Tamil Kendall / Eugenia López / Gabriela García

1. Challenges on ensuring universal access to reproductive health for women with HIV in 8 countries of Latin America Tamil Kendall / Eugenia López / Gabriela García

2. Objectives • Generate an evidence-base to support national, regional and international advocacy that promotes the sexual and reproductive rights of women with HIV • Catalyze linkages and joint action (specifically monitoring and evaluation of international commitments) between national chapters of ICW-Latin and feminist organizations

3. Activities • Situation analysis • Participatory identification of advocacy priorities • Technical support to foster linkages with feminist organizations and the inclusion of priority indicators in citizen observatories • Develop of fact sheets (national and regional) and use research results as inputs for national, regional and international monitoring and evaluation

4. Situation Analysis • Mesoamerica Mexico, Guatemala, Nicaragua y Honduras (Ford Foundation) • South America Bolivia, Colombia, Paraguay, Perú (UNFPA-LACRO) Additional support: IPPF, UNIFEM, Trudeau Foundation, Social Sciences and Humanities Research Council (Canada), University of British Columbia-Okanagan

5. Situation Analysis: Methods • Content analysis of HIV and Reproductive Health National Strategic Plans and HIV Laws in 8 countries • Interviews with decision-makers, women with HIV and feminists to describe gaps between the normative framework and the on-the-ground realities, as well as to identify good practices and lessons learned (n=48)

6. Framework:Preventing HIV Infections in Women and Infants • Primary prevention of HIV infection in women • Prevention of unintended pregnancies in women with HIV • Prevention of transmission from women living with HIV to their infants. • Provision of care, treatment and support for women living with HIV and their families. “it is important to support the rights of all women, including women living with HIV, to make informed choices about their reproductive lives”. WHO/UNFPA ( 2006) Glion Consultation on Strengthening the Linkages Between Reproductive Health and HIV/AIDS.

7. Situation Analysis: The right to information and services needed for a safe and satisfactory sexual life • Primary HIV prevention • Women and girls overlooked in national strategic plans • Specific actions for pregnant women and sex workers • Prevention strategies with women in «key populations» are not differentiated by gender • Married women, survivors of gender violence, and partners of MSM are not considered

11. Lack of political will to support prevention with women in concentrated epidemics There is a lot of resistance to admitting the impact of HIV on women’s lives, and the differences between men and women. (Feminist, Honduras) There is resistance from the Ministry of Health and some international agencies to dedicate resources to offering rapid tests to pregnant women (Woman with HIV, Activist, Bolivia)

13. Lack of political will to support perinatal HIV prevention in concentrated epidemics Caring for this population [MSM] in terms of prevention can help you break transmission networks. If you care for pregnant women you won’t break transmission networks, that is, other than perinatal. That is, you will only avoid, you won’t prevent the epidemic, you will prevent that children are infected. It seems to me that avoiding infection in children is enough, it is reason enough. But I don’t think that you have to choose between one think and another. And concretely, I don’t believe that pregnant women can be reached through the AIDS programs given the conditions of the AIDS programs. (Decision-maker, Mexico)

14. Priorities for improving coverage and quality of HIV testing during prenatal care • Logistics: • Decentralize testing and care • Ensure free services • Avoid stockouts (rapid tests and laboratory reagents) • Quality • Counselling: informed consent, communicate benefits of testing • Respect confidentiality of the HIV diagnosis

15. Women as Vectors The emphasis of the strategy has been to have the material available in health services, but there have been no community strategies to sensitive health care providers, particularly about confidentiality, which creates more stigma and discrimination. The State’s emphasis is the child. (Feminist, Honduras) They still treat us like machines. (Activist woman with HIV, Guatemala).

16. However… The offer of testing during pregnancy has been the only opportunity for heterosexual women to know their diagnosis. It is a door that has even helped us to advance in our knowledge of the HIV situation among women. (Activist woman with HIV, Bolivia)

17. Improving the implementation of perinatal HIV prevention • Access to intravenous ARV to prevent transmission during labour and delivery • Informed decisions: offer women with HIV adequate information about the relative benefits and risks of caesarean and vaginal delivery, and guarantee the implementation of their choice • Guarantee access to formula and/or comprehensive counselling about infant feeding that takes into account the economic, social and cultural situation of the woman with HIV • Provide paediatric ARV (liquid rather than tablets)

18. They practice sterilization without the consent of women with HIV—there is only one contraceptive method offered to women with HIV (Activist woman with HIV, Nicaragua)

19. Reproductive Choice: Access to contraceptives • None of the countries offers a full range of family planning methods as part of HIV care • Focus on the male condom: human and technical errors • Women taking Efavirenz (an ARV that can cause congenital malformations) at the time of conception • Unplanned and unwanted pregnancies • Abortion: Nicaragua—unsafe, Central Mexico—safe due to access to legal abortion in Mexico City* * Balance runs MARIA Abortion Fund For Social Justice which provides information, economic support for women in need from other states to travel to Mexico City to access legal and safe abortion, and accompaniment. For more information see http://www.ourbodiesourblog.org/blog/2010/04/saving-and-changing-lives-eugenia-lopez-uribe or http://www.redbalance.org/maria

20. Reproductive Choice: Right to choose to be a mother If they know they are HIV [sic] and they get pregnant, I think there must be a psychiatric issue. (Decision-maker, México) I am not sure if it is counselling or scolding, because what they say is that you can’t get pregnant. (Activist woman with HIV, Guatemala) You can’t talk about it with them because they think it is wrong, you’re not allowed to get pregnant . (HIV positive woman of reproductive age, Mexico)

21. The invisibility of the sexual lives of women with HIV limits their access to prevention tools and sexual health services, which has a direct impact on their quality of life (Feminist, Colombia)

22. Sexual and Reproductive Rights-PrioritiesNational Consultations with ICW(Mexico, Guatemala, Nicaragua, n=80) • Access to comprehensive family planning counselling and contraceptive methods as part of HIV care • Diagnosis and treatment of other STIs, including HPV and cervical cancer as part of HIV care • Screening and care for survivors of gender-based violence in HIV clinics • Implement administrative sanctions against physicians who violate the sexual and reproductive rights of women with HIV

23. Technical support • Increase knowledge of relevant international conventions and conference (CEDAW, Cairo, Beijing, MDGs, UNGASS) • Improve knowledge of technical/clinical aspects of perinatal HIV prevention and the sexual and reproductive health of women with HIV • Link the priorities identified by women with HIV to international commitments and indicators (MDG 5) • Develop specific indicators and a plan of action • Support coordination with local feminist organizations