www.aids2010.orgBuilding choices for women living with HIV and AIDS:Access to safe abortion

Phyllis Orner (South Africa), Maria de Bruyn (USA), Regina Barbosa (Brazil), Diane Cooper (South Africa), Heather Boonstra (USA), Jennifer Gatsi Mallet (Nambia)

XVIII International AIDS Conference18 23 July 2010Vienna, Austria

www.aids2010.orgBuilding choices for women living with HIV and AIDS [WLWHA]: Access to safe abortion To explore existing evidence and identify research gaps around the right of WLWHA to choose safe abortion services

To focus mainly on WLWHA in Brazil, Namibia, and South Africa looking at similarities and differences in countries with varying legal limitations for abortion

To outline global and country-specific barriers to safe abortion for all women

www.aids2010.orgGlobal obstacles and barriers to safe abortion Forty percent (40%) of pregnancies worldwide are unintended, and approximately 20% are voluntarily terminated

Up to 42 million abortions occur yearly: 20 million are unsafe leading to 70 000 deaths and 5 million disabilities amongst women each year

Globally a womans chance of having an abortion is basically the same the main difference is in safety

More than 95% of abortions in Africa and Latin America are unsafe and, excluding China, nearly 60% in Asia

Source: Malarcher, Olson & Hearst 2010; Shah & hman 2009

www.aids2010.orgAbortion globally (contin.) Africa accounts globally for 25% of all births and 13% of all women of reproductive age, but concurrently accounts globally for:A disproportionate 28% of all unsafe abortions54% of all unsafe abortion-related deathsThe highest prevalence of unsafe abortions among women under 25 years (approx. 60%)

In Sub-Saharan Africa, approximately 14% of maternal deaths are associated with unsafe abortion

Legal and safe abortions have declined worldwide, but unsafe abortions show no decline in numbers and ratesSource: Shah and hman, 2009

www.aids2010.org Brazil Population: 193 252 604 (2010) Unemployment rate: 7.4% (2010) Maternal mortality (per 100 000 live births) 260 (2000) Prevalence of HIV among adults (per 100 000 population 15 years and older) 510 (2007) Antiretroviral therapy coverage among people with advanced HIV infection 95.6%

Abortion: Legal practice of abortion restricted to cases in which pregnancy results from rape or life-threatening for women (HIV and Aids are not included) Despite the illegality of the practice, abortion is widely used by women in Brazil Number of abortions, estimates for 2005: 1 054 243, which corresponds to 2.07 abortions per woman (15 to 49 years of age) (Monteiro & Adesse 2007) 11,4% of maternal mortality was due to abortion complications (Laurenti, Mello Jorge, Gotlieb, 2004). Mortality from abortion complications is declining due to the use of misoprostol. Half of the abortions were induced by the use of medical drugs (Diniz, 2010)

www.aids2010.org Namibia Population: 2,074,000 Unemployment rate: 51% Maternal mortality (per 100 000 live births) - 300 (2000) Prevalence of HIV among adults (per 100 000 population 15 years and older) 13 885 (2007) Antiretroviral therapy coverage among people with advanced HIV infection 88%

Abortion: Legal for rape, fetal malformation, danger to a womans life, physical and mental health But 3 providers [in practice, physicians or psychiatrists] must authorize it Women given no information about legal abortion, and government public pronouncements refer to it as if it were illegal Number of abortions: No statistics available, but in 2005 38.1% of obstetric complications treated were abortion-related (WHO 2005) From November 1995-1998: 7,147 women were treated for abortion-related problems; only 107 women were able to have their pregnancies legally terminated (Minister of Health and Social Services)

www.aids2010.org South AfricaPopulation: 48 577 000Unemployment rate: 24%Maternal mortality (per 100 000 live births) 230 (2000)Prevalence of HIV among adults (per 100 000 population 15 years and older) 16 293 (2007)Antiretroviral therapy coverage among people with advanced HIV infection - 28 %Estimated total # of abortions through April 2010 - 916,049

