The impact of health care providers on female sterilization among HIV-positive women in Brazil

Access to sexual and reproductive health services for women living with HIV in Latin America and the Caribbean: systematic review of the literature

INTRODUCTION

Systematic reviews show that women living with HIV (WLHIV) have high unmet sexual and reproductive health (SRH) needs due to barriers to access sexual and reproductive health services (SRHS). In Latin America and the Caribbean (LAC), as of 2016, there were nearly one million WLHIV, but the existing evidence of their SRH needs comes from a few individual studies. This systematic review provides an overview of these women's needs to help define new and/or adapt existing public health strategies to the local context. This review synthesizes the evidence from the literature on the use of and access to SRHS related to family planning, antenatal care, abortion services and violence against WLHIV in LAC.

METHODS

Using a systematic review of mixed studies, a search was performed in MEDLINE, EMBASE, LILACS, INASP, POPLINE, SCOPUS, for studies conducted in LAC, from 2004 to 2017, as well as contact with authors and hand search as needed. Two independent reviewers evaluated the quality of the studies using the Mixed Methods Appraisal Tool; inclusion was conducted according to the PRISMA flow diagram. An exploratory narrative synthesis followed by quantitative synthesis data was undertaken. Group analysis or meta-analysis was not considered appropriate given the level of heterogeneity of the studies.

RESULTS

A total of 18 studies in 13 LAC countries for a population of 5672 WLHIV were included. Data from individual studies reported unmet family planning needs; higher, but inconsistent use of condom as the sole contraceptive method OR=1.46 [1.26 to 1.69]; lesser use of other non-permanent contraceptive methods OR=0.26 [0.22 to 0.31]; more unplanned pregnancies OR=1.30 [1.02 to 1.66]; more induced abortions OR=1.96 [1.60 to 2.39]; higher risk of immediate postpartum sterilization; and higher exposure to sexual and institutional violence by WLHIV when compared with women without HIV.

CONCLUSIONS

This review presents evidence from LAC about the SRH unmet needs of WLHIV that must be addressed by decreasing institutional and structural barriers, facilitating services and reducing stigma, and discrimination among healthcare providers to improve access to SRHS based on human rights, so women independently of their HIV status can make their own reproductive decisions, free of violence and coercion.

Preventing syndemic Zika virus, HIV/STIs and unintended pregnancy: dual method use and consistent condom use among Brazilian women in marital and civil unions

Syndemic Zika virus, HIV and unintended pregnancy call for an urgent understanding of dual method (condoms with another modern non-barrier contraceptive) and consistent condom use. Multinomial and logistic regression analysis using data from the Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS), a nationally representative household survey of reproductive-aged women in Brazil, identified the socio-demographic, fertility and relationship context correlates of exclusive non-barrier contraception, dual method use and condom use consistency. Among women in marital and civil unions, half reported dual protection (30% condoms, 20% dual methods). In adjusted models, condom use was associated with older age and living in the northern region of Brazil or in urban areas, whereas dual method use (versus condom use) was associated with younger age, living in the southern region of Brazil, living in non-urban areas and relationship age homogamy. Among condom users, consistent condom use was associated with reporting Afro-religion or other religion, not wanting (more) children and using condoms only (versus dual methods). Findings highlight that integrated STI prevention and family planning services should target young married/in union women, couples not wanting (more) children and heterogamous relationships to increase dual method use and consistent condom use.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

A systematic review of contraceptive continuation among women living with HIV

BACKGROUND

Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors.

METHODS

We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation.

RESULTS

Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle-Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%-91% continuation rates at ≥12months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes.

CONCLUSIONS

Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12months are needed to strengthen integration of RH and HIV care.

Differences in the Access to Sterilization between Women Living and Not Living with HIV: Results from the GENIH Study, Brazil

BACKGROUND

In many countries, young women of reproductive age have been especially affected by the HIV epidemic, which have fostered research to better understand how HIV infection influences and shapes women´s fertility and reproductive and sexual decisions. In Brazil, few studies have focused on the impact of the HIV epidemic on contraceptive choices among women living with HIV (WLHIV).

OBJECTIVE

This study evaluates the impact HIV infection may have in the access to female sterilization in Brazil, using a time-to-event analysis.

