Safe Abortion for HIV-Positive Women with Unwanted Pregnancy: A Reproductive Right

Abstract

About 2.5 million women who become pregnant each year worldwide are HIV-positive. UNAIDS recommends that HIV-positive women should be able to control their fertility and to prevent HIV transmission perinatally if they decide to have children. Yet a literature review on these matters found that termination of pregnancy for HIV-positive women receives very little attention. This paper describes the difficulties faced by HIV-positive women in obtaining safe legal, affordable abortion services. It shows that voluntary HIV counselling and testing for women seeking induced abortions and post-abortion care may not be provided. HIV-positive women wanting to avoid pregnancy for the same reasons as other women, but they also do not want to infect their partners through unprotected sex, worry about effects of pregnancy and childbirth on their own health, and about infecting a child and the child's future care. Little research has been done on whether HIV-positive women have a greater risk of morbidity following unsafe abortions than HIV-negative women, but evidence suggests they might. Studies in Zimbabwe and Thailand show that when information and access to legal pregnancy termination are lacking, HIV-positive women may be prevented from terminating a pregnancy. The paper concludes that it is essential for women living with HIV/AIDS to be able to exercise their right to decide whether and when to have children.

Résumé

Près de 2,5 millions des femmes qui commencent une grossesse chaque année dans le monde sont séropositives. L’ONUSIDA recommande que les femmes séropositives puissent maı̂triser leur fécondité et prévenir la transmission périnatale du VIH. Pourtant, une analyse des publications révèle que l’interruption de grossesse pour les femmes séropositves reçoit très peu d’attention. L’article décrit les difficultés rencontrées par les femmes séropositives pour obtenir un avortement sûr et d’un prix abordable. Il montre que les conseils et les tests du VIH pour les femmes demandant des services de planification familiale, les interruptions de grossesse et les soins après avortement ne sont pas toujours assurés. Les femmes séropositives souhaitent éviter une grossesse pour les mêmes raisons que d’autres femmes, mais elles veulent aussi protéger leur partenaire de l’infection, elles craignent les conséquences de la grossesse et de l’accouchement sur leur santé, et s’inquiètent des risques de transmission du virus à l’enfant et de l’avenir de celui-ci. Peu de recherches ont étudié si le risque de morbidité des femmes séropositives était supérieur à celui des femmes séronégatives après un avortement non médicalisé, mais il semble que ce soit le cas. Des études au Zimbabwe et en Thaı̈lande montrent que quand l’information et l’accès à un avortement légal font défaut, les femmes séropositives peuvent être empêchées d’interrompre leur grossesse. Il est donc essentiel que les femmes séropositives puisse décider si elles veulent des enfants et à quel moment.

Resumen

Aproximadamente 2,5 millones de mujeres que se embarazan cada año en todo el mundo están infectadas con VIH. ONUSIDA recomienda que las mujeres viviendo con VIH tengan la posibilidad de controlar su fecundidad y prevenir la transmisión perinatal de VIH si deciden tener hijos. Sin embargo, en un análisis de la literatura sobre estos temas se encontró poca atención prestada a la terminación de embarazo para mujeres viviendo con VIH. Este artı́culo describe las dificultadas que enfrentan las mujeres viviendo con VIH para obtener servicios de aborto seguros y económicos. Muestra que a las mujeres que solicitan servicios de legales aborto inducido y atención post aborto no necesariamente se les proveen servicios voluntarious de consejerı́a y pruebas de anticuerpos al VIH. Las mujeres viviendo con VIH tienen las mismas razones que otras mujeres por evitar un embarazo, además de no querer infectar a sus parejas mediante relaciones sexuales no protegidas, ni preocuparse por los efectos de un embarazo y parto sobre su propia salud, por infectar a un bebé o por el cuidado de un bebé a futuro. Poco se ha investigado si las mujeres viviendo con VIH corren un mayor riesgo que otras mujeres de morbilidad después de un aborto inseguro, pero la evidencia sugiere que sea ası́. Estudios en Zimbabwe y Tailandia muestran que cuando falta información y acceso a servicios legales de terminación de embarazo, a las mujeres viviendo con VIH les puede faltar la posibilidad de terminar un embarazo. El artı́culo concluye que es esencial que las mujeres viviendo con VIH/SIDA puedan ejercer su derecho a decidir tener hijos y cuando tenerlos.

