Building choices for women living with HIV and AIDS: Access to safe abortion

1. Building 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 Conference 18 – 23 July 2010 Vienna, Austria www.aids2010.org

2. Building 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.org

3. Global 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 woman’s 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 & Åhman 2009 www.aids2010.org

4. Abortion 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 abortions 54% of all unsafe abortion-related deaths The 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 rates Source:Shah and Åhman, 2009 www.aids2010.org

5. 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

6. 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 woman’s 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

7. South Africa Population: 48 577 000 Unemployment 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 weeks After 12 weeks up to 20 weeks: on recommendation of a midwife or medical practitioner, with the women’s consent – all health reasons and includes socioeconomic reasons After 20 weeks: only due to severe fetal abnormalities, severe maternal physical or mental disease Upon 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

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9. Unwanted 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 partners Inability to chose preferred contraceptive Judgemental health professionals In South Africa, HIV+ women had unwanted pregnancies due to (Orner et al, forthcoming): Inability to negotiate condom use Irregular or non-contraceptive use Being refused a sterilization Fear of hormonal injectables “side-effects” No money to travel to family planning clinic Frequently don’t know how the fertility cycle works www.aids2010.org

10. Unwanted 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 / families Women had the number of children desired, did not want another child, were not ready to have a child The 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 abortion SRH 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.org

11. Barriers 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.org

12. Barriers to safe abortion for women living with HIV/AIDS In Brazil (Barbosa et al 2009): A very restrictive abortion law Lack of support and information regarding use of misoprostol In Namibia, women don’t go to hospital for abortion: Widely deemed illegal Only for “sick” people No information on how to access legal abortion In South Africa, still diverse challenges to safe abortion: Lack of resources, providers as “gatekeepers” Difficulties in making SRH decisions Unsupportive male partners Women’s religious beliefs – abortion as “sinful” / “murder” Fear that abortion would further harm health www.aids2010.org

13. When WLWHA seek/have legal or illegal abortions, what happens? Notable similarities in Brazil and Namibia: Women resort to unsafe backstreet abortions and / or sterilization Women 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 reported Women told they cannot have a second abortion, although not legislated Given injectables post-abortion without their consent Disclosure of HIV status not mandatory to access abortion – no discrimination reported if providers know women’s status Resort 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.org

14. Human rights framework Supports women’s 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 People’s 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.org

15. Research 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 treatment Determine the prevalence and effects of unsafe abortions in WLWHA Determine whether different abortion methods (vacuum aspiration, medical abortion) require specific attention to the needs of WLWHA who are and are not on antiretroviral treatment Determine how HIV services and (post)abortion care and vice-versa can best be linked/integrated Determine what information WLHWA would like regarding all their reproductive options in counselling Determine per country the barriers to safe abortion for WLWHA and recommend policies to overcome these www.aids2010.org

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