The Reproductive Healthcare Disparities Among HIV Positive Women in Rural Parts of Africa

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Overview

HIV or human immunodeficiency virus is a chronic condition that attacks the immune system, and is commonly transmitted via bodily fluids, sexual intercourse or shared injection equipment.[1] While an estimated "20- 50% of men and women living with HIV" plan on having children, becoming pregnant may posit risks for transmitting HIV to their "infants or HIV- uninfected partners" [2] While it is less common for pregnant HIV positive women to pass on the virus to their baby due to the positive rate of antiretroviral treatments, it is still possible, particularly, if they live in developing countries who lack STI diagnosis, reproductive technologies, or antiretroviral treatments (ART)- a triple drug antiviral therapy that is not a cure, but a treatment that suppresses the virus over time and helps the individual live longer.[3] Further, the profusion of impoverished women in rural Africa are disproportionately exposed to intersecting forms of stigma and bigotry from healthcare professionals who pre-emptively infringe upon their reproductive autonomy due to their callous and biased beliefs regarding HIV. The misconception that individuals who contract HIV lead sexually indiscriminate lifestyles is a prevailing stereotype that discourages the women from attending health facilities. Thus, the social stigmas compounded with having a chronic virus could lead to shame and isolation for women in Africa who often restricted by reproductive healthcare from contraception to abortion, and are exposed to unjust reproductive discrimination in the healthcare system.

Reproductive options

Contraception

Contraception is less common in lower socioeconomic countries (LSC) due to the low use of contraceptive products and procedures in rural areas, along with conflations in the individual's personal or religious beliefs. [4] While it is proven that condoms reduce HIV transmission significantly and prevent pregnancies by 98%, it is not widely common in Subsaharan Africa specifically among married women, and women who use hormonal contraception.[5][6] [4] Further, the World Health Organization(WHO) suggests that half a million expecting mothers die annually due to pregnancy complications.[4] 90 percent of these cases stem from subsaharan Africa and Asia where there is as a "unmet need for contraception provision" and an increase in HIV cases.[4] WHO's Medical Eligibility Criteria for Contraceptive Use explains that while most contraceptive methods are safe for HIV positive women, there is minimal data or studies that suggests that the majority of HIV positive women in Subsaharan Africa are using contraception to prevent unintended pregnancies.[7]

Abortion

95% of unsafe abortions occur in poorer countries, while "an estimated 4.2 million [occur] in Africa alone".[7] The stress is highly cumbersome as managing a chronic condition with minimal HIV treatments could potentially elicit unpredictable implications for the mother and her baby. In addition, many women are not informed of their HIV diagnosis until later in their pregnancy which could elevate anxiety and lead to negative implications for the infant. Although abortion is illegal in many impoverished countries, the illegality does not prevent women from seeking the procedure under harmful conditions. A study conducted in Cote d’Ivoire, West Africa found that a third of pregnant HIV-positive women terminated a pregnancy despite the legal restrictions.[7]

Prevention of Mother to child Transmission programs (PMTCT)

Disparities among Healthcare providers

Social Stigma

The women who live in lower socioeconomic areas of Africa are often unable to make autonomous decisions regarding their reproductive health partly due to the conflicting policies and hegemonic and cultural attitudes towards women's rights, specifically from healthcare providers.[4] For example, the counselling services that are offered in a number of South African clinics often provide discouraging advice for HIV positive couples who intend on bearing a child. They instead violate their reproductive autonomy and insensibly express a sense of control over their bodies by being passive agressive and lacking objective information to support the couple.[8] One women stated that she confided in her health care provider looking for answers, but instead she made her feel like she could never bear a child.[8]. Although South Africa has implemented the prevention of mother to child transmission program to help improve pregnancy services for HIV positive women, it is hindered by the biased beliefs of healthcare providers who lack proper training in handling situations of this sort. Further, the HIV positive participants from a study reported that the attitudes from their providers "ranged from frank discouragement" to passive aggression by judging their decision to bear a child.[8] The knowledge that healthcare providers have for treating HIV positive patients varies and is largely skewed when implicating their own biases and beliefs onto the patient. Their use of normative language defies that bioethical codes which prevents their patient from feeling safe and informed. Abolishing the social stigmas and providing objective healthcare advice would strengthen the reproductive decision making for HIV patients who are not constrained by coercion or cultural pressures from their healthcare providers.[8]

Poor Access to Healthcare Services

In 2018, roughly 82 percent of pregnant HIV positive women ,worldwide, had access to ART which reduced their "perinatal transmission to less than 2%".[3] In sub-Saharan Africa, however, HIV treatment is limited to people who do not have access to nearby health facilities and must travel far distances to receive treatment. The high cost of transportation and long distance travel often a deterrant.[9] Otherwise, many women omit themselves from receiving treatment due to the social stigmas in their healthcare system coupled with it's inaccessibility. In turn, the restrictions may lead to higher HIV positive cases among their newborns, and compromise the health of the mother. [10] In the rural areas of Zambia, antenatal care among pregnant women was significantly lower compared to their wealthier counterparts living in urban areas.[9] The economical and geographical barriers in rural areas limit the amount of HIV testing and healthcare care for expecting mothers, causing less PMCT services.[9]

Improving Communication
  1. "HIV Transmission". Centres for Disease Control and Prevention. August 6, 2019. Retrieved July 21, 2020.
  2. T. Matthews, Lynn; Beyeza-Kashesya, Jolly; Cooke, Ian; Davies, Natasha; Heffron, Renee; Kaida, Angela; Kinuthia, John; Mmeje, Okeoma; E. Semprini, Augusto (2017). "Consensus statement: Supporting Safer Conception and Pregnancy For Men And Women Living with and Affected by HIV". AIDS and Behavior. 17 (2): 461–470. doi:10.1007/s10461-011-0068-y.
  3. 3.0 3.1 Carlsson-Lalloo, Ewa; Mellgren, Asa; Berg, Marie (18 July 2020). "Ensuring the sexual and reproductive health and rights in healthcare of women living with HIV". Sexual & reproductive healthcare: 100541. doi:10.1016/j.srhc.2020.100541.
  4. 4.0 4.1 4.2 4.3 4.4 Mitchell, H S; Stephens, E (June 2004). "Contraception choice for HIV positive women". Sexually Transmitted Infections. British Medical Association. 80 (3): 167–173. doi:10.1136/sti.2003.008441.
  5. Morrison, Charles S.; Skoler-Karpoff, Stephanie; Kwok, Cynthia; Chen, Pai-Lien; van de Wijgert, Janneke; Gehret-Plagianos, Marlena; Patel, Smruti; Ahmed, Khatija; Ramjee, Gita (20 Feb 2012). "Hormonal contraception and the risk of HIV acquisition among women in South Africa". AIDS (London). 26: 497–504. doi:10.1097/qad.0b013e32834fa13d.
  6. Heikinheimo, Oskari; Lahteenmaki, Pekka (1 November 2008). "Contraception and HIV infection in women". Human Reproduction Update. 15: 165–176. doi:10.1093/humupd/dmn049.
  7. 7.0 7.1 7.2 Delvaux, Thérèse; Nöstlinger, Christiana (23 May 2007). "Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility". Reproductive Health Matters. 15: 46–66. doi:10.1016/S0968-8080(07)29031-7.
  8. 8.0 8.1 8.2 8.3 London, Leslie; J. Orner, Phyllis; Myer, Landon (2008). "'EVEN IF YOU'RE POSITIVE, YOU STILL HAVE RIGHTS BECAUSE YOU ARE A PERSON': HUMAN RIGHTS AND THE REPRODUCTIVE CHOICE OF HIV-POSITIVE PERSONS". Developing World Bioethics. 8 (1): 11–22. doi:10.1111/j.1471-8847.2007.00223.x.
  9. 9.0 9.1 9.2 Akullian, Adam N; Mukose, Aggrey; Levine, Gillian A; Babigumira, Joseph B (10 Feb 2016). "People living with HIV travel farther to access healthcare: a population-based geographic analysis from rural Uganda". Journal of the International AIDS Society. 19: 1–8. doi:10.7448/IAS.19.1.20171.
  10. Kaida A, Laher F,Strathdee SA; Money D; Janssen PA; et al. (5 November 2010). "Contraceptive Use and Method Preference among Women in Soweto, South Africa: The Influence of Expanding Access to HIV Care and Treatment Services". PLoS ONE. 5: 1–11. doi:10.1371/journal.pone.0013868. line feed character in |title= at position 46 (help); Explicit use of et al. in: |last= (help)CS1 maint: multiple names: authors list (link)