Experiences of coercion to sterilize and forced sterilization among women living with HIV in Latin America

Pregnancy incidence, outcomes and associated factors in a cohort of women living with HIV/AIDS in Rio de Janeiro, Brazil, 1996-2016

The aim of this research was to analyze pregnancy incidence and associated factors in a cohort of 753 women living with HIV/AIDS (WLWHA) in Rio de Janeiro, Brazil, from 1996 to 2016. Women aged 18-49 years who were not on menopause (surgical or natural) and did not have a tubal ligation were eligible for the study. Data were collected by medical professionals during initial and follow-up visits. Person-time pregnancy incidence rates were calculated throughout the follow-up period. Pregnancy incidence-associated factors were investigated by univariate and multiple analyzes, using an extension of the Cox survival model. Follow-up visits recorded 194 pregnancies, with an incidence rate of 4.01/100 person-years (95% CI: 3.47; 4.60). A higher pregnancy incidence was associated with CD4 nadir ≥ 350 cells/mm³, use of an antiretroviral regimen not containing Efavirenz, and prior teenage pregnancy. In turn, women with a viral load ≥ 50 copies/mL, age ≥ 35 years old, with two or more children and using a highly effective contraceptive method showed a lower incidence. Results showed a significant reduction in pregnancy incidence after 2006, a significant reduction in female sterilization from 1996 to 2016, and a high rate of cesarean sections. The association found between pregnancy incidence and the use of contraceptive methods and virological control markers suggests a good integration between HIV/AIDS and reproductive health services. The high rate of cesarean section delivery indicates the need to improve childbirth care.

A critical interpretive synthesis of power and mistreatment of women in maternity care

Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one's rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to "drivers of the drivers," the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Indigenous Women's Resistance of Colonial Policies, Practices, and Reproductive Coercion

This analysis of urban Indigenous women's experiences on the Homeland of the Métis and Treaty One (Winnipeg, Manitoba, Canada), Treaty Four (Regina, Saskatchewan, Canada), and Treaty Six (Saskatoon, Saskatchewan, Canada) territories illustrates that Indigenous women have recently experienced coercion when interacting with healthcare and social service providers in various settings. Drawing on analysis of media, study conversations, and policies, this collaborative, action-oriented project with 32 women and Two-Spirit collaborators demonstrated a pattern of healthcare and other service providers subjecting Indigenous women to coercive practices related to tubal ligations, long-term contraceptives, and abortions. We foreground techniques Indigenous women use to assert their rights within contexts of reproductive coercion, including acts of refusal, negotiation, and sharing community knowledge. By recognizing how colonial relations shape Indigenous women's experiences, decision-makers and service providers can take action to transform institutional cultures so Indigenous women can navigate their reproductive decision-making with safety and dignity.

The role of female permanent contraception in meeting the demand for family planning in low- and middle-income countries

OBJECTIVE

Our aim was to describe the reliance on female permanent contraception among women with demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries (LMICs) and to describe socio-economic and demographic patterns of permanent contraception in countries with high use.

METHODS

Using data from the latest national health survey carried out in LMICs we estimated mDFPS and the share of each contraceptive method used. Countries with a share of more than 25% of female permanent contraception were further explored for differences by wealth, number of living children, woman's age, and by the intersection of woman's age and number of living children.

RESULTS

In the 20 countries studied, between 6% and 94% of the contracepting population used modern methods. Female permanent contraception accounted for more than half of women using modern contraceptives in India, Dominican Republic, El Salvador, Mexico, and Colombia. In India and Tonga, more than 20% of women using contraceptives with fewer than two living children were using female permanent contraception. Among women with two living children, countries with the highest reliance on permanent contraception were India (79%), El Salvador (61%), Cuba (55%), Colombia (52%), and Thailand (51%). Dominican Republic, El Salvador, India, and Mexico presented high levels of permanent contraception among younger women, with reliance higher than 30% among women aged 25 to 29 and 50% or more among women aged 30 to 34.

CONCLUSIONS

Reliance on permanent contraception was high in several countries and among women aged less than 35 years.

Experiences of forced sterilisation and coercion to sterilise among women living with HIV (WLHIV) in Namibia: an analysis of the psychological and socio-cultural effects

The forced and coerced sterilisation of women living with HIV (WLHIV) is a phenomenon reported in several countries. In Namibia, litigation efforts for cases of forced and coerced sterilisation were successful, yet the psychological and socio-cultural well-being of those affected has not been adequately investigated and addressed. To determine the psychological and socio-cultural effects of involuntary sterilisation on WLHIV in Namibia, qualitative data from seven WLHIV were collected through face-to-face interviews. Our analysis showed that, firstly, there are negative psychological effects manifesting in psychological symptoms associated with anxiety and depression. Secondly, there are negative socio-cultural effects including discrimination, victimisation and gender-based violence. Patriarchal cultural values regarding reproduction, marriage and decision-making contribute to negative psychological and socio-cultural effects. Finally, negative psychological and socio-cultural effects of involuntary sterilisation are long-lasting. For participants, coping remains difficult, even over a decade after the sterilisations. Given the considerable long-lasting negative psychological and socio-cultural effects, psychological interventions to expedite positive coping and well-being must be prioritised.

Community Mobilization to Promote and Protect the Sexual and Reproductive Rights of Women Living with HIV in Latin America

Between 2009 and 2014, the International Community of Women Living with HIV in Latin America and the Mexican feminist civil society organization Balance coordinated a five-country community-led intervention that brought together women living with HIV (WLHIV), trans women, sex workers, and feminist lawyers to document and respond to sexual and reproductive health and rights (SRHR) violations of WLHIV and advocate for legal, policy, and programmatic changes to fulfill SRHR. The experiences of involved community leaders (n=26) indicate that knowledge of national, regional, and international human rights commitments and up-to-date medical information positively influenced personal health behaviors, empowered WLHIV as subject matter experts, and emboldened them to hold duty-bearers to account. The research evidence generated through collective action was critical for legitimating SRHR violations of WLHIV with decision-makers and for positioning the issue in the advocacy agendas of national and regional HIV and women's movements. Collective action contributed to social cohesion among diverse groups of women living with and affected by HIV and increased available technical, financial, and organizational resources and political opportunities by linking organizations and networks. Collectively, community leaders mobilized to influence policy, legal frameworks, and service delivery to promote and protect the SRHR of WLHIV.

Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries?

INTRODUCTION

While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies.

DISCUSSION

A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers.

CONCLUSIONS

As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.

Motherhood and HIV: reproductive desire, ambivalent feelings and a/an (not) offered care

OBJECTIVE

To identify in the scientific literature the feelings of women living with HIV in relation to reproduction and motherhood, as well as the care provided by health professionals regarding reproductive health as a right.

METHOD

Integrative review carried out in 2017, in the databases LILACS, PUBMED, BDENF and SciELO Virtual Library. We analyzed 30 articles.

RESULTS

As feelings, the motivation for reproduction and self-care, fears, uncertainties and hopes were evidenced. As care, services that support reproductive decisions were evidenced, but, predominantly, the disregard for the desire and care incipience for reproductive planning.

CONCLUSION

There is no comprehensive and humanized work on the reproductive issues of these women, either through the neglect of the desire and viability of gestation or by the incipient care to the ambivalent emotional experiences. There is a need to qualify the care model in order to configure it, in fact, as care, aiming at guaranteeing reproductive rights.

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.

Revisiting the 'sterilising cure' terminology: a call for more patient-centred perspectives on HIV cure-related research

The literature on HIV therapeutics research is rife with terminology associating 'sterilisation' with HIV cure. We find connotations of the word 'sterilising' problematic for the HIV cure research field. In this viewpoint, we review associations of sterilising with concepts of disinfection or cleansing, as well as coerced sterilisation. We discuss emerging findings from socio-behavioural research that show aversion from people living with HIV towards the 'sterilising cure' nomenclature. We call for more collaborations with people with HIV as partners to help define what would be a more acceptable terminology for describing an HIV cure.

Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey

Background

Efforts to improve maternal health are increasingly focused on improving the quality of care provided to women at health facilities, including the promotion of respectful care and eliminating mistreatment of women during childbirth. A WHO-led multi-country research project aims to develop and validate two tools (labor observation and community survey) to measure how women are treated during facility-based childbirth. This paper describes the development process for these measurement tools, and how they were implemented in a multi-country study (Ghana, Guinea, Myanmar and Nigeria).

Methods

An iterative mixed-methods approach was used to develop two measurement tools. Methodological development was conducted in four steps: (1) initial tool development; (2) validity testing, item adjustment and piloting of paper-based tools; (3) conversion to digital, tablet-based tools; and (4) data collection and analysis. These steps included systematic reviews, primary qualitative research, mapping of existing tools, item consolidation, peer review by key stakeholders and piloting.

Results

The development, structure, administration format, and implementation of the labor observation and community survey tools are described. For the labor observations, a total of 2016 women participated: 408 in Nigeria, 682 in Guinea, and 926 in Ghana. For the community survey, a total of 2672 women participated: 561 in Nigeria, 644 in Guinea, 836 in Ghana, and 631 in Myanmar. Of the 2016 women who participated in the labor observations, 1536 women (76.2%) also participated in the community survey and have linked data: 779 in Ghana, 425 in Guinea, and 332 in Nigeria.

Conclusions

An important step to improve the quality of maternity care is to understand the magnitude and burden of mistreatment across contexts. Researchers and healthcare providers in maternal health are encouraged to use and implement these tools, to inform the development of more women-centered, respectful maternity healthcare services. By measuring the prevalence of mistreatment of women during childbirth, we will be able to design and implement programs and policies to transform maternity services.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0603-x) contains supplementary material, which is available to authorized users.

Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).

DESIGN

We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.

PARTICIPANTS

Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.

OUTCOME MEASURES

Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.

RESULTS

Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I²=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).

CONCLUSIONS

Of the many studies examining FSWs' sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.

PROSPERO REGISTRATION NUMBER

CRD42016029185.

Involuntary sterilization among HIV-positive Garifuna women from Honduras seeking asylum in the United States: Two case reports

Voluntary sterilization is one of the most widely used forms of contraception by women worldwide; however, involuntary sterilization is considered a violation of multiple human rights and grounds for asylum in the United States. Women have been disproportionately affected by this practice. We report two cases of involuntary sterilization in HIV-positive Garifuna women from Honduras who sought asylum in America and were medically evaluated at the request of their attorneys. Key lessons can be drawn from these cases with regard to the importance of medical evaluations in establishing persecution. These include the need for a detailed account of the events surrounding sterilization, radiologic proof of tubal blockage if at all possible, and confirmation of significant and enduring mental distress as a result of the involuntary sterilization. Immigration attorneys and medical evaluators need to be attuned to the possibility of a history of involuntary sterilization among at risk women seeking asylum in the United States.

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.

Non-consensual sterilization of women living with HIV

Women living with HIV are stigmatized and discriminated against. They often wish to have children, but they are subjected to the practice of forced (involuntary) sterilization in at least 27 countries under the guise of protecting maternal health and preventing the birth of infected infants. Some women are not asked to give consent, or a third party consents on their behalf. Others are given insufficient information or fed misinformation. The circumstances under which such women have been asked to sign consent forms for sterilization include fear, coercion, intimidation, and undue influence. Courts have been clear that such practice is a breach of human rights, but, so far, it has not been formally declared in courts that such practice constitutes discrimination. More needs to be done in terms of education, sanctions against those who carry out this practice, and help for victims.

