Contraception is a smart choice but HIV positive women have to jump through the hooks to get it. Credit: Amy Fallon/IPS

By Amy Fallon
KAMPALA, Aug 18 2014 (IPS)

Barbara Kemigisa used to call herself an “HIV/AIDS campaigner”. These days she would rather be known as an “HIV/AIDS family planning campaigner”.

“We need to reduce unplanned pregnancies and the HIV infection rate in our country,” Kemigisa told IPS during Uganda’s first national family planning conference on July 28. “It’s about dual protection.”

Raped by two uncles from an early age, Kemigisa later became promiscuous. When she was 22, she discovered she was HIV positive – and two months pregnant. Her daughter, Kourtney, now five, was born negative. But the mother couldn’t afford to buy her formula milk and, when she was just six-months-old, the baby tested positive, through breastfeeding.

Kemigisa, an informed activist who gets her ARVs the Infectious Diseases Institute at Mulago Hospital and works with KiBO Foundation in Kampala,never had any problem obtaining contraceptives.

The same can’t be said for many young HIV positive women Kemigisa regularly meets.

“Health workers tell them ‘you’re positive, you’re not supposed to be having children’,” she says.

In the last decade, Uganda’s modern contraceptive use among women has slowly increased from 18 percent to 26 percent.

Though low, this level of contraceptive use likely averted 20 percent of paediatric HIV infections and 13 percent of AIDS-related children’s deaths, says a study. Expanding family planning services can substantially reduce child infections, it concluded.

This is crucial. Uganda’s HIV infection rate of seven percent is steadily rising after a steep drop in the 1990s, when more than a quarter of the population was infected.

Uganda now accounts for the third largest number of annual new HIV infections in the world, after South Africa and Nigeria, according to the United Nations Joint Programme on HIV/AIDS (UNAIDS).

Turning women away

Contraception is the second pillar of preventing mother to child HIV transmission (PMTCT) but one that is often neglected although, at an average of six children per woman, Uganda has one of the world’s highest fertility rates.

Women trying to cope with HIV also struggle to get the “right and correct information” on family planning, says Dorothy Namutamba, of the International Community of Women living with HIV/AIDS Eastern Africa (ICWEA).

“Information doesn’t reach women living with HIV in their reproductive age,” she says.

Women may face violence at home for being HIV positive and for using contraception, only to be further mistreated when they turn to health workers, says Namutamba.

“Some are told ‘oh, this is best for you’ and brushed off at the health facility,” says Namutamba.

In the worst-case scenarios, some HIV positive women have undergone coerced sterilisation.

Namutamba says this may happen when the woman has a caesarean section or goes for family planning services: “They’re told that this is the best for you as a HIV positive woman.”

In Kenya, ICWEA and other groups have documented about fifty cases of coerced sterilisation and will release later this year a report about similar cases in Uganda.

Because of discriminatory attitudes, “a large percentage of women are hesitant to share their status with health workers when they come to receive family planning services,” Dr Deepmala Mahla, country director for Marie Stopes Uganda, told IPS.

Two services, one trip

Inadequate coverage, frequent stock outs of commodities, limited offer of contraceptive methods and lack of trained staff affect family planning services for all women in Uganda, says Dr Primo Madra, programme officer with the United Nations Population Fund (UNFPA) in Kampala.

But for women living with HIV, he says, the main problem is the time and effort required.

An HIV positive woman who goes to the clinic for a refill of ARV pills must line up at the HIV clinic and then at the family planning clinic, both likely with long queues. She may have to do two trips.

“Most often the woman will prioritise the ARVs,” says Madra.

In a number of districts, the government and UNFPA are setting up “one-stop-shops” that offer both HIV and reproductive health services, and training health workers in the new system.

“This will enable a woman who walks into an ARV clinic to access all services more conveniently,” Primo told IPS.

But, he adds, the nationwide rollout of one-stop-shops is constrained by lack of staff: “Many health facilities have vacant health worker positions and are overwhelmed by the patient load.”

