Interventions to link HIV-related and reproductive health services must not only include access to modern contraceptive methods and non-discriminatory antenatal, delivery and postnatal care, but also access to safe legal abortion, says Maria de Bruyn
Social justice and human rights require that women and girls who are living with, and affected by, HIV be able to take informed decisions regarding their reproductive health. In this context laws and policies that criminalize or penalize sexual and reproductive health actions, or that prevent access to information and services, form a major obstacle to these women and girls being able to enjoy their full reproductive rights.
All women need to have autonomy in decision-making, comprehensive sexuality education, information about family planning and options for safe motherhood, good nutrition, and access to modern methods of contraception of their choice so that they can plan their pregnancies - and those living with HIV are no exception. Yet the right of HIV-positive women to bear children is still contested by some people, including health-care providers. All women further need access to comprehensive antenatal, delivery and post-partum care that includes antiretroviral therapy (ART) if they are HIV-positive and good information on and options for breastfeeding and bottle-feeding in relation to preventing HIV transmission to their baby after birth. This is their human right, though many women find this hard to exercise.
A failure to prevent violence against women and girls can lead to more HIV infections and more deaths among women and girls. Women living with HIV are also vulnerable to domestic and sexual violence, which can increase the risk of (re)infection with HIV and sexually transmitted infections; fears of increased abuse may prevent them from seeking support and treatment. Enabling all women who have experienced violence to deal with this situation includes: ensuring they have information on services for survivors of violence (e.g., shelters, support groups); facilitating access to emergency contraception, post-exposure prophylaxis of HIV and legal abortion; screening and treatment for sexually-transmitted infections; and legal assistance. Information on, and access to, precautionary measures also fall within this area: some women take self-defence courses in anticipation of need and restraining orders may sometimes be useful in places where these can be enforced. For women and girls living with HIV especially, awareness of the risks associated with human papilloma virus (HPV), which can lead to cervical cancer, means that they may wish to take HPV vaccines and have regular Pap smears.
There are also reproductive health issues of which women living with HIV are aware but which they do not include in their life planning. Termination of an unwanted pregnancy is one of these. Like any other woman or girl, she may wish to have an abortion when a pregnancy results from non-use or failure of a contraceptive method, occurs as a result of rape or incest, or if she does not want to bring a(nother) child into an abusive relationship, does not have the socio-economic resources to care for the child, or wishes to focus on preserving her health without undergoing a pregnancy. In addition, a woman with HIV may lack access to ART , both to keep herself healthy and to prevent HIV transmission during pregnancy. Women living with or affected by HIV are also concerned about unwanted pregnancies because they sometimes need to care for daughters and other women confronting morbidity and life-threatening consequences of unsafe abortions, such as excessive bleeding and massive infection. Access to safe legal abortion is therefore a service they need in such situations.
Despite our knowledge of the information and services needed to help women manage both the events for which they plan and those they do not, laws and policies of countries around the world are criminalizing or prohibiting reproductive health-related information and services. The UN Special Rapporteur on the right to health, Anand Grover, issued a report in 2011 calling for the amendment of such laws, removing obstacles to the provision of comprehensive sexuality education, abolishing penalties on women’s conduct during pregnancy, and the decriminalization of abortion.
In the field of HIV and AIDS, much attention has been given to the need to repeal laws that specifically criminalize HIV transmission and which affect women with regard to their sexual relationships and possible vertical transmission of HIV. UNAIDS states it is necessary to address laws and policies that form legal barriers to sexual and reproductive health information and services because HIV prevention, treatment, care and support require supportive regulatory environments that advance human rights and gender equality.
Accordingly, the Global Commission on HIV and the Law issued guidance in July 2012 regarding laws that penalize sex work, drug use, same-sex sexual relations, HIV transmission and violence against women. However, while a recommendation was made to stop coerced and forced sterilization and abortion among women living with HIV, it failed to call for revision of restrictive abortion laws so that HIV-positive women and girls (as well as all other women and girls) have access to comprehensive reproductive health care that can prevent unsafe abortions.
Why is it important for UNAIDS and others working on HIV and AIDS to address abortion care, including amendment of restrictive laws? Women living with and affected by HIV will not enjoy their full reproductive rights unless they can manage unwanted pregnancies with emergency contraception and safe legal abortion.
The right of all women right to terminate unwanted pregnancies has been affirmed by international human rights bodies, both in terms of violations of women’s rights and as a measure to reduce preventable maternal morbidity and mortality. The Protocol on the Rights of Women in Africa explicitly mentions access to safe abortion and the World Health Organization has issued technical guidance for health systems on the provision of safe abortion care.
Nevertheless, access to safe legal abortion is only sometimes mentioned in the HIV and AIDS field as an essential component of a human rights-based approach to providing reproductive health care for HIV-positive women. Perhaps this is because the main focus has been on guaranteeing women’s rights in relation to reproductive matters for which they plan. But enabling women and girls living with HIV to avoid the complications of unsafe abortions is a vital component of ensuring they have access to comprehensive reproductive health care.
Interventions to link HIV-related and reproductive health services must not only include access to modern contraceptive methods and non-discriminatory antenatal, delivery and postnatal care, but also access to safe legal abortion. Advocates and agencies in the HIV and AIDS field should consistently include access to contraception, emergency contraception and safe abortion care in their work to ensure full reproductive rights. Work on laws that impede access of people living with and affected by HIV to comprehensive health care should include advocacy to amend restrictive abortion laws and remove penalties for women who have had abortions. This will ultimately benefit not only women and girls living with HIV but other women and girls as well.