Access to Sexual and Reproductive Health Services for Women Living with HIV in Latin America and the Caribbean

2. “Access to sexual and reproductive health services for women living with HIV in Latin America and the Caribbean: an overview” Marcela Gomez-Suarez

3. I have no potential conflict of interest with this presentation

5. Number of people living with HIV-2017

7. Outline • 1. Introduction • Women’s right to SRH • WHO 2017- Guideline for WLHIV • 2. Methodology of the SRL • Objective • Methods • Results • Discussion • 3. Conclusions

8. Introduction • right to access SRHS The right to SRH is an integral part of women’s right to health [1] - easy access - timely and efficient care - meets SRH needs - freedom to make decisions ______________________________ [1] article 12 ofthe International CovenantonEconomic, Social and Cultural Rights (ICESCR)

9. STUDIES REGARDING WLHIV SHOW THAT THEIR SRH NEEDS ARE LARGELY UNMET [1,3] Unsafe abortions Unplanned pregnancies ____________________________________________________ 1. Orza L, Bewley S, Chung C, Crone T, Nagadya H, Vazquez M, et al. “Violence.Enough already”: findings from a global participatory survey among women livingwith HIV. J Int AIDS Soc. 2015;18 Suppl 5:65–71. 23. Loutfy M, Raboud J, Wong J, Yudin M, Diong C, Blitz S, et al. High prevalence of unintended pregnancies in HIV-positive women of reproductive age in Ontario, Canada: a retrospective study. HIV Med. 2012;13(2):107–17. Introduction

10. Introduction Evidence-based interventions to improve access to SRHSR Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO

11. Objective Present To present the results of the Systematic Review of the Literature (SRL) Provide • To provide an overview of the SRH needs of WLHIV in LAC Define To help define public health strategies for the local context.

12. Methods Systematic mixed methods review Outcomes related to WHO Guideline Exploratory narrative synthesis of the results 1 2 3 4 5 Studies from 2004–2017 Inclusion of studies using a PRISMA flow diagram

13. Results 2 4 • 18 studies included • 5,672 WLHIV • 13 LAC countries 2* 10 *Multicentric

14. Age 25 -35 • Average-low education • Medium-low income • Without a partner • Ethnicity Sociodemographic characteristics Results

15. Thematic Categories-Subcategories • 1.Family planning • Use of contraceptives • Dual contraception • 3. Sterilization • Post-diagnosis sterilization • 4. Violence against WLHIV • Sexual, physical, and interfamily  • Institutional • 2. Pregnancy and abortion • Unplanned pregnancies • Voluntary induced abortion Results

16. Family Planning • Higher use of condom as the sole contraceptive in WLHIV • Inconsistent use due to limited ability to negotiate with partner • Lower use of other and dual • Restricted availability in HIV services • Misunderstandings about effectiveness of condoms • Absence of FP counseling • Contraceptives on top of ART OR = 1,28 [1,11 to 1,40] Results

17. Pregnancy and Abortion • Higher frequency of unplanned pregnancies in WLHIV • Unplanned pregnancies related to greater social and economic vulnerability • 66- 79% more unplanned pregnancies in WLHIV ended in abortions • Fear of perinatal HIV transmission was the principal reason for abortion Results

18. Sterilization • No significant differences in risk of sterilization • High unmet needs for sterilization in both groups • Sterilization more frequent during c-section in WLHIV • Institutional barriers for interval sterilization • Fear of perinatal transmission as a reason for sterilization OR =1,41 [1,02,1,95]

19. Violence against WLHIV • Higher risk of suffering violence in WLHIV • The disclosure of HIV status and condom usage negotiation as triggers • Institutional violence outside HIV services (FP, antenatal care) INSTITUTIONAL VIOLENCE

20. Discussion • Besides the structural health determinants for HIV, there are barriers to access SRH that should be addressed as part of the public health strategies for these populations • The sole use of condom is not recommended to avoid unplanned pregnancies and should not be the only option for WLHIV • Low dual contraception use highlights the difficulties to access information and modern contraceptives for WLHIV in the region

21. Unplanned pregnancies resulting in induced abortion raise an important public health alert • HIV diagnosis as a justification for immediate postpartum sterilization (prevention of PT or to gain access) Poor quality of reproductive counseling Stigma, discrimination, institutional violence Discussion

22. HIV should never be a motivation for unwanted sterilization or abortion Lack of integration of HIV care services and SRHS limits access WLHIV can have planned pregnancies Succesful evidence-based intervention Discussion

23. Conclusions WLHIV in LAC have unmet SRH needs and limitations to access SRHS, that must be addressed from the perspective of human rights, and LAC countries’ commitment to universal health coverage Improving the use and access to SRHS among WLHIV dictates the need for preventive interventions, modern contraceptive options and support in making informed decisions This systematic review contributes to existing knowledge providing an overview of WLHIV’s sexual and reproductive needs to support public health decision-making for the region Access to sexual and reproductive health services for women living with HIV in Latin America and the Caribbean Marcela Gómez-Suárez

24. Acknowledgements • Maeve B. Mello • Freddy Perez • Monica Alonso Gonzalez • Massimo Ghidinelli  • Department of Communicable Diseases and Health Analysis, • Pan American Health Organization, Washington, DC • The National University of Colombia, Interfaculty Doctoral Program in Public Health, Bogota, Colombia