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Pregnancy in an HIV-positive woman often carries serious consequences.
Without treatment, about a third of HIV-infected mothers pass the virus to
their newborns. Many of these children eventually sicken and die of AIDS.
Worldwide, some 3.8 million children younger than 15 years old have
already died in this way.1
Some HIV-positive women choose to conceive, despite the chances of a
poor pregnancy outcome. Other sexually active, HIV-positive women want
contraception. Providers need to understand how to counsel and serve
HIV-positive women, and providers should know that some HIV-positive women
will not reveal to them that they are infected.
In settings where HIV prevalence is high, family planning providers
should discuss with clients how HIV could affect family health. Ideally,
contraceptive counseling should include a description of HIV risk factors
and an evaluation of the client's risk of infection. Some programs may
also be able to offer HIV testing to women at high risk for HIV infection.2
Desire for children
Most HIV-infected women do not know their HIV status before they
conceive. Some may only find it out when they receive antenatal services,
if testing is available. Still, other HIV-infected women know their HIV
status before they conceive. Sixteen of 52 HIV-positive women interviewed
in Zimbabwe, for example, became pregnant after their diagnosis, with
seven of the 16 pregnancies desired.3
All seven women with desired pregnancies very much wanted to have a
child and their pregnancy histories reveal that some were prepared to risk
their health to have a child who would survive. Unfortunately, only one
had a healthy baby. Such grim pregnancy outcomes for HIV-positive women
are not uncommon in Zimbabwe.
"In Zimbabwe, as in most places, the desire of women to have
children is rooted in a context of a need for both love and financial
security, especially where women are economically vulnerable,"
explains Dr. Rayah Feldman. "Marriage, especially if lobola or
bride-price has been paid by a man's family to a woman's family, is based
on an expectation of having children. Also, many women find personal
satisfaction in having children." Dr. Feldman was an advisor for the
Zimbabwean research developed by the London-based International Community
of Women Living with HIV/AIDS in collaboration with the Zimbabwean Women
and AIDS Support Network.
Antiretroviral treatment during pregnancy to prevent mother-to-child
transmission is unavailable to all but a few women in Zimbabwe and most
other developing countries. Also, almost all women breastfeed their
babies, providing another route of infection.
In Kenya, "HIV-infected women who do not have any children tend to
want to have at least one baby and we now have access in a few hospitals
to affordable drug regimens to reduce mother-to-child HIV
transmission," says Dr. Zahida Qureshi, an obstetrician and lecturer
at the University of Nairobi. "But even when these drugs are not
available, HIV-infected women want to have babies, regardless of the risks
involved."
A 27-year-old Kenyan housewife explained in an interview why she wished
to conceive, despite the fact that both she and her husband are
HIV-positive. "My husband doesn't want any children. ... But I want a
child. I cannot live without kids. I am always alone and I am not barren.
If I have a child, I will take care of my child and I will be active. I
can work because I know I have somebody to take care of. I will have a
responsibility."
In Yaoundé, Cameroon, a third of 40 HIV-positive men and women
responding to a questionnaire said that they had unprotected sex primarily
because they wished to have a child or their partner objected to the use
of a barrier method. (About half continued to be sexually active without
revealing their HIV status to their sexual partners.4) And, a
study among some 10,000 men and women in Rakai district, Uganda, who
received HIV testing and counseling showed that, despite these services,
HIV-positive women were no more likely than HIV-negative women to use
female-controlled family planning methods. Condom use was moderately (but
not significantly) higher among HIV-positive than HIV-negative men. A
strong desire for children may have reduced HIV-infected respondents'
acceptance of family planning methods, the study's authors concluded.5
That many HIV-infected women actively seek and continue pregnancies
despite potential risks for their infants has been demonstrated in several
U.S. studies, as well.6 In interviews with 82 HIV-positive U.S.
women, awareness of HIV infection or knowledge that risk of
mother-to-child HIV transmission can be decreased by prenatal zidovudine
treatment did not significantly influence pregnancy planning,
contraceptive choice or use, or consideration of induced abortion. Only 15
percent of respondents used condoms consistently. Only half used any form
of contraception. About two-thirds of pregnancies were unplanned, but only
6 percent were terminated. Most women (70 percent) reported that their
desire for a child was the most important reason for carrying the
pregnancy to term.7
Reasons why many HIV-infected women do not contracept are abundant. Not
only is motherhood a primary source of self-esteem for many women, but an
HIV-infected woman may want to replace a child lost to AIDS.8
Pregnancy may provide hope for the future: A dying woman can console
herself if she has healthy children to survive her.
