The Reproductive Healthcare Disparities Among HIV Positive Women in sub-Saharan Africa

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Allison Cadigal

Overview

Living in Subsaharan Africa posits serious concerns for pregnant women living with HIV due to the negative social stigmas and reproductive injustices in healthcare services.[1] While an estimated "20- 50% of men and women living with HIV" plan to have children, becoming pregnant increases the risk of mother-to-child transmission of HIV.[2] That issue is less common for people who have access to antiretroviral treatments(ART), since in 2018, ART was readily available to approximately 82 percent of pregnant HIV positive women, worldwide, which reduced their "perinatal transmission to less than 2%".[3][4] In sub-Saharan Africa, however, HIV medication is highly limited in rural areas due to the lack of healthcare facilities.[5] Without proper treatment, an estimated 25% of HIV positive women will "transmit the virus to their newborns during pregnancy, childbirth, or breastfeeding," exposing the mother and her infant to long term negative health implications.[6] In addition, expecting mothers who have HIV are belittled by healthcare providers who feed into the negative social stigmas surrounding HIV, causing them to avoid healthcare providers in fear of being discriminated against. The misconception that individuals who contract HIV lead sexually indiscriminate lifestyles is a prevailing stereotype that discourages women from attending health facilities. Thus, the social stigmas compounded with having a chronic virus could lead to shame and isolation for pregnant women in sub-Saharan Africa who are often restricted by the healthcare system.Their inability to attend health facilities combined with unjust reproductive disparities in the healthcare system generates further issues, likely compromising their health and pregnancy.

Reproductive options

Contraception

The World Health Organization(WHO) suggests that half a million expecting mothers die annually due to pregnancy complications.[7] Ninety percent of these cases stem from sub-Saharan Africa and Asia, where there is an "unmet need for contraception provision" and an increase in HIV cases.[7] Contraception is less common in lower socioeconomic countries due to the low use of contraceptive products and procedures in rural areas, along with conflations in the individual's personal or religious beliefs. [7] While it is proven that condoms reduce HIV transmission significantly and prevent pregnancies by 98%, it is not common in Subsaharan Africa, particularly, among married women or women who use hormonal contraception; in addition, access to contraceptive products are often limited in poorer areas, often causing unintended pregnancies.[8][9] [7] WHO's Medical Eligibility Criteria for Contraceptive Use explains that while most contraceptive methods are safe for HIV positive women in sub-Saharan Africa, there is minimal data or studies that found if they are actually using contraception to prevent unintended pregnancies.[10]

Abortion

95% of unsafe abortions occur in poorer countries, while "an estimated 4.2 million [occur] in Africa alone".[10] 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.[10] The stress is highly cumbersome as managing a chronic condition with minimal treatments may potentially elicit unpredictable implications for the mother and her baby. 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, it does not prevent women from seeking the procedure under harmful conditions.

Prevention of Mother to Child Transmission programs (PMTCT)

PMTCT is a program that offers a number of services to HIV positive women in Africa to help them cope with their condition and prevent their "infants from acquiring HIV".[11] It begins with antenatal care where the woman is tested for HIV; if positive, she is provided antiretroviral treatments to prevent further transmission during pregnancy or post pregnancy.[6] Although PMTCT programs can reduce the risk of HIV transmission to less than 1 percent, most of the sites are in South Africa, making it harder to access for people living in other parts of sub-Saharan Africa, especially in rural areas .[6] Utilization is also suboptimal for expecting mothers who are either uninformed of their diagnosis or unable to access these services.[6] In most urban cities of Africa, free HIV medications are steadily available, however roughly 50% of HIV positive pregnant women in sub- Saharan Africa do not have access to them nor are they adhering to safety guidelines in preventing transmission.[6] Thus, improving PMTCT utilization, education, and accessibility is paramount to reducing HIV cases in rural cities.

Healthcare Disparities

Social Stigmas from Healthcare Providers

HIV epidemics in Africa tend to be generalized to the entire population, and not critically focused on small or at risk groups.[1][2] In Subsaharan Africa, HIV positive women are more vulnerable social stigmas than their male counterparts. Thus, the profusion of women are exposed to intersecting forms of stigma and bigotry from healthcare professionals who pre-emptively infringe upon their reproductive rights due to their callous and biased beliefs of HIV.

The women who live in lower socioeconomic and rural areas are often unable to make autonomous decisions regarding their reproductive health partly due to conflicting policies or hegemonic and cultural attitudes towards women's rights stemming from healthcare providers.[7] For example, the counselling services (PMTCT) offered in a number of South African clinics often provide discouraging advice for HIV positive couples who plan on bearing a child. They violate their reproductive autonomy and insensibly express a sense of control over their bodies, by displaying passive aggression, suggesting sterilization, and lacking objective information to support the couple's endeavours.[12] One woman stated that she confided in her health care provider in search of answers, but instead, she made her feel ashamed as if she could never bear a child.[12] Although South Africa has implemented PMTCT to help improve pregnancy services exclusively for HIV positive women, it is hindered by the biased beliefs of healthcare providers who lack proper training in handling situations of this sort.[13] HIV Participants from a study reported that their health provider's attitudes "ranged from frank discouragement" to micro-aggressions, and judged their decision to bear a child.[12][13]The knowledge that healthcare professionals have for treating HIV positive patients varies and is largely skewed when they implicate their own biases and beliefs onto the patient. Their use of normative and prejudicial language defies the bioethical codes in a medical setting, which prevents their patient from feeling safe or reassured.[12] Abolishing the social stigmas and providing objective healthcare advice would strengthen reproductive decision making for HIV patients so that they are not constrained by coercion or cultural pressures from their providers.[12]

Inequitable Access to Healthcare Services

The high cost of transportation and long-distance travel is often a deterrent for expecting mothers living in rural cities of sub- Saharan Africa.[5] Many of them omit themselves from receiving treatment due to the geographical barriers and social stigmas from healthcare professionals. In turn, the restrictions may lead to higher HIV positive cases among newborns, and compromises the health of the mother. [14] In rural areas of Zambia, antenatal care among pregnant women was significantly lower compared to their wealthier counterparts living in urban areas.[5] Prior to 2013, 21.2 million individuals in Africa were eligible for Antiretroviral treatments, however in 2013, the World Health organization reported that only 7.6 million received it.[5] Even if medical interventions are available, however, the economical, social, and geographical barriers in rural areas restrict HIV testing and healthcare care for expecting mothers, causing less PMCT services and higher fatalities.[5]

References

  1. ↑ 1.0 1.1 "HIV Transmission". Centres for Disease Control and Prevention. August 6, 2019. Retrieved July 21, 2020.
  2. ↑ 2.0 2.1 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. ↑ "Antiretroviral therapy".
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 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.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Hampanda, Karen (24 September 2012). "Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT". Hindawi Publishing Corporation. 2013: 1–5. doi:10.5402/2013/420361.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 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.
  8. ↑ 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.
  9. ↑ Heikinheimo, Oskari; Lahteenmaki, Pekka (1 November 2008). "Contraception and HIV infection in women". Human Reproduction Update. 15: 165–176. doi:10.1093/humupd/dmn049.
  10. ↑ 10.0 10.1 10.2 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.
  11. ↑ "PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV". Retrieved 29 July 2020.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 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.
  13. ↑ 13.0 13.1 "Prevention of mother-to-child transmission (PMTCT)".
  14. ↑ Kaida, Angela; Later, Fatima; Strathdee, Steffanie A.; Money, Deborah; Janssen, Patricia A.; Hogg, Robert S.; Gray, Glenda (5 November 2010). Myer, Landon (ed.). "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)
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