Edited by: Mercedes Sayagues

Excerpt:

Because men wield power in decisions around pregnancy, family planning services should include them. Couple-centred family planning services are sorely needed in Africa. Credit: Mercedes Sayagues/IPS

By Miriam Gathigah
NAIROBI, Aug 14 2014 (IPS)

Beatrice Njeri had just come home from her job as a janitor at a primary school in Nairobi. It was August 2009.

Arriving home earlier than usual, the married mother of two found her husband waiting for her in their shanty at Kisumu Ndogo, in the sprawling Kibera slums.

He had just discovered he was HIV positive. A week later, she too tested positive.

Both were 29 years old at the time. “We were very young and knew very little about HIV,” she says.

Having had two daughters, both HIV negative, they desired a son, but decided not to have another baby.

At the time, to prevent pregnancy, Njeri was on Depo-Provera, a hormone injection that lasts three months, and she needed a new shot.

On discovering that Njeri was HIV positive, the nurses encouraged her to undergo tubal ligation as a permanent birth control method – a step that neither Njeri nor her husband were prepared to take.

Unbeknown to Njeri, during this period, the country was facing a massive contraceptives shortage. It was so bad that rumours spread that women seeking the hormone injection, the most popular, family planning method, were injected with water instead of the hormone.

Njeri told IPS that the nurses said that they were giving priority to other women with pressing need of contraceptives.

“They said I was being selfish for not agreeing to have my tubes tied,” she says. “The nurses were forcing me to give up the only thing that made me feel like a real woman. I did not want that taken away from me.”

Sex became a chore

She was advised to use a condom to prevent a pregnancy. Condoms were new to them, and not easy.

“Using it all the time was very difficult. Sex became a chore. I hated it,” she says.

Price was another issue. “We are both casual labourers. In the slums, putting food on the table is the only priority,” she says. Their sole support comes from her church, parcels of clothes and food every now and then.

Njeri shared her predicament with a traditional birth attendant, who advised her to only have sex on safe days.

But neither knew that antibiotics can interfere with the menstruation cycle, and Njeri was taking them to fend off HIV-related opportunistic infections.  This made safe days ineffective as a contraceptive method.

Eight months later, Njeri found out that she had conceived. At her first antenatal visit, her CD4 count was a low 400. After delivering her baby boy in 2011, she was down to 180. She began using antiretrovirals, as did her husband.

But her son is infected with HIV.

Although Njeri was on the prevention of mother to child transmission program at the government’s Mbagathi Hospital near Kibera, she chose to deliver with a traditional birth attendant because they are kinder than hospital staff.

“Most government hospitals are too crowded; they don’t have time to show kindness or respect. You are lucky if a nurse actually attends to you,” she says.

Between 2012 and 2013, a series of labor strikes in the health sector resulted in shortages of injectables. Reluctantly, the couple resorted to condoms.

Being HIV positive, sexually active and young enough to get pregnant is a big problem, she says.

“Many health facilities are not able to take care of our needs,” she told IPS.

Some clinics have set aside a day of family planning services for HIV positive women but Njeri is not always able to attend because of work.

For now, Njeri is back on the injectable contraceptive. She prays that when she returns to the clinic in two months for another injection, it will still be available.

Edited by: Mercedes Sayagues

Excerpt:

The contraceptive needs of HIV positive women are often put on the background. Credit: Mercedes Sayagues/IPS

By Miriam Gathigah
NAIROBI, Aug 14 2014 (IPS)

In the rush to save babies from HIV infection and treat their mothers, experts warn that a key element of HIV prevention is being neglected in Africa – contraceptives for HIV positive women.

Yet contraception is the second pillar of successful prevention of HIV transmission from mother to child (PMTCT), along with preventing infection among women and babies, and caring for those infected.