METHODS

A cross-sectional quantitative study (GENIH study) was conducted between February 2013 and April 2014 in the city of São Paulo, comparing two probabilistic samples of 975 WLHIV and 1,003 women not living with HIV (WNLHIV) aged 18 to 49. Sexual and reproductive data was collected retrospectively in order to reconstruct women's reproductive trajectories. Given the objectives of this study, the analysis was restricted to women with parity one or more and, in case of WLHIV, to those sterilized after HIV diagnosis and not infected through vertical transmission. The final sample analysis included 683 WNLHIV and 690 WLHIV. A series of multivariable-adjusted Cox models estimated the probability of being sterilized after HIV diagnosis, compared with WNLHIV. Models were adjusted for schooling, race/color, and stratified by parity at last delivery (1-2, 3+). Hazard ratios were calculated for female sterilization, and separately for interval and postpartum procedures (performed in conjunction with caesarean section or immediately after vaginal delivery). Additionally, information regarding unmet demand for female sterilization was also explored.

FINDINGS

No statistical difference in the overall risk of sterilization between WLHIV and WNLHIV in the two parity-related groups is observed: HR = 0.88 (0.54-1.43) and 0.94 (0.69-1.29), respectively, among women with 1-2 children and those with three and more. However, significant differences regarding the impact of HIV infection at sterilization are observed depending on the timing and the type of sterilization procedure. The probability of obtaining an interval sterilization is significantly lower for WLHIV compared to those not living with HIV. The reverse occurs regarding postpartum sterilization. Although sterilization is mainly performed in conjunction with caesarean section in Brazil, it is evident that caesarean sections are not the sole factor increasing the risk of sterilization among WLHIV.

CONCLUSION

The results indicate barriers in the access to services offering interval sterilization for WLHIV and certain facilitation in obtaining the procedure in conjunction with caesarean section. Health policy makers at local and national levels should promote institutional changes in order to facilitate access to interval sterilization and to confront the sensitive discussion of WLHIV's eligibility for postpartum sterilization. It is also urgent to increase access to a wider range of contraceptive methods for WLHIV and promote dual method protection strategies. Moreover, since condom use may decrease in the future in the context of the preventive effect of antiretroviral therapy, promoting dual methods will expand the choices regarding the reproductive rights of women living with HIV.

Que desejo é esse? Decisões reprodutivas entre mulheres vivendo com HIV/Aids sob o olhar da psicanálise

Realizou-se um estudo qualitativo para conhecer como mulheres vivendo com HIV/Aids atribuem sentido às suas decisões reprodutivas, bem como caracterizar seu desejo inconsciente. Foram realizadas entrevistas em profundidade com 15 mulheres adultas, atendidas em um hospital especializado em doenças infecciosas e em uma organização não-governamental. Foi construído um relato sobre a trajetória de vida das entrevistadas com base na técnica da história oral do tipo temática e na perspectiva teórica psicanalítica. Referiu-se aos conceitos de identificação imaginária e identificação simbólica para explicitar aspectos do desejo inconsciente. As falas das entrevistadas mostraram contradições e suas decisões reprodutivas são pautadas por uma lógica inconsciente, sendo que a gravidez, nesse contexto, tem a função de restauração narcísica cujo objetivo é gerar um rebento soronegativo. Outra contradição é que as entrevistadas avaliam as decisões reprodutivas de outras mulheres soropositivas como uma "loucura" ou "irresponsabilidade", enquanto justificam suas próprias decisões procurando se desresponsabilizar por seu desejo inconsciente. Assim, uma contribuição da Psicanálise para o campo da saúde pública é a inclusão das idiossincrasias na relação do sujeito com o outro e, deste modo, viabilizar o resgate da singularidade do desejo inconsciente dos sujeitos, além de permitir uma reflexão sobre a interferência dessas questões no cuidado integral, o que, afinal, pode interferir no acolhimento das necessidades complexas de mulheres vivendo com HIV/Aids.

"Silent Voices": A Description of Views and Attitudes of Health Professionals towards Reproduction by HIV Positive People

Objective. The role of health professionals in the decision making process of patients is usually heard or seen from the perspective of the patients. This paper gives the usually silent and invisible health professionals voice and visibility. It describes their views and attitudes towards reproduction by couples who are HIV positive and attempts to understand their perspectives. Methods. In-depth interviews were conducted with twelve health professionals at an opportunistic infections clinic. Transcribed interviews were analysed using the grounded approach to identify patterns and themes concerning views and attitudes of health professionals towards reproduction by HIV positive people. Results. The study found that most health professionals generally had a negative attitude towards childbearing by HIV positive couples. Their views and approaches on the issue were based mainly on biomedical considerations. The main discourses on childbearing that emerged from the study were the conditional choice, the antichildbearing, and the prorights. Conclusion. Most of the health professionals interviewed tend to take a generally negative stance towards reproduction by people with HIV/AIDS. There is a need for a clear set of guidelines for health professionals (HPs) on how to deal with HIV positive people who may desire to reproduce.

Contemplating abortion: HIV-positive women's decision to terminate pregnancy

Research on pregnancy termination largely assumes HIV status is the only reason why HIV-positive women contemplate abortion. As antiretroviral treatment (ART) becomes increasingly available and women are living longer, healthier lives, the time has come to consider the influence of other factors on HIV-positive women's reproductive decision-making. Because ART has been free and universally available to Brazilians for more than two decades, Brazil provides a unique context in which to explore these issues. A total of 25 semi-structured interviews exploring women's pregnancy termination decision-making were conducted with women receiving care at the Reference Centre for HIV/AIDS in Salvador, Brazil. Interviews were transcribed, translated into English and coded for analysis. HIV played different roles in women's decision-making. In all, 13 HIV-positive women did not consider terminating their pregnancy. Influential factors described by those who did consider terminating their pregnancy included fear of HIV transmission, fear of HIV-related stigma, family size, economic constraints, partner and provider influence, as well as lack of access to pregnancy termination services and abortifacients. For some HIV-positive women in Brazil, HIV can be the only reason to consider terminating a pregnancy, but other factors are significant. A thorough understanding of all variables affecting reproductive decision-making is necessary for enhancing services and policies and better meeting the needs and rights of HIV-positive women.

Falling short of universal access to reproductive health: unintended pregnancy and contraceptive use among Mexican women with HIV

A favourable context for women with HIV to prevent unintended pregnancy is a cornerstone of reproductive rights and will contribute to achieving universal access to reproductive health, a Millennium Development Goal target. This analysis explores the reproductive trajectories of Mexican women with HIV post-diagnosis and their access to reproductive counselling and use of contraceptives. In-depth interviews and short surveys were conducted with women of reproductive age living with HIV. Results indicate that sexual and reproductive health counselling in HIV care focuses on the male condom and does not routinely address reproductive desires or provide information about or access to other contraceptive methods. Unintended pregnancies result from inconsistent condom use and condom breakage. Women experienced discriminatory denial of and pressure to accept particular contraceptive methods because of their HIV status. Mexican women with HIV are not enjoying their constitutionally guaranteed right to freely choose the number and spacing of their children. Mexico's commitment to reproductive rights and the Popular Health Insurance offer policy and financial frameworks for providing family planning services in public HIV clinics. To ensure respectful implementation, rights-based training for HIV healthcare providers and careful monitoring and evaluation will be needed.

[Motives and circumstances surrounding induced abortion among women living with HIV in Brazil]

The impact of HIV/AIDS infection on the decision of women living with HIV/AIDS to interrupt a pregnancy remains an understudied topic. In an effort to understand the influence of HIV/AIDS diagnosis on abortion practices, a qualitative study was carried out in seven Brazilian municipalities with women living with HIV/AIDS who reported inducing an abortion at some point in their lives. This study presents the analysis of interviews with thirty women who became pregnant after diagnosis. The results show that for some women, infection was the primary motive for terminating their pregnancy, while for others, the motives for abortion were predominantly related to life circumstances. The decision to abort due to HIV infection is not the same for all women. It is related to the timing of the diagnosis and other aspects of the woman's life during her pregnancy, such as the relationship with her partner, her job and family support. The results suggest the need for more attention from health services to the reproductive decisions of women living with HIV/Aids; the incorporation of men into sexual and reproductive health prevention actions; and a deeper discussion of the illegality of abortion in Brazil and its harmful consequences for women, men, and children.

Factors associated with the use of irreversible contraception and continuous use of reversible contraception in a cohort of HIV-positive women

BACKGROUND

Effective contraception can be lifesaving by reducing maternal mortality linked to childbirth and unsafe abortion and by reducing vertical and horizontal transmission of HIV, in the case of an HIV-positive woman.

STUDY DESIGN

This study is a secondary analysis of a prospective cohort study. We assessed factors associated with the use of irreversible contraception and the continuous use of reversible contraception in HIV-positive Thai women. We used descriptive statistics to present baseline characteristics and logistic regression to assess the association between contraceptive use and factors in the study.

RESULTS

Of 196 women included in the analysis, 87% self-reported always using male condoms and 56% continuously using another effective contraceptive method during the period of the study (12-18 months). The choice of effective contraceptive methods was suboptimal--42% were sterilized, 14% used hormonal contraception and no participant reported the use of an intrauterine device. Sexual activity and past contraceptive use were factors associated positively with current continuous contraceptive use. Live births and lower levels of education were additional factors associated positively with sterilization.

CONCLUSIONS

Despite high contraceptive use, there are still uncovered contraceptive needs among HIV-positive women in Thailand. HIV-positive women need established specialized family planning services, offering an optimal variety of contraceptive choices and tailored to their individual needs. As sterilization is an irreversible choice, it cannot be a viable alternative for every woman. Due to the positive trend between current and past contraceptive use, we consider that it may be possible to improve family planning programs if they start as early as possible in a woman's life and are continued throughout her sexually active and reproductive years.

Sexual life, options for contraception and intention for conception in HIV-positive people on successful antiretroviral therapy in Thailand

This article reports on the sexual life of HIV-positive heterosexual men and women in a stable relationship and on successful antiretroviral therapy in Thailand. We focused on one side on their sexual practices and options for contraception, and on the other on their intention for conception and factors influencing it, in the time of highly active antiretroviral therapy. In a cross-sectional study, 200 participants completed a questionnaire. Eleven female participants took part in focus group discussions (FGD), based on their intention for conception. We used descriptive statistics, logistic regression, and Chi-square exact test to present the results from the questionnaire, and a narrative approach for the FGD results. The median age of the participants was 37 years. Almost all were sexually active (88%) and rarely engaged in risky sexual behavior. The most common method of contraception for women was the male condom (95%), followed by female sterilization (40%). Almost all men reported consistent condom use. One-third of the main sexual partners were HIV-negative. The intention for conception was significantly less after being diagnosed with HIV (29% intended pregnancies after HIV diagnosis vs. 72% before HIV diagnosis). Nevertheless, 25% of the participants expressed a desire to have a child. We found a significant positive association between the intention for conception and less years of being married, the lower number of children and the higher levels of education. Therefore, we conclude that HIV-positive men and women are sexually active and in need of comprehensive reproductive health care services including counseling on safe ways to conceive and offering a diverse choice of contraceptive methods to those who do not wish to have children.

Access to safe abortion: building choices for women living with HIV and AIDS

In many areas of the world where HIV prevalence is high, rates of unintended pregnancy and unsafe abortion have also been shown to be high. Of all pregnancies worldwide in 2008, 41% were reported as unintended or unplanned, and approximately 50% of these ended in abortion. Of the estimated 21.6 million unsafe abortions occurring worldwide in 2008 (around one in 10 pregnancies), approximately 21.2 million occurred in developing countries, often due to restrictive abortion laws and leading to an estimated 47,000 maternal deaths and untold numbers of women who will suffer long-term health consequences. Despite this context, little research has focused on decisions about and experiences of women living with HIV with regard to terminating a pregnancy, although this should form part of comprehensive promotion of sexual and reproductive health rights.

In this paper, we explore the existing evidence related to global and country-specific barriers to safe abortion for all women, with an emphasis on research gaps around the right of women living with HIV to choose safe abortion services as an option for dealing with unwanted pregnancies. The main focus is on the situation for women living with HIV in Brazil, Namibia and South Africa as examples of three countries with different conditions regarding women's access to safe legal abortions: a very restrictive setting, a setting with several indications for legal abortion but non-implementation of the law, and a rather liberal setting.

Similarities and differences are discussed, and we further outline global and country-specific barriers to safe abortion for all women, ending with recommendations for policy makers and researchers.

Patient-provider communication and reproductive health among HIV-positive women in Rio de Janeiro, Brazil

OBJECTIVE

To qualitatively assess the influence of patient-provider communication on contraceptive choice among HIV-positive women in the context of universal antiretroviral therapy (ART) access.

