Linking reproductive health services and HIV interventions: human rights considerations

1. Linking reproductive health services and HIV interventions: human rights considerations Luisa Cabal Center for Reproductive Rights

2. “I learned that they had sterilized me at the time of the cesarean when I awoke from anesthesia a few hours later. I was in the recovery room at the Curicó Hospital when [the nurse] entered and, after asking me how I was feeling, told me that I was sterilized and that I would not be able to have any more children […] They treated me like I was less than a person. It was not my decision to end my fertility; they took it away from me.” F.S.

3. Human Rights Framework Framework: Reproductive rights stem from the right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so free from discrimination, coercion, and violence. (ICPD 1994, Beijing 1995) This basic right rests on a host of human rights that are recognized in national laws and binding international and regional human rights agreements. • Importance of linking SRH and HIV is widely recognized • Challenge: create a generalized understanding that human rights need to be respected and protected in providing services. WHY?

4. What happens when HIV-positive women access reproductive health services? • Research shows that in spite of these legal standards, pervasive stigma around HIV-positive people exercising reproductive rights leads to discriminatory treatment that infringes women’s rights to: • Make free and informed decisions to become pregnant or to prevent pregnancy; • Receive acceptable, quality prenatal, delivery, and postnatal care; • Access information and services on contraception, safe legal abortion and/or post-abortion care; and • Make informed decisions around their continued fertility and future pregnancies.

5. What happens on the ground … • Documentation in Latin America (and other parts of the world) on stigma and discrimination at the intersection of SRH and HIV: • Discouraged from becoming pregnant or given misinformation about HIV and pregnancy • Denied information on contraception or on how to conceive safely (e.g., sero-discordant couples) • Mandatory HIV screening and/or testing without informed consent • Lack of confidentiality • Inadequate PMTCT and post-partum counseling • Delays or denial of treatment • Verbal abuse • Coercive or forced sterilization

6. Repercussions of Discrimination and Coercion in Health Care Settings • Discrimination and coercion in the healthcare setting carries significant public health consequences, and undermine prevention and treatment efforts. For example: • Discourages testing or returning for test results. • Deters institutional births, undermining PMTCT programs. • Interferes with adherence to treatment programs and can otherwise deter individuals from seeking necessary treatment and care. • Perpetuates self-stigmatization and a sense of shame and worthlessness for PLHIV.

7. Case study: Coercive and Forced Sterilizations of HIV-Positive Women • Coercive and forced sterilizations have long been used to control the fertility of marginalized populations. Over the past decade, cases of involuntary sterilizations of HIV-positive women have emerged as a growing concern and one that lacks geographical boundaries. • Women and HIV in Chile • One of the richest countries in the region • Low HIV prevalence rate (.3%) • Universal access to ART • Laws prohibit discrimination against PLHIV in health care • Women make up 28% of PLHIV in Chile

8. F.S. v. Chile: A Case Study But widespread coercion around motherhood and HIV: • 56% women surveyed were pressured by health workers to prevent pregnancy • 29% underwent surgical sterilization under pressure from healthcare providers • 12.9% were sterilized without their consent (Vivo Positivo, 2004) • In 2002, F.S. learned she was HIV-positive during routine prenatal testing. She did not receive any counseling on what she was testing for or what a positive result might mean. • She took all precautions throughout her pregnancy to minimize the risk of MTCT. She underwent a cesarean operation, giving birth to a healthy, HIV-negative boy.

9. F.S. v. Chile: A Case Study When she awoke from the anesthesia several hours later she learned that she would not have any more children—the surgeon had sterilized her without her knowledge or consent during the surgery. F.S. did not know that the doctor’s actions violated Chilean law. Vivo Positivo, a Chilean advocacy organization, helped empower F.S. to claim her rights and to take action to hold the doctor who sterilized her accountable. F.S. wanted to ensure that other women did not have to experience the trauma of forced sterilization. In 2007, after many failed attempts to get legal representation, F.S. filed a criminal complaint against the surgeon who had sterilized her, but the investigation and trial were marked by bias and irregularities and in August 2008, the case was dismissed. In February 2009, the Center for Reproductive Rights and Vivo Positivo presented F.S.’s case to the Inter-American Commission on Human Rights.

10. Prevent, Address, Redress • Higher GDP and gr’eater access to ARV does not prevent violations from happening in the context of access to reproductive health services for people living with HIV. • The importance of the legal and policy framework: symbolic and the real consequences it can have (what happens when a court sends a message that PLWHA should not marry/law goes to the extreme of making a pregnant woman a criminal if she transmits HIV to her child) • Law is not enough: need to address the implementation gap; address role of health sector in ensuring access to services that are protective of human rights. A core priority needs to be to reduce stigma and discrimination from health care professionals by implementing and intensifying training programs • Who will be the eyes and ears on the ground? Importance of accountability: from the community and health-care setting level to institutionalized forms (human rights institutions, judicial bodies)

11. Thank youwww.reproductiverights.org