The prospect of caring for a child may give an HIV-positive woman
reason to go on living. Motherhood means "I do not have to dwell on
my misfortune," said one of 11 HIV-positive women in a U.S. study in
which participants learned both of their pregnancy and HIV infection
before 24 weeks gestation. Three women terminated their pregnancies, but
eight -- including this woman -- carried their pregnancies to term.
"Keeping them [my children] healthy and happy keeps me alive,"
she said.9
Still other HIV-positive women may not be able to accept the
seriousness of their diagnosis and, denying it, become pregnant. Other
HIV-positive women may become pregnant to conceal their HIV status from
relatives, especially in-laws.
Finally, some HIV-infected women using contraception believe the
incorrect idea that HIV-related symptoms are a result of contraceptive
use. In Family Planning Association of Kenya clinics, "HIV cases are
guided through counseling to choose a contraceptive method that provides
dual protection against both pregnancy and HIV transmission," says
Sarah Kirowo, assistant program officer. "However, it is difficult to
convince women who are HIV-infected that their ailments or symptoms have
nothing to do with family planning methods. As a result, they tend not to
use contraception."
Preventing pregnancy
Women who are HIV-positive may want to end childbearing for various
reasons. Some are worried that pregnancy will further compromise their
health. They are concerned about transmitting their infection to children
they might conceive. They realize that, particularly without treatment,
HIV infection will shorten their own lives, and they fear leaving orphans.
A 25-year-old, HIV-positive Kenyan housewife who suspects that her
husband also is infected explained in an interview why she is
contracepting with the injectable depot-medroxyprogesterone acetate
(DMPA): "I feel the two children I have are enough. If I continue to
give birth, I will have no energy to take care of those many children. If
I get more children, maybe I will die and leave them suffering. Also, if
my husband goes first and I be rendered a widow, I will have no way of
taking care of them."
Some HIV-positive women, however, continue bearing children because
they do not know how to stop. In the Zimbabwean study of 52 HIV-positive
women -- 16 of whom became pregnant after diagnosis -- seven of nine women
who reported unplanned pregnancies were married with children. Researchers
concluded that "long-term married women, particularly in rural areas,
often have no history of contraceptive use before they are affected by
HIV. They may be ready to terminate childbearing, but often cannot put
that decision into practice because they lack control over contraception
and access to abortion."
To control contraception, women must be able to negotiate contraceptive
use with their partners and have access to family planning services.
However, some providers may limit or deny HIV-positive women's access to
such services. For example, some 1,500 U.S. primary care physicians were
found in a survey to be generally less willing to provide gynecologic,
contraceptive or pregnancy-related care to HIV-infected women than to
uninfected women.10
Even when family planning services are available, they may not address
the needs of HIV-positive women. One reason is that HIV-positive women
seldom reveal their HIV status to family planning providers, particularly
if those providers do not ask. None of six HIV-positive women recently
interviewed in Kenya had revealed their HIV status to family planning
providers. One 32-year-old woman who tested positive for HIV in 1990
shared the test result with her husband. Although the couple already had
two children, her husband wanted more due to pressure from family members.
"He started insisting that I had to have a baby ... that there are
some HIV people who are having healthy babies and that it was OK to take a
risk," she said.
But finding the risks unacceptable and not knowing how to get drugs to
reduce the risk of mother-to-child HIV transmission, the woman secretly
began using DMPA, never telling providers that she was HIV-positive.
"I did not tell them because medical practitioners are very difficult
people," she explained. "They are the ones who really stigmatize
people who are HIV-positive." Another mother of two interviewed by
FHI described why she did not tell a family planning service provider that
she was HIV-positive. "I never told her because I can never trust
her," says the 21-year-old woman, who tested HIV-positive at age 14.
"You know, these days, doctors -- if you tell them something like
that -- will fear you, not give you services or might tell someone else
you see."
Providers who are aware of a woman's HIV-positive status still may not
offer adequate counseling about reproductive options. Most of 69
HIV-positive women in a U.S. study said they had access to methods to
prevent conception and sexually transmitted infections (STIs), including
HIV. But fewer than half felt that the family planning counseling they
received was adequate.11 Most of 150 HIV-positive women seen at
an HIV/AIDS clinic in São Paulo, Brazil, rated clinic services very
highly. Yet, they lacked correct information about contraception,
reproduction, and the reduced possibility of mother-to-child HIV
transmission with use of antiretroviral drugs.12 Various
African studies show that counseling HIV-positive women does not
substantially increase contraceptive use, often because HIV-infected women
-- fearing abandonment -- hide their status from their partners.13
Contraceptive options
HIV-infected women need to know that, aside from abstinence, condoms
offer the best protection against STIs. Male or female condoms should be
used every time intercourse occurs. This is to avoid HIV transmission to
partners and to protect the woman herself from other STIs, including other
strains of HIV.
An HIV-infected woman should be taught correct condom use and skills
for negotiating condom use with her partner. Some women are determined to
prevail in such negotiations, even when difficult. As a 46-year-old
widowed mother of four in Kenya explains, "My husband passed away in
1990. ... There was a time in 1994 when I got another man, and he refused
to use a condom. So the relationship could not go on." A 32-year-old
Kenyan woman says that when a man refuses to use a condom "we go
without sex."
If she does not wish to become pregnant, an HIV-positive woman should
consider dual method protection -- using a condom for disease prevention
and another, more effective method for contraception. Because some women
erroneously believe that a method effective in preventing pregnancy also
will be effective in preventing disease transmission, HIV-infected women
must understand which methods are appropriate for pregnancy versus disease
prevention.14
In typical use, diaphragms and cervical caps are associated with
relatively high rates of pregnancy. Twenty percent of diaphragm users
experience an unintended pregnancy within the first year of typical use.
Twenty percent and 40 percent of nulliparous and parous cervical cap
users, respectively, experience an unintended pregnancy during this time.15
But there are no medical restrictions on HIV-infected women's use of these
methods.
For HIV-infected women who have decided against childbearing, female
sterilization is a good option. The procedure should be delayed, however,
if a woman has an AIDS-related illness. All hormonal contraceptive methods
are good options for HIV-positive women (using the same clinical criteria
as with HIV-negative women), even women who have developed AIDS.16Hormonal
contraceptives tend to be more effective for preventing pregnancy than
barrier methods. However, there is concern that sexual partners of
HIV-positive women using more effective contraception may not use condoms
as consistently as partners of women using less effective contraception.17
Also, there is some evidence that anti-retroviral drugs can reduce the
effectiveness of oral contraceptives, thus requiring an adjustment in
dosage or change to another contraceptive.18
Due to concerns about pelvic infection and increased blood loss, use of
intrauterine devices (IUDs) by HIV-infected women is usually undesirable,
according to World Health Organization (WHO) guidelines. However, recent
research by the University of Nairobi and FHI suggests that the IUD can be
safely used by appropriately selected, HIV-infected women with regular
access to medical services.19 HIV-infected women can generally
use the levonorgestrel intrauterine system, according to WHO.
The Lactational Amenorrhea Method, also known as LAM, is a temporary
contraceptive option used for up to six months postpartum by women who are
fully or nearly fully breastfeeding and continue to have no menses.
However, HIV-positive women need to know that any children they bear may
become infected with the virus during breastfeeding. The average risk of
acquiring HIV infection through breastmilk is at least 16 percent.20
According to WHO, an HIV-positive mother can eliminate the risk of HIV
transmission through breastmilk by using infant formula, modified animal
milks or boiled expressed breastmilk. However, she must have access to a
sufficient, ongoing and clean supply of this alternative form of milk. If
there is no safe alternative form of milk, an HIV-positive mother should
give her infant only breastmilk. Limiting breastfeeding to the first six
months may also reduce the risk of HIV transmission.21
-- Maureen Kuyoh and Kim Best
Maureen Kuyoh, a senior project coordinator in FHI's Nairobi office,
conducted interviews with HIV-positive women for this article.
References
- Report on the Global HIV/AIDS Epidemic.
Geneva: Joint United Nations Programme on HIV/AIDS, 2000.
- Rutenberg N, Biddlecom A, Kaona F. Reproductive
decision-making in the context of HIV and AIDS: a qualitative study in
Ndola, Zambia. Int Fam Plann Perspect 2000;26(3):124-30.
- Feldman R, Maposhere C. Voices and choices: a
participatory research and advocacy study of reproductive health and
rights of HIV positive women in Zimbabwe. The XIII International
AIDS Conference, Durban, South Africa, July 9-14, 2000.
- Atangana MJ. Sexual behavior of people living with
HIV/AIDS in Yaoundé, Cameroon. The XIII International AIDS
Conference, Durban, South Africa, July 9-14, 2000.
- Lutalo T, Kidugavu M, Wawer M, et al. Contraceptive
use and HIV testing and counseling in rural Rakai district, SW Uganda.
