- HIV-positive Phindile Madonsela always used a condom with her partner, but one day it broke. When it had happened before, she had gone to the local clinic and obtained emergency contraception, also known as the morning-after pill, but this time she did not go because she feared the disapproving attitude of the nurses. Later she discovered she was pregnant.
Madonsela, a volunteer HIV/AIDS educator for AIDS lobby group, the Treatment Action Campaign (TAC), had mixed feelings. "I promote condoms, so I felt very bad about being pregnant," she told PlusNews. "But I said to people, 'I'm positive, and I still have the right to have a baby.'"
She received no advice from counsellors or health workers but consulted her church elders and her mother. "My mother was very angry with me that I was pregnant - she didn't realise I could have a negative baby."
From her work with the TAC, Madonsela knew that if she took Nevirapine, an antiretroviral (ARV) drug available from the public health sector, during labour and also gave it to her baby soon after birth, she could significantly reduce the chances of infecting her child with HIV, and formula feeding instead of breastfeeding would further reduce the risk. Her little girl, now 2 years old, is healthy.
According to the Guttmacher Institute, a sexual and reproductive health nongovernmental organisation (NGO), research in both the developed and developing world suggests that HIV status does not significantly dampen people's desire to have children. As more and more HIV-infected South Africans access life-prolonging antiretroviral (ARV) treatment, the question of whether or not to have a child, and how to do so as safely as possible, is bound to become more common.
There is no official framework to guide health workers on advising HIV-positive people about their reproductive rights and options. Dr Anna Amos, head of women's health in the health department, said guidelines were being developed and a policy document was likely to be released some time in 2007.
"I think there's a realisation that there's a need, but at the moment it's very haphazard," said Dr Vivienne Black of the Reproductive Health and HIV Research Unit (RHRU) at the University of the Witwatersrand.
The disapproval of friends and family, and even some health workers, may deter those less well-informed than Madonsela from learning more about their options. "Most people think if you're positive you don't have the right to be in a relationship, or to have a baby," she said.
HIV-positive pregnant women in many countries face pressure by health workers to have abortions or to be sterilised, according to the International Community of Women Living with HIV (ICW).
Despite these obstacles, a small but growing number of HIV-positive men and women are deciding to have children. In the developed world there are a number of options: a process called 'sperm washing', which separates sperm from HIV-causing agents before being used for insemination, is safest for couples where a positive man wants to avoid the risk of infecting his negative female partner or reinfecting his positive partner; artificial insemination is the safest way of conceiving for couples with a positive woman and a negative man.
In the developing world, where most HIV-positive pregnant women still aren't even accessing treatment to prevent mother-to-child transmission (PMTCT), sperm washing or artificial insemination are generally either unavailable or unaffordable. In South Africa, they are only available through the private health sector.
"We know there are ways to get pregnant without having sex, but that's not accessible to most positive women," said AIDS activist Phindi Malaza, of the AIDS Consortium, a national umbrella organisation for AIDS NGOs.
Amos of the health department said one of the areas being investigated for the new guidelines was the demand and cost of providing fertility services to HIV-infected people.
Black believes that reproductive health services for HIV-infected people have not been prioritised until now because of a persistent belief that they should not be having children. "Because our PMTCT programmes are not that strong, a lot of children are still being born HIV infected," she said. "I think you'd have to get on top of that before that attitude would change."
According to Department of Health figures, 23 percent of babies born to HIV-positive mothers in South Africa between April 2004 and April 2005 were infected. A combination of two or more ARV drugs has been shown to be more effective than Nevirapine in reducing mother-to-child HIV transmission, but the health department has yet to start using them except in the Western Cape Province. Lack of counselling and support for HIV-positive mothers in their feeding choices has also been blamed for the high number of mother-to-child infections.
Black said HIV-infected couples who want to conceive, but cannot afford sperm washing or artificial insemination, should be advised to take ARVs and limit unprotected sex to the one or two days in the woman's cycle when she is most fertile. They should also plan for the care of their child if one or both of them died prematurely from an AIDS-related illness.
"The problem with the healthcare system is that you don't have time to spend with your patients to go into these things," Black commented. Family planning clinics often process hundreds of patients in a day and the staff receive little or no special training on advising HIV-positive clients.
These hurdles are unlikely to deter HIV-positive men and women who are determined to experience parenthood. "If I decide I want a child, I know what I will face, but I think we all have choices and rights," Malaza said. "I wouldn't want to be told I couldn't have a baby."
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