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Where are the Sexual and Reproductive Health and Rights of HIV-Positive Women on the Global Agenda?

02/07/2011

Harvard's Sofia Gruskin and Sarah MacCarthy on the threat to the rights of HIV+ women

The health of women who are mothers received renewed attention in 2010 through a series of global meetings and strategies but it remains unclear if these efforts will adequately address the sexual and reproductive health and rights of women generally, and HIV-positive women in particular. The disturbing trend away from sexual and reproductive health, and back to the "safer" confines of maternal and child health, is problematic for all women but, unless checked, threatens to seriously undermine the rights and health of HIV-positive women around the world.

The Millennium Development Goals (MDG), adopted in 2001, underpin all relevant global health and development efforts, MDG 5 - improving women's heath - is measured primarily in relation to maternal mortality reduction and MDG 6 - providing universal access to treatment available to all who need it - by the proportion of the population with advanced HIV infection with access to antiretroviral drugs. The target of universal access to reproductive health, reluctantly added only after five years of intense lobbying efforts, is interpreted simply as women's access to antenatal care and to contraception. Efforts at the global level to bring these together to promote and protect the health and rights of the 15.9 million women estimated to be HIV-positive are woefully insufficient, and we fear the trend is getting worse not better.

The Women Deliver and Global Maternal Health conferences last summer, the G8 summit focus on maternal and child health and the UN Secretary General's Global Strategy for Women's and Children's Health signal positive attention to maternal health but together demonstrate limited engagement with the sexual and reproductive health and rights of HIV-positive women. For example, the August 2010 Global Maternal Health Conference held in New Delhi, India addressed the needs of HIV-positive women as a sub-theme and only explicitly referenced HIV/AIDS in the context of service integration. A few weeks later, the Global Strategy for Women's and Children's Health was launched. Largely giving attention to HIV/AIDS only in the context of service integration, the strategy mostly references HIV in combination with other diseases such as malaria and tuberculosis and gives little recognition to the unique circumstances, including stigma and discrimination, that women living with and affected by HIV/AIDS face.

A three-day conference convened in 2010 at the Harvard School of Public Health highlighted the needs and rights of HIV-positive women before, during, and after pregnancy. The resulting report, "The Pregnancy Intentions of HIV-Positive Women: Forwarding the Research Agenda," in addition to underscoring needs in relation to safer pregnancy and pregnancy prevention, two issues continuing to receive a modicum of attention on the global stage with respect to HIV-positive women, also highlights the importance of desired pregnancy and pregnancy termination as key issues for HIV-positive women. These are the issues which, unless deliberately addressed, threaten to slide off the agenda of the donors, policy makers, researchers and programmers whose work is so crucial to the realization of the health and rights of HIV-positive women.

Studies from a range of geographic and economic contexts affirm that HIV-positive and HIV-negative women alike desire children, and that enhanced access to antiretroviral treatment enables HIV-positive women to better express and realize their sexual and reproductive rights. However, a huge information gap remains among HIV-positive women and men about potentially effective methods of conception, including assisted reproductive technologies, even as questions of efficacy, safety and best practice persist. These are not issues which can be ignored. Going forward, there is a need for sufficient technical, financial and logistical support to HIV-positive women and their partners even if at odds with the global priorities noted above.

It is well established, and well documented, that a woman's ability to terminate a pregnancy safely is affected by the legal status of abortion where she lives, which in turn affects the capacity of the health system to provide safe abortion services, including the existence (or not) of clandestine and potentially unsafe services. For women who experience spontaneous abortions or whose only option is unsafe abortion, post-abortion care (PAC) can be life-saving. But accessing PAC can pose significant problems for women in countries where abortion is criminalized. And criminalization has been shown to make existing problems, such as maternal morbidity and mortality, worse for HIV-positive women by delaying or inhibiting women from seeking PAC even where it is available. For HIV-positive women, the risks of unsafe abortion are not only high, but rarely discussed. The 2010 International AIDS Conference was the first ever to dedicate a major session to abortion, highlighting in particular the need for HIV-positive women to have access to a full range of sexual and reproductive health services, including abortion, as central to a human rights based response to the HIV epidemic. While the fact that this session occurred was encouraging, the highly politicized nature of the abortion debate highlights the need for deliberate attention to these issues at the global level.

The Harvard conference proposed a number of targeted recommendations for further research and action, drawing attention not only to the services needed by women living with and affected by HIV, but the importance of their communities and the broader legal and policy environment in which they live. Despite renewed interest in maternal and infant health at the global level, the specific needs and rights of HIV-positive women before, during, and after pregnancy must be given sufficient consideration. Moving forward, deliberate attention is needed - and attention which truly engages the sexual and reproductive health and rights of HIV-positive women today.

Professor Sofia Gruskin, based at the Harvard School of Public Health, is director of the Program on International Health and Human Rights (PIHHR) and faculty chair of the Group on Reproductive Health and Rights (GRHR). Sarah MacCarthy is a doctoral candidate working with Professor Gruskin at PIHHR and coordinates GRHR.