Morroni, Chelsea

Myers, Landon

South African Medical Journal (SAMJ)

November 2005, Vol. 95, No. 11  SAMJEDITORIAL852The past 10 years have seen major advances in health carepolicy and services that support sexual and reproductive rightsin South Africa. Significant milestones include the legalisationof termination of pregnancy (TOP) and the provision of freepublic sector services for maternal and child health (MCH) andcontraception.1 At the same time the HIV epidemic hasexpanded rapidly during the last decade, and today anestimated 29% of women of reproductive age (15 - 49 years) inSouth Africa are HIV-infected.2 Despite these paralleldevelopments, little attention has been paid to the way inwhich advances in sexual and reproductive rights in SouthAfrica are extended to HIV-infected individuals. In some settings health care providers may have a negativeattitude towards sexual activity and childbearing by HIV-infected women.3,4 These attitudes are also reflected in popularopinions regarding the sexual and reproductive rights of HIV-infected individuals – a recent survey of women attendingprimary care clinics in the Western Cape found that 57%reported negative attitudes to continued sexual activity byHIV-infected individuals, and 87% negative attitudes tochildbearing.5 Related to this, the provision of contraceptionwithin services that provide antiretroviral therapy (ART) toHIV-infected women and men has received strong emphasis,6,7with little consideration given to broader issues of reproductivechoice. Here we examine the ethical, clinical and public healthrationale for promoting the sexual and reproductive rights ofHIV-infected women and men, and suggest approaches thatmay be used by health service providers and policy makers tosupport these rights and to improve the quality of health careservices. There is a strong ethical imperative to support the sexual andreproductive rights of HIV-infected individuals. Autonomy indecisions regarding whether and when to have children is awidely recognised component of human rights,8 and in SouthAfrica this is explicitly supported by the section on ‘Freedomand Security of the Person’ in the Bill of Rights in theConstitution. Any health service that denies individuals theright to reproduce without their informed consent represents aclear infringement of established legal and ethical conduct; as aresult, there are few situations in which individual choicesaround sexual activity or childbearing are overruled by healthcare providers or policies. Violations of individual autonomy insexual and reproductive health, such as coerced sterilisation ormandatory contraception, are commonly cited examples of theways in which health care services may threaten humanrights.9,10Services that support the sexual and reproductive health ofHIV-infected individuals are also an important component ofeffective clinical care. Such services should be centred aroundpatient-provider discussions on sexual activity and fertilitydesires, and how these shape the need for specific services. Forexample, sexually active HIV-infected women who do not wishto have children may require counselling on contraceptiveoptions, including emergency contraception, and theimportance of consistent condom use. Services for the earlyidentification of unintended pregnancies, along withcounselling on and access to TOP, are also critical in thisinstance.11 Women who wish to have children would alsobenefit from provider-assisted pregnancy planning (tomaximise likelihood of conception and minimise risk to thepatient, her partner, and their child) and referral to MCHservices for the prevention of mother-to-child transmission(PMTCT) of HIV infection.Clinical services for HIV-infected individuals that recogniseand meet sexual and reproductive health needs can make avaluable contribution to improved HIV care more generally.Patient-provider discussions on sexual and reproductive healthissues may provide a platform for enhanced communicationfor health promotion, including adherence to ART and sexualrisk reduction.12 More generally, the recent rapid expansion ofaccess to ART throughout South Africa has been aimed atimproving the health and quality of life of HIV-infectedindividuals. However, the health and quality of life of HIV-infected patients does not depend solely on ART; instead,comprehensive services for HIV-infected individuals thatinclude ART, sexual and reproductive health services, and arange of other primary care services are necessary to make themaximum contribution towards the quality of life of HIV-infected patients.13In addition to the benefits for individual clinical care,supporting the sexual and reproductive rights of HIV-infectedindividuals can potentially have significant public healthbenefits. Recognising the rights of HIV-infected individuals istantamount to destigmatising HIV disease. In turn, reducedstigmatisation of HIV can contribute to increased uptake ofHIV-related services, including voluntary counselling andtesting (for individuals who do not know their serostatus) andHIV care and treatment (for individuals who are HIV-infected).14,15 Moreover, throughout much of South Africainvoluntary childlessness is associated with significantstigmatisation;16 as a result, denying HIV-infected women theright to have children may compound pre-existingpsychosocial concerns for many women.Given the importance of supporting the sexual andreproductive rights of HIV-infected women and men, strategiesto address these rights require specific attention in healthSupporting the sexual and reproductive rights of HIV-infected individuals Pg 852-857 Tib  10/16/05  10:08 AM  Page 852EDITORIAL853November 2005, Vol. 95, No. 11  SAMJUncertainty as to the cause or causes of sudden andunexpected infant death and difficulty in excluding thepossibility of infanticide, even after the performance of a‘complete’ autopsy, was graphically illustrated in the Londoncourts recently.1 A mother wrongly convicted of killing her twosons had her conviction quashed, and the eminentpaediatrician who had given the court erroneous statisticalinformation was struck off the medical register for seriousprofessional misconduct.In the developed world cot death or sudden infant deathsyndrome (SIDS) is the commonest cause of death amonginfants between 1 week and 1 year of age. Although it occurs inall countries and socioeconomic groups, the rates vary widely.  