Abortion:On request up to & including 12 weeksAfter 12 weeks up to 20 weeks: on recommendation of a midwife or medical practitioner, with the womens consent all health reasons and includes socioeconomic reasonsAfter 20 weeks: only due to severe fetal abnormalities, severe maternal physical or mental diseaseUpon liberalization of abortion in 1996, morbidity from abortion complications declined by almost 50% and mortality by 91% (Gabriel 2008)Public health arguments most compelling in changing the law as can be seen in the cartoon that follows

www.aids2010.org

www.aids2010.orgUnwanted pregnancies and abortion In Brazil, underlying gender inequities / lack of SRH services underline both unwanted pregnancies and why HIV+ women seek abortions In Namibia, unwanted pregnancies amongst HIV+ women are largely due to:Dependence on male partnersInability to chose preferred contraceptiveJudgemental health professionals In South Africa, HIV+ women had unwanted pregnancies due to (Orner et al, forthcoming):Inability to negotiate condom useIrregular or non-contraceptive useBeing refused a sterilizationFear of hormonal injectables side-effectsNo money to travel to family planning clinicFrequently dont know how the fertility cycle works

www.aids2010.orgUnwanted pregnancies and abortion In South Africa (Orner et al. forthcoming) and Namibia, WLWHA reported wanting abortions due to fear of worsening health and / or infecting the baby Additionally, in SA women reported that (Orner et al. forthcoming):They could not afford to have a child / another child, often due to not working and / or not getting support from partners / familiesWomen had the number of children desired, did not want another child, were not ready to have a childThe pregnancy was due to rape or an abusive relationship Community support to terminate an unwanted pregnancy?WLWHA in South Africa unlikely to get community support for abortionSRH rights movement in Brazil focusses on the right of HIV+ persons to have children the right to safe abortion and to other SRH rights is not addressed

www.aids2010.orgBarriers to safe abortion for women living with HIV/AIDS Similar barriers to safe abortion, despite differences in law Most HIV+ women are impoverished, face gender inequities, lack knowledge / information on SRH services and rights the norm for most women Limited access to appropriate SRH services including abortion services - and contraceptives, including emergency contraception [EC] Reluctance to seek post-abortion care in Brazil / Namibia fear that health professionals questions could lead to arrest / imprisonment Women reporting in some countries being compelled [Brazil] or coerced [Namibia] to have sterilizations or to seek clandestine abortions as an alternative Stigma

www.aids2010.orgBarriers to safe abortion for women living with HIV/AIDS In Brazil (Barbosa et al 2009):A very restrictive abortion lawLack of support and information regarding use of misoprostol In Namibia, women dont go to hospital for abortion:Widely deemed illegalOnly for sick peopleNo information on how to access legal abortion In South Africa, still diverse challenges to safe abortion:Lack of resources, providers as gatekeepersDifficulties in making SRH decisionsUnsupportive male partnersWomens religious beliefs abortion as sinful / murderFear that abortion would further harm health

www.aids2010.orgWhen WLWHA seek/have legal or illegal abortions, what happens? Notable similarities in Brazil and Namibia:Women resort to unsafe backstreet abortions and / or sterilizationWomen use misoprostol to induce abortion have no information on correct dosages (Brazil: Barbosa et al. 2009; Diniz 2010)Women share information on clandestine abortions Differences, but also some overlaps in South Africa (Orner et al. forthcoming):Complexity of abortion experiences positive and negative experiences reportedWomen told they cannot have a second abortion, although not legislatedGiven injectables post-abortion without their consentDisclosure of HIV status not mandatory to access abortion no discrimination reported if providers know womens statusResort to backstreet abortions due to provider attitudes, etc.Women seek abortion in secret abortion is highly taboo seen as a disgrace and killing in many communities

www.aids2010.orgHuman rights framework Supports womens access to safe abortion care Importance regarding fulfilling MDGs 3, 5, 6 Namibia & SA ratified the Protocol on the Rights of Women for the African Charter on Peoples and Human Rights access to legal and safe abortion Treaty Monitoring Committees for Convention on the Rights of the Child, Covenant on Civil & Political Rights, Covenant on Economic, Social & Cultural Rights, CEDAW, Convention Against Torture - recommend governments to permit legal abortion WHO guidelines on SRH for HIV+ women

www.aids2010.orgResearch recommendations Determine whether there are differences in the reproductive/abortion intentions of women living with HIV and AIDS who are and who are not on antiretroviral treatmentDetermine the prevalence and effects of unsafe abortions in WLWHADetermine whether different abortion methods (vacuum aspiration, medical abortion) require specific attention to the needs of WLWHA who are and are not on antiretroviral treatmentDetermine how HIV services and (post)abortion care and vice-versa can best be linked/integratedDetermine what information WLHWA would like regarding all their reproductive options in counsellingDetermine per country the barriers to safe abortion for WLWHA and recommend policies to overcome these

www.aids2010.orgAcknowledgementsIpas, WHO, women living with HIV and AIDS, study site health care staff, interviewers, Ron MacInnis and team, IAS