The XIII International AIDS Conference, Durban, South Africa,
July 9-14, 2000.
- Barbacci M, Chaisson R, Anderson J, et al. Knowledge
of HIV serostatus and pregnancy decisions, abstract no. MBP 10. Int
Conf AIDS 1989;5:223; Wiznia A, Bueti C, Douglas C, et al. Factors
influencing maternal decision-making regarding pregnancy outcome in
HIV-infected women, abstract no. MBP 7. Int Conf AIDS 1989;5:223;
Sunderland A, Minkoff HL, Handte J, et al. The impact of human
immunodeficiency virus serostatus on reproductive decisions of women. Obstet
Gynecol 1992;79(6):1027-31; Kline A, Strickler J, Kempf J. Factors
associated with pregnancy and pregnancy resolution in HIV seropositive
women. Soc Sci Med 1995;40(11):1539-47; Ahluwalia IB, DeVellis
RF, Thomas JC. Reproductive decisions of women at risk for acquiring
HIV infection. AIDS Educ Prev 1998;10(1):90-97.
- Smits AK, Goergen CA, Delaney JA, et al.
Contraceptive use and pregnancy decision-making among women with HIV. AIDS
Patient Care STDS 1999;13(12):739-46.
- Williams H, Watkins C, Risby J. Reproductive
decision-making and determinants of contraceptive use in HIV-infected
women. Clin Obst Gynecol 1996;39(2):333-43.
- Hutchison M, Kurth A. "I need to know that I
have a choice ..." a study of women, HIV, and reproductive
decision-making. AIDS Patient Care 1991;5(1):17-25.
- HIV prevention practices of primary-care physicians
-- United States, 1992. MMWR 1994;42(51):988-92.
- Duggan J, Walerius H, Purohit A, et al. Reproductive
issues in HIV-seropositive women: a survey regarding counseling,
contraception, safer sex, and pregnancy choices. J Assoc Nurses
AIDS Care 1999;10(5):84-92.
- Santos N, Ventura-Filipe E, Paiva V. HIV positive
women, reproduction and sexuality in São Paulo, Brazil. Reprod
Health Matters 1998;6(12):31-40.
- Ryder RW, Batter VL, Nsuami M, et al. Fertility
rates in 238 HIV-1 positive women in Zaire followed for 3 years
post-partum. AIDS 1991;5(12):1521-27; Allen S, Semfilira A,
Gruber V, et al. Pregnancy and contraceptive use among urban Rwandan
women after testing and counselling. Am J Public Health 1993;83(5):705-10;
Temmerman M, Chomba EN, Piot P. HIV-1 and reproductive health in
Africa. Int J Gynecol Obstet 1994;44(2):107-12.
- Galavotti C, Schnell J. Relationship between
contraceptive method choice and beliefs about HIV and pregnancy
prevention. Sex Transm Dis 1994;21(1):5-7.
- Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive
Technology, Seventeenth Revised Edition. (New York: Ardent Media,
Inc., 1998)800.
- World Health Organization. Improving Access to
Quality Care in Family Planning. Medical Eligibility Criteria for
Contraceptive Use. Geneva: World Health Organization, 1996.
- Díaz T, Schable B, Chu S, et al. Relationship
between use of condoms and other forms of contraception among human
immunodeficiency virus-infected women. Obstet Gynecol 1995;86(2):277-82.
- Leitz G, Mildvan D, McDonough M, et al. Nevirapine
(VIRAMUNE, NCP) and ethinyl estradiol/norethindrone (ORTHO-NOVUM 1/35
[21 pack] EE/NET) interaction study in HIV-1 infected women. The
7th Conference on Retroviruses and Opportunistic Infections. San
Francisco, January 30-February 2, 2000; Piscitelli S, Flexner C, Minor
J, et al. Drug interactions in patients infected with human
immunodeficiency virus. Clin Infect Dis 1996;23(4):685-93.
- Morrison C, Sekadde-Kigondu C, Sinei S, et al. Is
the IUD appropriate contraception for HIV-infected women? Presentation
at Thirteenth Meeting of the International Society for Sexually
Transmitted Diseases Research, Denver, CO, July 11-14, 1999.
- Nduati R, John G, Mbori-Ngacha D, et al. Effect of
breastfeeding and formula feeding on transmission of HIV-1: a
randomized clinical trial. JAMA 2000;283(9):1167-74.
- De Cock KM, Fowler MG, Mercier E, et al. Prevention
of mother-to-child HIV transmission in resource-poor countries:
translating research into policy and practice. JAMA 2000;283(9):1175-82.
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Counseling HIV-positive Women
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Anyone counseling women known or suspected to be HIV-positive
should support the client's family planning decisions, even if the
counselor disagrees with the client.1
For example, a counselor may believe that permanent
contraception is the best option for an infected woman. Such
personal beliefs should not influence counseling. A family
planning provider should adopt a neutral attitude and give the
following information to each HIV-infected client:
- Her life expectancy.
- Pregnancy does not appear to accelerate HIV progression,
even among women not receiving antiretroviral therapy.2
- An HIV-infected mother can transmit the virus to her child.
Rates of mother-to-child HIV transmission in some developing
countries exceed 40 percent.3
- Although it may be too expensive in developing-world
settings, preventive treatment can reduce HIV transmission
risks during childbirth.
- The implications of rearing an infected child, including the
course of the child's infection and likelihood of premature
death.
- The kind of family or social support the HIV-positive woman
can expect to receive. Given that without treatment the mother
is likely to develop AIDS and die, will family members be
available to raise motherless children?
-- Kim Best
References
- Chervenak FA, McCullough LB. Common ethical
dilemmas encountered in the management of HIV-infected women
and newborns. Clin Obstet Gynecol 1996;39(2):411-9.
- McIntyre J. HIV in Pregnancy: A Review (Geneva:
World Health Organization/UNAIDS, 1999)7; Bessinger R, Clark
R, Kissinger P, et al. Pregnancy is not associated with the
progression of HIV disease in women attending an HIV
outpatient program. Am J Epidemiol 1998;147(5):434-40;
Immunological markers in HIV-infected pregnant women. The
European Collaborative Study and the Swiss HIV Pregnancy
Cohort. AIDS 1997;11(15):1859-65; Vimercati A, Greco P,
Lopalco PL, et al. Immunological markers in HIV-infected
pregnant and non-pregnant women. Eur J Obstet Gynecol
Reprod Biol 2000;90(1):37-41.
- The Working Group on Mother-to-Infant
Transmission of HIV. Rates of mother-to-infant transmission of
HIV-1 in Africa, America, and Europe: results from 13
perinatal studies. J Acquir Immune Defic Syndr Hum
Retrovirol 1995;8(5):506-10
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HIV-infected Women Less Fertile
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Fertility rates for HIV-infected women are lower than for
uninfected women. There are several possible explanations.
In developed countries, where women tend to know their HIV
status, many infected women may be abstaining from sexual
relations, using contraception or having abortions to avoid giving
birth to children who might sicken, die or be orphaned.1
But in sub-Saharan Africa -- where most women do not know their
HIV status and seldom use contraception or have induced abortions
-- fertility rates among infected women still remain lower than
among healthy women.2
Some experts have suggested a direct, biological effect of HIV
infection on conception and pregnancy. However, reduced fertility
before HIV infection may account for much of the lowered fertility
observed after infection.3 In a study in Uganda of 80
HIV-infected and 96 uninfected women, low pregnancy rates before
HIV infection accounted for almost half of the reduced fertility
observed after infection.4
-- Kim Best
References
- Stephenson JM, Griffioen A, the Study Group
for the Medical Research Council Collaborative Study of Women
with HIV. The effect of HIV diagnosis on reproductive
experience. AIDS 1996;10(14):1683-87; De Vincenzi I,
Jadand C, Couturier E, et al. Pregnancy and contraception in a
French cohort of HIV-infected women. AIDS 1997;11(3):333-38.
- Gray R, Wawer M, Serwadda D, et al.
Population-based study of fertility in women with HIV-1
infection in Uganda. Lancet 1998;351(9096):98-103;
Ryder RW, Batter VL, Nsuami M, et al. Fertility rates in 238
HIV-1-seropositive women in Zaire followed for 3 years
post-partum. AIDS 1991;5(12):1521-27; Sewankambo NK,
Wawer MJ, Grey RH, et al. Demographic impact of HIV infection
in rural Rakai District, Uganda: results of a population-based
cohort study. AIDS 1994;8(12):1707-13.
- Lee LM, Wortley PM, Gray RH, et al. Reduced
fertility and duration of HIV-1 infection in American women,
abstract no. 24198. Int Conf AIDS 1998;12:479-80.
- Ross A, Morgan D, Lubega R, et al. Reduced
fertility associated with HIV: the contribution of
pre-existing subfertility. AIDS 1999;13(15):2133-41.
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