Key Words:

• HIV/AIDS
• abortion law and policy
• prevention of mother-to-child transmission of HIV
• reproductive rights

In December 2002, UNAIDS estimated that about 2.5 million of the 200 million women who become pregnant each year are HIV-positive; the risk of perinatal transmission of HIV in the absence of effective prevention measures is well known.¹ UNAIDS has stated that antenatal/maternity clinics as well as HIV prevention, reproductive health and family planning services “should ensure that women can choose whether or not to know their HIV status; to control their fertility; to terminate a pregnancy, where this is safe and legal; and to take advantage of [PMTCT] drugs and other interventions if HIV-positive and having a child”.² Prevention of mother-to-child transmission of HIV (PMTCT), particularly through the administration of antiretroviral therapy, has become a major element of many governmental HIV/AIDS policies, and donors have greatly increased funding to implement PMTCT programmes. Research on contraceptive methods in relation to HIV to date shows that most contraceptives are appropriate for women living with HIV,³ but questions remain, for example in relation to hormonal contraceptives, transmission of HIV and HIV progression,⁴⁵ Issues surrounding unwanted pregnancy and induced abortion for HIV-positive women have received little attention.

This paper summarises the results of a literature review on the subject of unwanted pregnancy and induced abortion among women living with HIV/AIDS. Searches were done using the Medline, Popline, Sociofile and Psychinfo databases, various websites, abstract books and CD-ROMs from International Conferences on AIDS in 1999–2002; a supplemental search on abortion and HIV/AIDS was done through July 2003 on the electronic databases. Because so little was found on abortion, anecdotal information from newspaper articles and e-mail forums was also included. About 270 documents were included in the review.

It should be noted that some researchers do not distinguish spontaneous from induced abortions when discussing pregnancy outcomes. In countries with very restrictive abortion laws, hospitals may also record induced abortions as miscarriages, so that researchers doing retrospective studies using hospital charts may have inadequate data. For these reasons, the data available on miscarriages and induced abortions among HIV-positive women are likely to be incomplete.

HIV counselling and testing: antenatal vs. abortion clinic settings

To support reductions in pregnancy-related transmission of HIV to infants, UNAIDS and others recommend the provision of voluntary HIV counselling and testing to pregnant women attending antenatal clinics. Nevertheless, even where such antenatal policies exist, HIV counselling and testing for women seeking induced abortions or post-abortion care may not be provided.

For example, the UK Department of Health issued guidelines for HIV testing at antenatal clinics in 1999 but not for clinics offering abortions,⁶⁷⁸ although a revision to the notification form for abortion in August 2002 now requires data on whether chlamydia screening was offered.⁹ A survey among 141 consecutive patients at five London clinics offering pregnancy terminations found that 39.8% of patients reported at least one potential risk factor for HIV infection. Just over 73% of the women said that they would favour receiving information or counselling on HIV testing at clinics offering abortions.⁶

Research in southeastern France showed that only 50% of women attending gynaecology and obstetrics departments and abortion clinics in 1996 were offered an HIV test in connection with pregnancy termination, though the proportion had increased since 1992.¹⁰ In Sweden, HIV testing is offered at almost all antenatal clinics but not all abortion clinics. Women found to be HIV-positive at abortion clinics are given the chance to reconsider their abortion applications but the HIV test results have not always been available at the time of the procedure.¹¹ Researchers who investigated HIV testing among pregnant women in New Caledonia from April 1999 through March 2000 found that about 88.6% of women who gave birth underwent HIV testing compared with only 1.9% of women who had abortions; they speculated that the low rate among women seeking pregnancy terminations was not only due to refusals of testing but also because counselling and testing were not systematically offered.¹²

When an antenatal HIV test is offered, health care providers may be directive in their counselling. Reports from India, Russia, Thailand, the Ukraine and the USA indicate that some providers have put pressure on HIV-positive women to undergo abortions and sterilisation.^{13141516171819} However, there are indications that provider attitudes may be changing with the introduction of PMTCT programmes, e.g. in France and Sweden.¹⁰¹¹ UNAIDS and the Office of the United Nations High Commissioner for Human Rights stated in 1998 that pressure on HIV-positive pregnant women to undergo abortion is a violation of human rights and further said:

“Laws should also be enacted to ensure women's reproductive and sexual rights, including the right of independent access to reproductive and STD health information and services and means of contraception, including safe and legal abortion and the freedom to choose among these, the right to determine number and spacing of children, the right to demand safer sex practices and the right to legal protection from sexual violence, outside and inside marriage, including legal provisions for marital rape.” ²⁰

The World Health Organization has said:

“Where termination of pregnancy is both legal and acceptable, the HIV-positive woman can be offered this option. However, many women learn of their HIV status during pregnancy, and will not be diagnosed in time to be offered termination. If termination is an option, the woman, or preferably the couple, should be provided with the information to make an informed decision without undue influence from health care workers and counsellors.” ²¹

Unwanted pregnancy among HIV-positive women

A study in the Europe region among 449 women found that while incidence of pregnancy decreased with HIV disease progression, the number of induced abortions was high before HIV diagnosis and significantly increased thereafter, particularly among single women, women aged 15–25 and women with multiple partners.²² A UK/Ireland study found that pregnancy termination rates among HIV-positive women remained steady before and after the introduction of PMTCT programmes.²³ Still other research has shown that more HIV-positive women are now choosing to carry pregnancies to term. One US study compared women's decisions to have a tubal ligation or abortion before and after the introduction of PMTCT; while sterilisation rates remained unchanged, fewer women chose to terminate their pregnancies after antiretroviral therapy became available during pregnancy.²⁴ A Canadian cohort study, carried out in 1993–1997 in 11 cities, observed a significant drop in the proportion of abortions after publication of the first study on the efficacy of antiretroviral treatment in reducing perinatal transmission.²⁵ Researchers conducting a prospective study at two centres in France from 1985 to 1997 found that the proportion of abortions decreased from 59.4% before PMTCT was available to 37.5% thereafter.²⁶ Interviews with HIV-positive women recruited through two London clinics and NGOs found that access to antiretroviral treatment seemed to have increased the likelihood of pregnancy among some women, though others decided not to have more children because of continuing fears regarding perinatal transmission and their own reduced life expectancy.²⁷ In some cases, women also continued pregnancies because of personal convictions that abortion was wrong.¹¹²⁸

Nevertheless, some HIV-positive women have the same reasons for wanting to avoid pregnancy as other women, especially if they already have children. Women in India, Sweden, the USA, Thailand and Zimbabwe have cited concerns such as not wanting to be responsible for infecting their partner through unprotected sex, wanting to devote their attention to their existing offspring, worries about possible negative effects of pregnancy and childbirth on their own health, and worries about infecting the child and the child's future care.^{11272829303132333435}

The decision to terminate a pregnancy by some HIV-positive women has been associated with a history of previous abortions in Scotland³⁶ and the USA;³⁷³⁸ however, most of the women in these studies had a history of illegal drug use and the results may not be generalisable. A more recent study from Nigeria found no difference between HIV-positive and HIV-negative women regarding a history of prior abortions and the decision to terminate a pregnancy.³⁹

In some cases, women who receive a positive HIV diagnosis during antenatal care may be more apt to terminate a pregnancy than women who have known their HIV status for a longer period of time.²²⁴⁰⁴¹ Other studies show the opposite, however.⁴²⁴³ Research concerning pregnancy outcomes among HIV-positive women in industrialised countries has often included women exposed to multiple risk situations, and the factors complicating women's lives in addition to HIV infection, such as drug use, sex work and living in poverty, may play a significant role in the decision to terminate a pregnancy.⁴⁴⁴⁵⁴⁶

Like other women, women with HIV/AIDS may have unwanted pregnancies due to rape, contraceptive failure, lack of access to or partner refusal to allow use of contraception. From April 1999 to March 2000, the ANRS 049 DITRAME Project in Abidjan, Côte d'Ivoire, followed up 149 HIV-positive women post-partum in their PMTCT programme. Limited contraceptive services were available and only 39% of the women were using a modern contraceptive method in that period. Of the 37 pregnancies that occurred during the follow-up period, 51% were unwanted and 68% of these were terminated, despite legal restrictions on induced abortion.⁴⁷

Abortion complications in HIV-positive women

Very little research has been done on whether HIV-positive women have an increased risk of morbidity following abortions than HIV-negative women. A retrospective case–control study in Germany examined morbidity risks for HIV-positive and HIV-negative women following 235 obstetric and gynaecological surgical procedures between 1989 and 1999, of which 72 procedures were classified as “minor procedures with an intra-uterine component” (e.g. abortion and curettage). Higher complication rates occurred after abdominal surgeries such as tubectomy and caesarean sections (OR, 3.6; p=.001) and curettage (OR, 7.7; p=.06). Among HIV-infected women, the risk of complications was associated with immune status for abdominal surgery. The authors observed that antiretroviral therapy and standard peri-operative antibiotic prophylaxis did not decrease the risk of complications, commenting that standard antibiotic regimens used to prevent infections following obstetric and gynaecological procedures may not be sufficient for women with advanced HIV infection.⁴⁸ In addition, it could be concluded that use of curettage should be replaced by vacuum aspiration for abortions in high HIV prevalence areas.

