Decisions about whether a woman and her partner want to have children, how many they might want to have, and when they might want to have them, are not always clear-cut or predictable. Reproductive goals are often linked to a multitude of complicated and deeply personal hopes and beliefs. For this reason, healthcare providers have a responsibility to value clients as individuals with unique sets of life circumstances and priorities. All women, and all couples, deserve to access the information they need to make safe and informed choices…regardless of geography, regardless of socio-economic status, regardless of age, regardless of marital status, and regardless of the result of an HIV test.
Safe family planning (FP) as well as preconception planning, counseling, and care (PCC) are important in the continuum of care for all couples, including those affected by HIV. These critical services:
- Prevent unintended pregnancy;
- Promote appropriate birth spacing;
- Optimize maternal health before pregnancy and maternal and fetal health during pregnancy;
- Prevent maternal to child transmission of HIV; and
- Reduce the risk of HIV transmission to uninfected partner.
A considerable unmet need for FP exists for women living with HIV. In sub-Saharan Africa, for example, between 66 and 92 percent of HIV positive women do not want more children, but only 20 to 43 percent of women use contraception (Sarnquist et al. Curr HIV Res 2013;11:160). Irrespective of this need and of the safety of most FP methods for women living with HIV, some providers limit options for these women. Research demonstrates that providers are especially hesitant to recommend long acting reversible contraception or emergency contraception in the setting of HIV.
Similarly, some providers do not feel comfortable when these women and their partners want to conceive. Too many HIV positive women are told that intended pregnancies are irresponsible. All people have the right to respectful, quality care; not only do HIV positive women share similar feelings about motherhood as other women, but in the era of antiretroviral therapy, many also experience improvements in fertility.
This is not to suggest that women living with HIV are without particular healthcare needs. For instance, women who live with HIV may be more likely to experience violence within their intimate relationships. They are also particularly vulnerable to co-infections with tuberculosis or malaria and to suffer from anemia. Further, many of these women – up to 50 percent in a country like Kenya – are in serodiscordant relationships, and transmission to a partner is a concern. Appropriate PCC for couples allows for optimal prevention of transmission to HIV negative partners, as well as vertical transmission to children.
PCC also offers an excellent opportunity to promote healthy behaviors. PCC presents an opportunity to counsel couples about risk mitigation, FP, healthy eating habits, psychosocial and mental health issues, and long term care plans, as well as to address care and treatment of HIV and related issues. Additionally, through PCC, underlying medical conditions – such as tuberculosis, other opportunistic infections, or other chronic conditions such as hypertension or diabetes – can be identified and treated, optimizing maternal health and pregnancy outcomes.
Recent years have witnessed great strides in HIV prevention, care, and treatment. People living with HIV enjoy longer and healthier lives. As a public health community, there is a pressing need to look beyond a narrow biomedical treatment lens, and to acknowledge clients’ fundamental life goals. Do couples want to postpone pregnancy to attain other educational, professional, or relational goals? Do they want to conceive now, a year from now, five years from now, or not at all? It is time to better understand how to integrate FP and PCC services into HIV care, and to look closely at their effectiveness in achieving better outcomes for women and their families.
This post is part of a blog series on maternal health, HIV, and AIDS. To view the entire series, click here.
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