The particular poignancy of cot death and the elusiveness ofits cause have engendered a vast amount of research in theWestern world.  Cot death associations have sprung up inmany countries, and international conferences on the subjectare held regularly.  The list of proposed and discredited causesis a long one, including maternal overlaying, accidentalmechanical suffocation, overwhelming viral or bacterialinfection, a large thymus and hypersensitivity to cow’s milk,among many others. But several risk factors have beenidentified – the 2 - 4-month age group is at highest risk, andmales are more commonly affected. Deaths are more frequentin winter and over weekends. Rates are higher in poorerhouseholds and among infants with young mothers, and ratesincrease with parity, low birth weight, and maternal smokingand drug-taking.2Because of the need for a specialised autopsy to fully excludeother causes and because of the difficulties in ruling outsuffocation or wilful infanticide, expert committees haveattempted various definitions of SIDS.  The most recent, in July2004, defines SIDS as: ‘The sudden unexpected death of aninfant under one year of age with onset of the fatal episodeapparently occurring during sleep, that remains unexplainedafter a thorough investigation including performance of aservices and policies. For health care providers the challenge isto support these rights by assisting HIV-infected patients toarrive at their own informed decisions, regardless of theprovider’s personal opinions. Meanwhile, health policies mustsupport the availability and accessibility of relevant services,including contraception, pregnancy planning, TOP, and MCHservices that incorporate PMTCT. Involving men in discussionson sexual and reproductive health is particularly important,and couples counselling may lead to improved healthoutcomes; however, providers and services should constantlyreinforce the autonomy of women in reproductive decisionmaking. It is important to note that health care interventions tosupport the sexual and reproductive rights of HIV-infectedwomen and men require minimal additional resources,financial or human. In most settings, health care providers mayneed additional training on the evidence base regarding sexualand reproductive health issues among HIV-infectedindividuals. Specific input may also be necessary to assistproviders in divorcing personal opinions from the provision ofcare that meets individual patient needs. Policy makers, bothlocally and nationally, can support providers through thedevelopment of best-practice guidelines for service delivery. Landon MyerInfectious Diseases Epidemiology Unit School of Public Health and Family MedicineUniversity of Cape Town 1. Cooper D, Morroni C, Orner P, et al. Ten years of democracy in South Africa: documentingtransformation in reproductive health policy and status. Reprod Health Matters 2004; 12: 70-85. 2. Dorrington RE, Bradshaw D, Johnson L, Budlender D. The Demographic Impact of HIV/AIDS inSouth Africa. National Indicators for 2004. Cape Town: Centre for Actuarial Research, SouthAfrican Medical Research Council and Actuarial Society of South Africa, 2004.3. Feldman R, Maposhere C. Safer sex and reproductive choice: findings from ‘positive women:voices and choices’ in Zimbabwe. Reprod Health Matters 2003; 11: 162-173.4. Van de Wal BW. Preventing perinatal transmission in South Africa. S Afr Med J 1998; 88: 1823.5. Myer L, Morroni C, Cooper D. Community attitudes towards sexual activity andchildbearing by HIV-positive people in South Africa. AIDS Care (in press).6. Shelton JD, Peterson EA. The imperative for family planning in ART therapy in Africa. Lancet2004; 364: 1916-1918.7. Mitchell HS, Stephens E. Contraceptive choice for HIV positive women. Sex Transm Infect2004; 80: 167-173.8. Yanda K, Smith SV, Rosenfield A. Reproductive health and human rights. Int J GynaecolObstet 2003; 82: 275-283.9. Stern AM. Sterilized in the name of public health: race, immigration, and reproductivecontrol in modern California. Am J Public Health 2005; 95: 1128-1138.10. Miranda JJ, Yamin AE. Reproductive health without rights in Peru. Lancet 2004; 363: 68-69.11. De Bruyn M. Safe abortion for HIV-positive women with unwanted pregnancy: areproductive right. Reprod Health Matters 2003; 11: 152-161.12. Sabate E. Adherence to Long-term Therapies: Evidence for Action. Geneva: World HealthOrganization, 2003.13. Myer L, Rabkin M, Abrams EJ, Rosenfield A, El-Sadr WM. Focus on women: linking HIVcare and treatment with reproductive health services in the MTCT-Plus Initiative. ReprodHealth Matters 2005; 13: 136-146.14. Levy NC, Miksad RA, Fein OT. From treatment to prevention: The interplay betweenHIV/AIDS treatment availability and HIV/AIDS prevention programming in Khayelitsha,South Africa. J Urban Health 2005; 82: 498-509.15. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIVcounselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect2003; 79: 442-447.16. Dyer SJ, Abrahams N, Hoffman M, van der Spuy ZM. 'Men leave me as I cannot havechildren': women's experiences with involuntary childlessness. Hum Reprod 2002; 17: 1663-1668.Chelsea MorroniWomen’s Health Research Unit School of Public Health and Family MedicineUniversity of Cape Town Cot death controversiesPg 852-857 Tib  10/16/05  10:08 AM  Page 853

Supporting the sexual and reproductive rights of HIV-infected individuals

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Supporting the sexual and reproductive rights of HIV-infected individuals

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South African Medical Journal (SAMJ)