibia (ICW, 2009); Argentina, Mexico, Poland, Kenya, Lesotho, South Africa and Swaziland (de Bruyn, 2004 cited in Delvaux and Nostlinger, 2007); Zambia (Mark et al., 2007).
3. Efforts are needed to capitalize on opportunities to integrate family planning and HIV services. Studies found that both men and women wanted greater integration of services and also found high rates of unintended pregnancies among HIV-positive women. In one study, VCT clients report infrequent reproductive health counseling.
Gap noted, for example, in South Africa (Bera et al., 2010; Myer et al., 2010) and Ethiopia (Bradley et al., 2010).
4. Programs must adhere to the longstanding international agreement to voluntarism, informed consent, and ensuring the right of individuals and couples to decide freely and responsibly the number and spacing of their children. Studies found that women living with HIV had been sterilized against their will, were pressured by providers to terminate a pregnancy, or were stigmatized for becoming pregnant. Studies also found that provision of antiretroviral therapy was conditional on using certain types of contraception. Litigation is currently being undertaken. A study found that HIV-positive women who accessed contraceptive services were not informed of the benefits of PMTCT programs in reducing vertical transmission.
Gap noted, for example, in Dominican Republic and Ethiopia (IPPF et al., 2011); Ukraine (Finnerty et al., 2010); Mozambique (Hayford and Agadjanian, 2010); Uganda (Beyeza-Kashesya et al., 2009); Namibia (Orner et al., 2011b; Nair, 2011; Dumba, 2010; ICW, 2009); Venezuela (OSF, 2011); Brazil (Oliveira et al., 2007; Nobrega et al., 2007 cited in Oliveira et al., 2007; Knauth et al., 2003); Chile (Nair, 2011; Vivo Positivo and Center for Reproductive Rights, 2010); Ukraine (Yaremenko et al., 2004); Argentina, Mexico, Peru, Poland, Botswana, Kenya, Lesotho, Namibia, Nigeria, South Africa and Swaziland (de Bruyn, 2006a).
5. Interventions to increase dual protection and dual method use are needed. Studies found that couples are reluctant to use condoms in addition to other contraceptive methods because it may symbolize distrust of a partner, particularly among adolescents.
Gap noted, for example, in Kenya (Church, 2011); Rwanda (Elul et al., 2009); Ghana (Goparaju et al., 2003); general (Spieler, 2001 cited in Goparaju et al., 2003; Delvaux and Nostlinger, 2007).
6. Women living with HIV need information and access to services for emergency contraception and post-abortion care (PAC) services. Studies found that women did not have adequate knowledge of emergency contraception, nor access to services for post-abortion care.
Gap noted, for example, in South Africa (Orner et al., 2011a); Brazil (Friedman et al., 2011); Uganda (Kisakye et al., 2010); Argentina, Mexico, Peru, Poland, Botswana, Kenya, Lesotho, Namibia, Nigeria, South Africa and Swaziland (de Bruyn, 2006a); global literature review (de Bruyn, 2003); general (Delvaux and Nostlinger, 2007; Guttmacher Institute, 2006 cited in Esplen, 2007).
7. Policy guidelines, including service delivery guidelines, need to specify how contraception should be addressed in HIV prevention, treatment and care. Studies found that many guidelines did not explicitly address family planning in VCT and PMTCT guidelines and that providers and policymakers felt they had insufficient knowledge.
Gap noted, for example, in Argentina (Bianco et al., 2010) and South Africa (Harries et al., 2007).
8. Additional strategies are needed to address the cultural, gender and other contextual barriers that influence the behavior or decisions of people living with HIV to engage in unsafe sex. [See also Strengthening the Enabling Environment] Studies found that factors such as difficulties negotiating condoms, partner refusal, high unemployment, alcohol use, financial dependency, expectations of childbearing, fear of disclosure, etc., influenced protective behavior.
Gap noted, for example, in South Africa (Eisele et al., 2008); Uganda (King et al., 2009; Bakeera-Kitaka et al., 2008).
9. Further interventions providing HIV disclosure support are needed, particularly for women facing abandonment, violence, or other adverse events. [See also Antenatal Care - Testing and Counseling, HIV Testing and Counseling for Women and Reducing Stigma and Discrimination] Studies found many women faced abuse and abandonment upon disclosing their HIV status.
Gap noted, for example, in Malawi (Chinkonde et al., 2009); South Africa, Malawi, Swaziland, Lesotho and Tanzania (Greeff et al., 2008).
10. Further interventions are needed to ensure that women, especially women living with HIV, are screened and treated for cervical pre-cancer and cancer. Studies found that women were not aware of and/or did not receive regular screening and treatment of cervical cancer, despite higher risk of developing cervical cancer.
Gap noted, for example, in Argentina (Bianco et al., 2010); Botswana (Dryden-Peterson et al., 2012); Bahamas (Dames et al., 2009); Brazil (De Andrade et al., 2011); Nigeria (Dim et al., 2009); South Africa (Wake et al., 2009; Denny et al., 2008; Myer et al., 2007a; Gaym et al., 2007); United States (Massad et al., 2008); Kenya (Yamada et al., 2008); Uganda (Safaeian et al., 2008); Tanzania (Kahesa et al., 2008); France (Heard et al., 2006); general (Goldie et al., 1999).
11. Improved screening technologies to distinguish transient HPV infections from longer duration cancer-inducing infections to improve HPV test-based screening is needed.
Gap noted globally (Franceschi and Ronco, 2010).
12. Interventions are needed to meet the contraceptive needs of different groups of women who are living with HIV, such as sex workers, migrants, young women, etc. A recent review of studies using experimental or quasi-experimental design to attribute program exposure to observed changes in fertility or family planning outcomes at the individual or population level, with 63 studies from 1995 to 2008, found that studies did not assess the differential impact of interventions across target audiences.
Gap noted, for example, in Namibia and Brazil (Orner et al., 2011b); Asia, Africa, the Americas, Eurasia and the Middle East (Mwaikambo et al., 2011).
13. Additional programming, including access to antiretroviral therapy, is needed to reduce sexual transmission within stable heterosexual serodiscordant couples. Despite the majority of infections in some countries attributable to HIV transmissions between stable heterosexual serodiscordant couples, little programming had been directed toward this population.
Gap noted, for example, in Swaziland and Lesotho (Hankins and de Zalduondo, 2010).
14. Policies that demonstrate prejudice to women living with HIV—such as those that initiate family planning only on the first day of a woman’s menstrual cycle and women with HIV are more likely to have amenorrhea—must be changed.
Gap noted globally (Bekker et al., 2011; Torpey et al., 2010).
15. Adolescents living with HIV need information and treatment services through adolescent-friendly HIV and family planning services. [See also Increasing Access to Services]
Gap noted globally (Kancheva Landolt et al., 2011).
16. Screening and treating HIV-positive women and their partners for STIs may reduce HIV transmission and will improve health. [See Treating Sexually Transmitted Infections (STIs)]
17. Services to provide sex workers with access to antiretroviral therapy in the same clinics that provide them with condoms, contraceptives, HIV testing and STI services are needed. A study found that sex workers, particularly HIV positive sex workers, wanted integrated comprehensive care to meet all their needs if they tested positive for HIV.
Gap noted in Mozambique (Lafort et al., 2010).
18. Women living with HIV need access to information and services to address infertility.
Gap noted globally (Church and Lewin, 2010).
19. Greater efforts are needed to involve men in sexual and reproductive health.
Gap noted in Kenya (Imbuki et al., 2010) and Tanzania (Wanyenze et al., 2011a).