METHODS

Focus group discussions (FGD; n=3), in-depth (IDI; n=15) and freelist interviews (FLI; n=36) were conducted with HIV-positive women aged 18-40 years recruited from public health units in Rio de Janeiro/Brazil.

RESULTS

Of 70 participants, 49 used ART and the median time since HIV diagnosis was 6 years (range: 1-18). The majority of participants (71.4%) reported some degree of dissatisfaction with their health providers (usually lack of open dialogue) and a few reported experiences of stigma/prejudice during appointments. Intra, interpersonal and social factors modulated behaviors and reproductive health decisions, and those issues were rarely addressed by providers during HIV clinical care.

CONCLUSION

Despite dramatic increases in survival and life quality after universal ART implementation in Brazil, reproductive health issues are neglected by multiple cadres of HIV health providers. Communication on reproductive health issues remains fragmented and potentially contradictory, compromising care in these settings.

PRACTICE IMPLICATIONS

Adequate provider training to address reproductive health-related issues in a comprehensive, culturally sensitive manner and improved integration of HIV and reproductive health care are urgently needed in this setting.

Aborto induzido entre mulheres em idade reprodutiva vivendo e não vivendo com HIV/aids no Brasil

No presente estudo, buscou-se identificar e comparar as características das mulheres vivendo (MVHA) e não vivendo com HIV/aids (MNVHA) que declararam ter realizado aborto alguma vez na vida. Entre novembro de 2003 e dezembro de 2004, estudo de corte transversal foi conduzido com 1.777 MVHA e 2.045 MNVHA em treze municípios brasileiros. Após ajuste por algumas variáveis confundidoras, 13,3% das MVHA versus 11,0% das MNVHA relataram aborto induzido na vida (p>0,05). Para ambos os grupos, as variáveis que se mostraram associadas significantemente ao relato de aborto induzido após ajuste no modelo de regressão logística múltipla foram: idade, com as mulheres mais velhas relatando maiores proporções de aborto; residir na região Norte do país; idade na primeira relação sexual (até 17 anos); ter tido três ou mais parceiros sexuais na vida; ter usado drogas alguma vez na vida e ocorrência (auto-referida) de doença sexualmente transmissível. Os resultados sugerem que, de forma geral, o perfil das mulheres que relataram a prática de aborto é bastante semelhante entre MVHA e MNVHA, e que os contextos associados à infecção pelo HIV e às práticas e decisões reprodutivas podem guardar similaridades.

HIV-positive women in northeast Brazil: tubal sterilization, medical recommendation and reproductive rights

Tubal sterilization is the most common contraceptive method used by Brazilian HIV-positive women. This cross sectional study describes the main reasons why HIV-positive women decide to be sterilized and identifies factors associated with choosing sterilization in HIV-positive women in Ceará, northeast Brazil. Data from 229 non-sterilized women, 80 women sterilized before HIV diagnosis and 48 women sterilized after diagnosis were analysed. Of the women sterilized after HIV diagnosis, 96% had the procedure done in the postpartum, during a caesarean section. No desire for more children was the most common appointed reason to be sterilized (39.6%), followed by medical recommendation because of HIV (31.3%). Seventy-nine women (28.5%) had a child after HIV diagnosis. Of those, 46 (58.2%) were sterilized in the postpartum. Factors associated with sterilization for HIV-positive women were: having a child after diagnosis (AOR: 120.9; 95%CI: 27.8-525.4) and having at least three children (AOR: 2.8; 95%CI: 1.1-7.1). It is recommended that non-coercive counselling should be provided so that HIV-positive women can make informed decisions on their reproductive options.

'Even if you're positive, you still have rights because you are a person': human rights and the reproductive choice of HIV-positive persons

Global debates in approaches to HIV/AIDS control have recently moved away from a uniformly strong human rights-based focus. Public health utilitarianism has become increasingly important in shaping national and international policies. However, potentially contradictory imperatives may require reconciliation of individual reproductive and other human rights with public health objectives. Current reproductive health guidelines remain largely non prescriptive on the advisability of pregnancy amongst HIV-positive couples, mainly relying on effective counselling to enable autonomous decision making by clients. Yet, health care provider values and attitudes may substantially impact on the effectiveness of non prescriptive guidelines,particularly where social norms and stereotypes regarding childbearing are powerful, and where providers are subjected to dual loyalty pressures, with potentially adverse impacts on rights of service users. Data from a study of user experiences and perceptions of reproductive and HIV/AIDS services are used to illustrate a rights analysis of how reproductive health policy should integrate a rights perspective into the way services engage with HIV-positive persons and their reproductive choices. The analysis draws on recognised tools developed to evaluate health policies for their human rights impacts and on a model developed for health equity research in South Africa to argue for greater recognition of agency on the part of persons affected by HIV/AIDS in the development and content of policies on reproductive choices. We conclude by proposing strategies that are based upon a synergy between human rights and public health approaches to policy on reproductive health choices for persons with HIV/AIDS.

Gender, sexuality, and antiretroviral therapy: using social science to enhance outcomes and inform secondary prevention strategies

OBJECTIVES

To explore how, within the context of antiretroviral therapy (ART) uptake and adherence, social science research on gender and sexuality could complement existing epidemiological and behavioral research on uptake, adherence, disinhibition and reproduction.

METHODS

Bibliographical database searches on ART uptake and adherence, the sexual practices of HIV-positive individuals, and fertility management among HIV-positive men and women were conducted over a 6-month period using ISI Web of Science and Medline. Articles were sorted by main topic and then analysed to reveal the unarticulated assumptions that have framed research to date.

RESULTS

The adoption of more social scientific theoretical frameworks would move research on uptake, adherence, disinhibition, and reproduction among HIV-infected and affected individuals beyond the current overemphasis on how cognitive and ideological factors shape behavior and towards an understanding of how culture and inequality shapes the way people engage with ART and craft their sexual and reproductive lives. Research that pays greater attention to the social processes that create differentials in uptake and adherence, rather than just the quantification of those differentials, will open up new possibilities for community-based interventions. Similarly, social science research on gender and sexuality can provide insight into the social factors shaping reproductive and sexual behavior, and thus enhance our ability to manage the potentially competing priorities of limiting marital sexual risk and increasing access to reproductive choice among HIV-affected couples.

CONCLUSION

The ability to produce good clinical outcomes and to develop effective policies for secondary prevention will be enhanced by a deeper understanding of how gender inequality and the social organization of sexuality shape the sexual and reproductive behavior of individuals using ART.

Reproductive Choice for Women and Men Living with HIV: Contraception, Abortion and Fertility

From a policy and programmatic point of view, this paper reviews the literature on the fertility-related needs of women and men living with HIV and how the entry points represented by family planning, sexually transmitted infection and HIV-related services can ensure access to contraception, abortion and fertility services for women and men living with HIV. Most contraceptive methods are safe and effective for HIV positive women and men. The existing range of contraceptive options should be available to people living with HIV, along with more information about and access to emergency contraception. Potential drug interaction must be considered between hormonal contraception and treatment for tuberculosis and certain antiretroviral drugs. Couples living with HIV who wish to use a permanent contraceptive method should have access to female sterilisation and vasectomy in an informed manner, free of coercion. How to promote condoms and dual protection and how to make them acceptable in long term-relationships remains a challenge. Both surgical and medical abortion are safe for women living with HIV. To reduce risk of vertical transmission of HIV and in cases of infertility, people with HIV should have access to sperm washing and other assisted conception methods, if these are available. Simple and cost-effective procedures to reduce risk of vertical transmission should be part of counselling for women and men living with HIV who intend to have children. Support for the reproductive rights of people with HIV is a priority. More operations research on best practices is needed.

Navigating HIV, pregnancy, and childbearing in South India: pragmatics and constraints in women's decision making

Based on ethnographic research conducted in 2004 and 2002-3, this article examines how poor women living with HIV in Tamilnadu, India navigate decisions about pregnancy and birth, and demonstrates that these decisions are influenced by a complex web of sociocultural factors. I argue that these decisions are informed by: 1) institutional interests of the state, NGOs, and international aid donors; 2). cultural constructions of gender and of the self; 3). Christian-based organizations; and 4). support group organizations, known as "networks" for people living with HIV/AIDS. Childbearing decisions emerged through a synthesis of coexisting structures and discourses which sometimes converged at the same conclusion despite differences in their underlying logics. I argue that the discourse of "positive living" fostered by the networks provided women with a framework for making reproductive decisions that was enabling. The article highlights how women pragmatically negotiated these various factors as they engaged in reproductive decision-making.

Desire for a child among women living with HIV/AIDS in northeast Brazil

In Brazil, an increasing proportion of new HIV infections and AIDS cases involve women of reproductive age. To describe the reproductive desire of women with HIV/AIDS and to identify factors associated with the desire for motherhood, a cross-sectional study was carried out in the referral hospital for infectious diseases in Ceará State, northeast Brazil. In total, 229 women were included in data analysis. Median age was 32 years (interquartile range, 26-37), and 63% had a monthly family income of less than 210 USD. Forty-nine percent were using a contraceptive method, and 37% wished to undergo tubal ligation. Sixty-four percent of the latter women were motivated by the fear of having an HIV-positive child. Forty percent of the participants wanted to have a child. In the multivariate regression analysis, variables independently associated with women's desire to have a child were: younger age (in years, odds ration [OR] = 0.94; 95% confidence interval [CI]: 0.90-0.98), number of children (OR = 0.73; 95% CI: 0.57-0.96), and partner's desire for a child (OR = 3.35; 95%CI: 1.75-6.39). Having a partner who did not know about the woman's positive serostatus was negatively associated with the woman's desire for a child (OR = 0.17; 95% CI: 0.04-0.69). No variable related to clinical status was significantly associated with the outcome variable. Our data showed that many unsterilized HIV-positive women in northeast Brazil, at whatever stage of illness, have a desire for children. We recommend that nondirective counseling, consisting of helping women evaluate their own feelings, goals and needs with respect to reproductive options be provided.

Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil

Links between HIV/AIDS care and reproductive health, including fertility options for people living with HIV (PLWH), have not been sufficiently addressed by health care providers. Moreover, few studies have addressed men in this regard. To describe attitudes toward parenthood and identify factors associated with desire to have children among men and women living with HIV a cross-sectional study involving a sample of 533 women and 206 men (bisexual and heterosexual) attending two reference sexually transmitted disease (STD)/AIDS centers in São Paulo, Brazil. Participants answered a standardized questionnaire. Desire to have children as the study outcome was compared between men and women and associated factors searched for in multivariable regression analysis. In contrast to previous studies conducted in developed countries, desire to have children in this sample was more frequent among men than among women and it was reported by 27.9% of participants (50.1% of men versus 19.2% of women). Women were more likely to anticipate doctors' strong opposition to PLWH getting pregnant and men reported lower information level about HIV/mother-to-child transmission (MTCT). Bisexual men were more likely to desire to have biologic children. Male gender, younger age, having no children, living with 1-2 children, and being in a heterosexual partnership were independently associated with desire to have children. Regardless of gender, the childless as well as the youngest should be regarded as groups to be particularly targeted by counseling, to be provided with objective information about reproductive rights and options. Further research is warranted to address the desire for children among strictly homosexual men.

[Brazilian psychosocial and operational research vis-à-vis the UNGASS targets]

Items from the UNGASS Draft Declaration of Commitment on HIV/AIDS (2001) are analyzed. The Brazilian experience of new methods for testing and counseling among vulnerable populations, preventive methods controlled by women, prevention, psychosocial support for people living with HIV/AIDS, and mother-child transmission, is discussed. These items were put into operation in the form of keywords, in systematic searches within the standard biomedicine databases, also including the subdivisions of the Web of Science relating to natural and social sciences. The Brazilian experience relating to testing and counseling strategies has been consolidated through the utilization of algorithms aimed at estimating incidence rates and identifying recently infected individuals, testing and counseling for pregnant women, and application of quick tests. The introduction of alternative methods and new technologies for collecting data from vulnerable populations has been allowing speedy monitoring of the epidemic. Psychosocial support assessments for people living with HIV/AIDS have gained impetus in Brazil, probably as a result of increased survival and quality of life among these individuals. Substantial advances in controlling mother-child transmission have been observed. This is one of the most important victories within the field of HIV/AIDS in Brazil, but deficiencies in prenatal care still constitute a challenge. With regard to prevention methods for women, Brazil has only shown a halting response. Widespread implementation of new technologies for data gathering and management depends on investments in infrastructure and professional skills acquisition.