A prospective study was carried out from July 1996 to June 1997 of women who presented for treatment of incomplete abortions in Kampala, Uganda. The researchers compared 106 women with no signs of intra-uterine infection to 52 women with signs of endometritis–myometritis and found that a positive HIV status was not a significant risk factor for infection. However, they noted that bacterial vaginosis, a frequent condition in HIV-positive women, may predispose women to post-abortion infection. Life-threatening infections (septicaemia, peritonitis and pelvic abscesses) occurred in 23% of the women in this study.⁴⁹ In countries with numerous restrictions on abortion or where access to legal abortion services is difficult, it is not unreasonable to suggest that HIV-positive women who have unsafe abortions may experience even greater risks to their health than HIV-negative women from sepsis, haemorrhage or uterine perforation.

It has been suggested that medical abortion might be a preferable alternative to surgical abortion for HIV-positive women.⁵⁰ This would require further research, however, as the side effects of medical abortion include nausea and vomiting, and less frequently heavy bleeding,⁵¹ which could be problematic. The efficacy of antiretroviral treatment and drugs to treat opportunistic infections could be affected by vomiting, for example, while heavy bleeding can be a complication of both medical and surgical abortion, occurring in a small number of cases. HIV-positive women are at high risk for anaemia for a variety of reasons, including malaria in pregnancy;⁵²⁵³ Hence, heavy bleeding may present a considerable risk and as with other complications, should be treated without delay. Some medical abortion protocols allow women to leave a health facility before the treating physician has established that the abortion is complete. WHO states that the safety and appropriateness of this approach still needs to be reviewed;⁵¹ this may particularly be the case for HIV-positive women in rural areas who may find it difficult to return to the facility after 10–15 days for confirmation of the pregnancy termination.

Terminating a pregnancy: legal and financial barriers and provider fears of HIV

HIV-positive women who wish to terminate a pregnancy often lack safe options to do so. In many countries where HIV prevalence is high in women of reproductive age, the majority of women do not have access to safe abortion. A study carried out in 1999 and early 2000 asked health professionals in 49 developing countries to rate 81 maternal and neonatal health services in their countries. According to these experts, the least accessible service for women was safe abortion; treatment of post-abortion complications ranked a low 78 out of 81 with regard to accessibility for women in rural areas and 17 out of 81 for women in urban areas.⁵⁴ Even where abortion is permitted by law, e.g. on grounds of risk to the woman's health, women may be unaware of this and may not obtain post-abortion care or safe abortions due to lack of information, the costs of abortion or negative attitudes on the part of abortion providers.

Some informational materials on pregnancy and HIV do broach the topic of abortion directly,^55565758 but others avoid even mentioning it. For example, the US Centers for Disease Control and Prevention's revised guidelines for HIV screening of pregnant women (2001) state only: “HIV-infected pregnant women should receive information regarding all reproductive options. Reproductive counseling should be non-directive. Health care providers should be aware of the complex concerns that HIV-infected women must consider when making decisions regarding their reproductive options and should be supportive of any decision.”⁵⁹ A recent US-based online course about family planning and reproductive health for HIV-positive women in low-resource settings did not address the topic either.³

When information and access to legal pregnancy termination are lacking, HIV-positive women may be prevented from terminating unwanted pregnancies safely or at all. Researchers in Zimbabwe found that HIV-positive women may be ready to end childbearing, but often cannot put that decision into practice because they lack control over contraception and access to abortion, among other reasons due to the cost.²⁹³⁰³¹ In Phayao Province, Thailand, 30 of 50 women interviewed in a PMTCT programme in 2000–01 had considered terminating their pregnancies. Three said they had abandoned attempts to obtain a termination because of the costs involved. Four women had failed abortions, and in two of these cases hospital staff refused to complete the abortion afterwards. One woman did not take some of her antiretroviral drugs in the hope that this would cause fetal or neonatal death. Another woman described how she first tried to self-induce an abortion with medicines; next, she went to a private clinic but was refused because she was already four months pregnant. Then she visited a private hospital to which the clinic referred her, where she was asked to pay 7500 baht. As she only had 6500 baht, the hospital refused her the abortion.²⁸ Similarly, a governmental evaluation of the PMTCT programme in two regions of Thailand found that 28 of 54 (52%) HIV-positive women who had post-test HIV counselling had wanted to terminate their pregnancies but did not do so.⁶⁰ Although the cost of a private sector abortion may be prohibitive for poor HIV-positive women in the United States, in January 2002 women in 28 states could not obtain abortions under public health insurance coverage (Medicaid) except in cases of rape, incest and life endangerment.⁶¹