“The contraceptive needs of HIV positive women are often put on the background, the main focus is on keeping mother and child healthy,” Florence Ngobeni-Allen, a spokesperson with the  Elizabeth Glaser Paediatric AIDS Foundation, told IPS. A South African, she was diagnosed with HIV in 1996, lost a baby to AIDS and now has two healthy boys.

Contraception is crucial in East and Southern Africa, where high HIV prevalence combines with high unmet needs for family planning, and where eight in ten HIV positive women are within their reproductive years, according to the United Nations Population Fund (UNFPA). 

Studies suggest that women living with HIV have equal “if not more desire to limit childbearing compared with HIV negative women. Reducing unmet need for family planning among these women is critical for meeting the target of reducing new child HIV infections by 90 percent,” says the United Nations report Women Out Loud.

Surveys of HIV positive women in Kenya and Malawi show that nearly three-quarters did not want more children within the next two years or ever, but only a quarter used modern contraceptives.

Weakness in programmes

A study by Family Health International among HIV positive women in Rwanda, Kenya and South Africa showed that more than half did not plan their most recent pregnancy.

Although the women wanted family planning, access was difficult. One barrier was health staff: they were not trained on contraceptive options for women living with HIV; had misconceptions about contraceptive safety; most only offered male condoms, although women preferred long-acting implants and injections, and many were judgmental about the women’s sex lives

“Sometimes nurses forget that women are still sexual when they find out you are HIV positive,” says Ngobeni-Allen.

Kenya’s unmet need for contraceptives is 25 percent nationwide but 60 percent among HIV positive women, Dr John Ong’ech, assistant director at Kenyatta National Hospital, told IPS.

Low access to family planning for HIV positive women, who are six to eight times more likely to die from pregnancy-related complications compared to HIV negative women, “is a weakness in health programmes,” he told IPS, although it is cheaper and more effective to provide contraceptives than PMTCT.

Husbands and mothers-in-law

Mary Naliaka, who works in paediatric AIDS in Kenya’s health ministry, told IPS that family planning should be part of the HIV treatment package and offer a variety of contraceptive options.

But the health systems in East and Southern Africa often suffer commodity stock outs and many clinics lack adequate infrastructure.

“To insert an intrauterine device you need a sterile environment,” Ong’ech says.

Injection is the most popular method because women can use it without telling the husband, he adds.

Unequal gender relationships and weak negotiating power influence contraceptive use. Naliaka observes that in African culture, “the mother-in-law can engineer the end of a marriage if a baby is not forthcoming.”

Dorothy Namutamba, of the International Community of Women Living with HIV in East Africa (ICWEA), who is based in Kampala, Uganda, told IPS that women are raised to please husbands.

“If a man demands that you should have ten children [you must] and if you’re not able, he’ll look somewhere else,” she says. “Most men do not encourage women to go on family planning, it’s a big problem.”

Stigma and domestic violence compound the problem.  “Women fear to declare their HIV status because they may face gender violence, and this limits their access to family planning,” Anthony Mbonye, Commissioner of Health Services in Uganda, told IPS.

Given men’s power over decisions about pregnancy, couple-oriented reproductive health services are crucial, but “health facilities are too overcrowded to absorb the male partner,” Naliaka told IPS.

The coerced sterilisations of HIV positive women in Kenya, Malawi, Namibia, South Africa and Zambia, with lawsuits pending, further cloud the issue of reproductive rights and needs and HIV.

“This shamed the health sector,” says Naliaka.  However, she adds, “through these publicized cases, the health sector and the public have understood that these women have reproductive health needs similar to those of HIV negative women.”

One-stop shops

Moving forward, experts recommend integrating HIV, family planning and maternal and child health care services, saving time for both users and health staff.

Seven Southern African countries have set up such “one-stop shops” for reproductive health, where a woman can get ARVs, cervical cancer screening, breastfeeding advice and family planning in one visit, under one roof, sometimes in one room with one health worker.

Linking services is cost effective and efficient, says UNFPA. It makes “people sense”.

Edited by: Mercedes Sayagues

Excerpt: