By IAS Member Dr. Lynn Collins of the United Nations Population Fund (UNFPA)
Embedded in the challenging Sustainable Development Goal (SDG) platform for action are the hopes and needs of girls and women. Sexual and reproductive health and rights (SRHR) are at the forefront of realizing these aspirations. The Women Deliver 4th Global Conference and 21st International AIDS Conference (AIDS 2016) provide a prime opportunity to galvanize overdue support to guarantee the “health, rights, and general well-being of girls and women”, and achieve the ambitious related SDG targets. Although HIV is both an integral and distinct component of SRHR, the response to the AIDS epidemic has been somewhat de-linked from the SRHR response. Yet, globally, HIV is the leading cause of death for women of reproductive age and the second leading cause for adolescents aged 10-19 years. Despite the manifold connections between HIV and other elements of SRHR - especially family planning, maternal health, and rights – the need for joint action is still under-appreciated, inadequately resourced, and insufficiently exploited.
Family planning and HIV
Family planning and HIV intersect on many fronts. Female and male condoms simultaneously prevent HIV, other sexually transmitted infections (STIs), and unintended pregnancies, making them a life-saving low cost commodity. Yet in 2013 there were only an estimated 10 condoms available globally for every man aged 15-64, and one female condom available for every eight women in Sub-Saharan Africa. Even when available, carrying condoms can lead to arrest where sex work is criminalized. As a method dependent on consistent and correct use, health providers may tend to promote long-acting reversible contraceptives (LARCs) instead. In addition, condoms can be challenging for adolescent girls and women to obtain from judgmental health providers and to negotiate use of with partners. Moreover, contrary to the principles of reproductive rights and “positive prevention”, and the established benefits of treatment as prevention, women living with HIV may find their contraceptive options limited, as providers exclusively push condoms to prevent onward HIV transmission. As one women living with HIV stated, “When I chose the [hormonal contraceptive] injection they said you are trying to run away from using condoms so that you can infect others.” Or alternatively health providers may only promote LARCs since they are more effective at pregnancy prevention. Meanwhile, new evidence continues to be assessed to determine whether some forms of hormonal contraception may have implications for HIV by altering acquisition risk and for unintended pregnancies through potential drug-drug interactions with antiretroviral treatment.
Aside from the intrinsic economic, health, and educational benefits of family planning for women and adolescent girls, avoiding unintended pregnancies reduces the number of infants exposed to HIV. Family planning, however, should not be merely synonymous with contraception for preventing pregnancies, but also support safe conception including for women in HIV sero-discordant relationships for which various methods, including sperm-washing, artificial insemination, in-vitro fertilization, and peri-conception pre-exposure prophylaxis, are available to reduce risk of HIV acquisition and transmission.
Maternal health and HIV
Maternal health and HIV intersect on many fronts. AIDS-associated maternal mortality from indirect causes alone in high prevalence settings is significant ranging from 11 to 32% in five countries. The mother-baby pair is a symbiotic union, with maternal mortality contributing significantly to infant mortality, further exacerbated by HIV. HIV-related discrimination also takes its toll, with one woman living with HIV recalling that, “During contractions, the staff neglected me to take care of the [HIV] negative patients first.” HIV sero-conversion during pregnancy and breastfeeding is increasingly being chronicled and there is some albeit conflicting evidence that pregnant women may be at increased risk of acquiring and transmitting HIV due to a confluence of biological and socio-cultural causes. By preventing new HIV infections in pregnant women, the women themselves and their children are protected, especially since viral load spikes during acute infection facilitate HIV transmission. Syphilis screening and treatment are part of routine antenatal care, and connected to HIV since STIs increase HIV acquisition and transmission two-three fold. In addition, HIV and syphilis are both transmissible to infants. Consequently, efforts to validate dual elimination of mother to child transmission of HIV and syphilis are now underway, with Cuba being the first country to achieve this target.
Rights and HIV
Rights and HIV intersect on many fronts. Reproductive rights were enshrined in the UN Programme of Action adopted at the International Conference on Population and Development in 1994 and have direct implications for HIV. They encompass the right to decide freely and responsibly the number, spacing and timing of children and to have the information and means to do so; the right to the highest attainable standard of sexual and reproductive health; and the right to make decisions concerning reproduction free of discrimination, coercion and violence. In the context of HIV, the right to have children is being trampled upon when women living with HIV are subjected to forced abortion and sterilization, advised that they should not have children, and denied fertility treatment. In a recent survey only 50% of women living with HIV reported feeling that they had received support from service providers in realizing their fertility desires. One women living with HIV reported, “I did not consult [the health provider] because I was afraid that they would laugh at me [and] say, ‘Look at her, she wants to get pregnant and she is positive.’” Gender-based violence, in all its heinous forms, is an inherent human rights violation, interferes with the right to make sexual and reproductive health decisions, and is a cause and consequence of HIV. Violence can cause HIV infections directly and indirectly, and people living with HIV and sex workers have increased violence perpetrated against them.
Clearly the intersection of HIV with family planning, maternal health, and rights is irrefutable. Since the 2004 New York Call to Commitment: Linking HIV/AIDS and Sexual and Reproductive Health, national governments, civil society, and their partners have increasingly taken steps to address the legacy of HIV and SRHR vertical responses. At the policy level, national HIV and SRHR strategies are increasingly being integrated and joint advocacy undertaken to address a range of issues from promoting comprehensive sexuality education to addressing age of consent laws and policies. Health systems strengthening is underway including the creation of joint HIV and SRHR coordination mechanisms and changes in protocols to enable task-shifting/sharing. Delivery of integrated HIV and SRHR services - including reaching men and boys as recipients of health services - is increasing uptake of services and improving health outcomes.
The Women Deliver Conference and AIDS 2016 can further unite HIV and SRHR responses to reach the related SDG targets. The linked agenda is unequivocal, but the responsibility and will to make it happen rests with both the HIV and SRHR communities.