Some health-care providers fear occupational exposure to HIV and avoid or refuse to carry out any invasive gynaecological procedure, especially when they have little first-hand experience of treating HIV-positive women. A survey conducted in the late 1980s in New York City found that 20 of 30 clinics and private doctors refused to keep appointments with HIV-positive women seeking an abortion; 12 of the 20 said this was because they could not guarantee adequate infection controls.⁶² Similarly, in India in 2002, two nurses reported:

“I was working as a nurse in a reputed Mumbai hospital and came to know about being HIV-positive when I miscarried. I was bleeding profusely, but the gynaecologist refused to even touch me. I was shifted to a municipal hospital, but had a similar experience there.” ⁶³

“I did it myself. I was not admitted into the hospital... I induced with tablets through the vagina…It is an international tablet. In total I paid about… 2000 rupees for that tablet. It was very painful so I took pain-killing tablets also… Our doctor went to England and from there she brought the sample and she sold it to me. I paid and after that I came to know it was a sample.” ⁶⁴

In 1999, just before Thailand instituted its national PMTCT programme in 2000, 37–52% of surveyed physicians did not provide antiretroviral therapy to pregnant women; the failure to routinely provide the treatment was correlated with unfamiliarity with the protocol and working at a smaller hospital. Asked if termination of pregnancy was “the best option” for HIV-positive women, 41% of obstetricians and gynaecologists and 33% of general practitioners agreed.⁶⁵ Many were also unwilling to perform pelvic examinations (15%), vaginal delivery (28%), or caesarean sections (37%) for HIV-positive women. A proposal from the Thai Medical Council, under consideration since 2001, to amend the Thai abortion law does not include providing access to abortion by women living with HIV.⁶⁶

Increasing HIV-positive women's access to safe abortion

Sensitivity about abortion among politicians undoubtedly contributes to reluctance to address this aspect of reproductive health. For example, in the above-mentioned rating of maternal health services in developing countries, the experts rated official approval for treatment of post-abortion complications as the second lowest policy priority.⁵⁴ Nevertheless, if maternal morbidity and mortality rates are to be reduced, it is essential that unsafe abortion be addressed, including within the context of HIV/AIDS programmes. Fitzgerald and Behets recently reported the case of an HIV-positive woman in an unnamed country who, in the course of a clinical trial, told researchers that she was going to seek an illegal abortion; a few days later she died in hospital from septic shock following an unsafe procedure. They comment:

“Clearly, HIV prevention researchers cannot be expected to untangle the ethical issues surrounding abortion rights. However, if researchers want to enroll women of reproductive age [in clinical trials], then neither can they ignore such issues. The question arises: how can researchers best protect the welfare of female volunteers in a developing country with restrictive reproductive laws?” ⁶⁷

It might be questioned whether HIV/AIDS should be listed specifically as an indication for abortion in national laws due to concerns that this might be used as a means to pressure HIV-positive women to terminate pregnancies.⁶⁴ However, legal experts believe that a woman's HIV-positive status should entitle her to a legal abortion wherever abortion is permitted to protect a woman's health or life.⁶⁸ For example, HIV-positive women suffering from tuberculosis and opportunistic infections requiring certain antibiotics may wish to terminate a pregnancy because the drugs are contra-indicated in pregnancy.⁶⁹

Conclusion

Women living with HIV must have control over their reproductive lives and be enabled to carry out their decisions voluntarily and safely. From a human rights perspective, it is essential that measures be taken to ensure that women living with HIV/AIDS are able to exercise their right to decide whether and when to have children. HIV-positive women who wish to have children need access to PMTCT programmes and access to antiretroviral treatment during and after pregnancy to preserve their health and be able to care for their children. Those who wish to avoid pregnancy must also be able to do so. More research should be done on the advantages and disadvantages of contraceptive options in the context of HIV infection, alongside efforts to increase non-directive, comprehensive contraceptive information and counselling for people living with HIV/AIDS. Special emphasis should be given to making emergency contraception available and accessible.

Research is also needed on treatment regimens for post-abortion complications in HIV-positive women, especially at later stages of HIV infection. Studies should also be done on the comparative advantages of surgical versus medical abortion for women living with HIV/AIDS, including whether special measures are needed to prevent post-abortion sequelae. Only when contraception and abortion are addressed adequately in addition to PMTCT will HIV-positive pregnant women have access to comprehensive sexual and reproductive health care and be able to exercise their full reproductive rights.