INFORMED CHOICE AND FEMALE STERILIZATION IN SOUTH ASIA AND LATIN AMERICA

Globally, female sterilization is one of the most popular contraceptive methods despite concerns about quality of care for women who report being sterilized. In this study, informed choice among sterilized women was quantified using Demographic and Health Survey (DHS) data from 2000 to 2012 for countries in South Asia and Latin America. Three responses measured informed choice and knowledge about whether women were informed by a health worker or provider: that sterilization is permanent, the potential side-effects of sterilization and other methods of contraception. An ascending composite Method Information Index with scores ranging from 0 (women received no information) to 3 (women received information across all three indicators) was used. Using ordinal logistic regression analysis, the results indicated that women younger than 25 and older than 35 at the time of sterilization, and those at high parities, had lower odds of a high score on the index, while the opposite was true for women sterilized in the private sector in Latin America. Educated women in India had higher odds of a high score on the index, while the same was true for educated and wealthy women in Colombia. These findings indicate that not enough health care providers spend time informing women in South Asia and Latin America about different aspects of sterilization, and that there are specific groups of women that are more affected. There is an urgent need to improve quality of care within health systems providing sterilization for this very important and effective type of contraception.

If We Build It, Will They Come? Perceptions of HIV Cure-Related Research by People Living with HIV in Four U.S. Cities: A Qualitative Focus Group Study

Global interest and investment in the search for an HIV cure has increased. Research has focused on what experts refer to as a sterilizing or eradicating cure, where HIV is eliminated from the body, and on what is often called a functional cure, where HIV remains, kept durably suppressed in the absence of antiretroviral treatment and therapy (ART). Many believe that a functional cure is likely to be found first. HIV cure studies will require active participation by people living with HIV (PLWHIV). Their desires and perceptions will be important to effectively recruit study participants and for the uptake of any future strategy that demonstrates safety and efficacy. The perspectives of PLWHIV are essential to advancing HIV cure research, and they should be taken into consideration as biomedical research advances. We conducted 10 focus groups in four U.S. cities, eliciting perspectives of PLWHIV on HIV cure and cure research. Most participants conceived of a cure as eradicating, and felt favorably toward it. In addition to the physical benefits of a potential cure, participants valued the possible de-stigmatization related to no longer living with HIV, liberation from concerns about transmitting HIV, and freedom from the burden of daily medication. Many participants did not regard a functional cure as an improvement over controlling HIV through ART, were distrustful about viral rebound potential, and noted concerns about medical complications and accompanying psychological distress. Some felt that the risks of HIV cure research were not worth taking. Many were skeptical about science's ability to eliminate HIV from the body.

Achieving pregnancy safely for HIV-serodiscordant couples: a social ecological approach

The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and addressing HIV-related infertility are key components of such interventions. In this commentary, we present challenges and opportunities for achieving safe pregnancies for serodiscordant couples through a social ecological lens. At the individual level, knowledge (e.g. of HIV status, assisted reproductive technologies) and skills (e.g. adhering to antiretroviral therapy or pre-exposure prophylaxis) are important. At the couple level, communication between partners around HIV status disclosure, fertility desires and safer pregnancy is required. Within the structural domain, social norms, stigma and discrimination from families, community and social networks influence individual and couple experiences. The availability and quality of safer conception and fertility support services within the healthcare system remains essential, including training for healthcare providers and strengthening integration of SRHR and HIV services. Policies, legislation and funding can improve access to SRHR services. A social ecological framework allows us to examine interactions between levels and how interventions at multiple levels can better support HIV-serodiscordant couples to achieve safe pregnancies. Strategies to achieve safer pregnancies should consider interrelated challenges at different levels of a social ecological framework. Interventions across multiple levels, implemented concurrently, have the potential to maximize impact and ensure the full SRHR of HIV-serodiscordant couples.

Chronicles of communication and power: informed consent to sterilisation in the Namibian Supreme Court's LM judgment of 2015

The 2015 judgment of the Namibia Supreme Court in Government of the Republic of Namibia v LM and Others set an important precedent on informed consent in a case involving the coercive sterilisation of HIV-positive women. This article analyses the reasoning and factual narratives of the judgment by applying Neil Manson and Onora O'Neill's approach to informed consent as a communicative process. This is done in an effort to understand the practical import of the judgment in the particular context of resource constrained public healthcare facilities through which many women in southern Africa access reproductive healthcare. While the judgment affirms certain established tenets in informed consent to surgical procedures, aspects of the reasoning in context demand more particularised applications of what it means for a patient to have capacity and to be informed, and to appropriately accommodate the disruptive role of power dynamics in the communicative process.

Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV

INTRODUCTION

Globally, women constitute 50% of all persons living with HIV. Gender inequalities are a key driver of women's vulnerabilities to HIV. This paper looks at how these structural factors shape specific behaviours and outcomes related to the sexual and reproductive health of women living with HIV.

DISCUSSION

There are several pathways by which gender inequalities shape the sexual and reproductive health and wellbeing of women living with HIV. First, gender norms that privilege men's control over women and violence against women inhibit women's ability to practice safer sex, make reproductive decisions based on their own fertility preferences and disclose their HIV status. Second, women's lack of property and inheritance rights and limited access to formal employment makes them disproportionately vulnerable to food insecurity and its consequences. This includes compromising their adherence to antiretroviral therapy and increasing their vulnerability to transactional sex. Third, with respect to stigma and discrimination, women are more likely to be blamed for bringing HIV into the family, as they are often tested before men. In several settings, healthcare providers violate the reproductive rights of women living with HIV in relation to family planning and in denying them care. Lastly, a number of countries have laws that criminalize HIV transmission, which specifically impact women living with HIV who may be reluctant to disclose because of fears of violence and other negative consequences.

CONCLUSIONS

Addressing gender inequalities is central to improving the sexual and reproductive health outcomes and more broadly the wellbeing of women living with HIV. Programmes that go beyond a narrow biomedical/clinical approach and address the social and structural context of women's lives can also maximize the benefits of HIV prevention, treatment, care and support.

Advancing the sexual and reproductive health and human rights of women living with HIV: a review of UN, regional and national human rights norms and standards

Introduction

The right to sexual and reproductive health (SRH) is an essential part of the right to health and is dependent upon substantive equality, including freedom from multiple and intersecting forms of discrimination that result in exclusion in both law and practice. Nonetheless, general and specific SRH needs of women living with HIV are often not adequately addressed. For example, services that women living with HIV need may not be available or may have multiple barriers, in particular stigma and discrimination. This study was conducted to review United Nations Human Rights Council, Treaty Monitoring Bodies and Special Rapporteur reports and regional and national mechanisms regarding SRH issues of women living with HIV. The objective is to assess areas of progress, as well as gaps, in relation to health and human rights considerations in the work of these normative bodies on health and human rights.

Methods

The review was done using keywords of international, regional and national jurisprudence on findings covering the 2000 to 2014 period for documents in English; searches for the Inter-American Commission on Human Rights and national judgments were also conducted in Spanish. Jurisprudence of UN Treaty Monitoring Bodies, regional mechanisms and national bodies was considered in this regard.

Results and discussion

In total, 236 findings were identified using the search strategy, and of these 129 were selected for review based on the inclusion criteria. The results highlight that while jurisprudence from international, regional and national bodies reflects consideration of some health and human rights issues related to women living with HIV and SRH, the approach of these bodies has been largely ad hoc and lacks a systematic integration of human rights concerns of women living with HIV in relation to SRH. Most findings relate to non-discrimination, accessibility, informed decision-making and accountability. There are critical gaps on normative standards regarding the human rights of women living with HIV in relation to SRH.

Conclusions

A systematic approach to health and human rights considerations related to women living with HIV and SRH by international, regional and national bodies is needed to advance the agenda and ensure that policies and programmes related to SRH systematically take into account the health and human rights of women living with HIV.

Attitudes Toward Restricting the Sexual and Reproductive Rights of Women Living With HIV Infection in Yemen

A considerable amount of research has demonstrated the pervasive and destructive power of discrimination against people living with HIV, which limits their full and equal participation in society. This study surveyed 613 young adults from Yemen about their attitudes toward the sexual and reproductive rights of women living with HIV (WLWH). Among survey respondents, 80% believed that WLWH should be sterilized and not allowed to get married. Furthermore, 62% thought that WLWH should be forced to have abortions if they became pregnant. Men were more likely than women to impose restrictions on the sexual and reproductive rights of WLWH. HIV stigma predicted respondent attitudes toward WLWH, but religiosity and knowledge about HIV did not. The results of the study have implications for developing programs to protect and promote the rights of WLWH in Yemen.