Exploring the relationship between induced abortion and HIV infection in Brazil

Abstract

Abstract

The impact of HIV on the decision to interrupt pregnancy remains an understudied topic in Brazil and the world. The technical means to implement HIV prevention and treatment interventions are widely available in Brazil. Although Brazil has restrictive abortion laws, induced abortion occurs frequently. This qualitative study investigates the extent to which Brazilian women are motivated to seek abortion as a consequence of having HIV disease, and the extent to which the decision is part of a larger reproductive decision-making context. Researchers interviewed 30 women who were living with HIV and had terminated pregnancies or attempted to do so. Many women identified their HIV status as an important aspect of their decision-making regarding abortion. Women also took into account issues such as the stage of life when the pregnancy occurred and the absence of support from partners and families. Contraceptive practices, pregnancy and abortion in this population are influenced by multiple factors that act on the structural, social, interpersonal and individual levels. We hypothesize that HIV infection and abortion are sometimes associated with similar contexts of vulnerability. Health services therefore should address HIV and reproductive issues together, with reproductive and sexual rights serving as the fundamental basis of health care.

Résumé

L’impact du VIH sur la décision d’interrompre une grossesse demeure un sujet sous-étudié au Brésil et dans le monde. Les moyens techniques pour mettre en łuvre des interventions de prévention et de traitement du VIH sont largement disponibles au Brésil. Même si ce pays a une législation restrictive en matière d’avortement, les interruptions volontaires de grossesse y sont fréquentes. Cette étude qualitative examine dans quelle mesure les Brésiliennes sont incitées à avorter du fait de leur séropositivité et dans quelle mesure cette décision s’inscrit dans un contexte plus large de prise de décision. Les chercheurs ont interrogé 30 femmes qui vivaient avec le VIH et avaient avorté ou tenté de le faire. Beaucoup de ces femmes identifiaient leur séropositivité comme un aspect important de leur décision d’avorter. Elles avaient aussi tenu compte de questions comme le stade de la vie où la grossesse s’était produite et l’absence de soutien du partenaire et de la famille. Dans cette population, les pratiques contraceptives, la grossesse et l’avortement sont influencés par de multiples facteurs qui agissent aux niveaux individuel, interpersonnel, social et structurel. Nous supposons que l’infection à VIH et l’avortement sont parfois associés à des contextes similaires de vulnérabilité. Les services de santé devraient donc aborder ensemble le VIH et les questions génésiques, les droits sexuels et génésiques servant de base fondamentale aux soins de santé.

Resumen

El impacto del VIH en la decisión de interrumpir un embarazo continúa siendo un tema poco estudiado a nivel mundial y específicamente en Brasil, donde los medios técnicos para la prevención del VIH y la implementación de intervenciones de tratamiento están disponibles de manera extendida. Aunque en Brasil existen leyes restrictivas referentes al aborto, el aborto inducido ocurre con frecuencia. En este estudio cualitativo se investiga hasta qué grado las mujeres brasileñas están motivadas para buscar servicios de aborto como consecuencia de tener VIH y hasta qué grado la decisión es parte de un contexto más amplio de toma de decisiones sobre la salud reproductiva. Los investigadores entrevistaron a 30 mujeres que estaban viviendo con VIH y habían interrumpido su embarazo o intentando hacerlo. Muchas mujeres identificaron su estado de VIH como un aspecto importante de su toma de decisiones respecto al aborto. Las mujeres tomaron en cuenta asuntos como la etapa de la vida cuando ocurrió el embarazo y la falta de apoyo de su pareja y familia. Múltiples factores que actúan a nivel estructural, social, interpersonal e individual, influyen en las prácticas anticonceptivas, el embarazo y el aborto en esta población. Planteamos como hipótesis que la infección por VIH y el aborto a veces están asociados con similares contextos de vulnerabilidad. Por lo tanto, los servicios de salud deben tratar los asuntos relacionados con el VIH y la salud reproductiva de manera conjunta, y los derechos sexuales y reproductivos deben servir como la base fundamental de los servicios de salud.

Key Words:

• abortion
• women
• HIV/AIDS
• sexual and reproductive health
• Brazil

In many countries, young women of reproductive age have been especially affected by the HIV epidemic. The resulting sexual and reproductive health issues and challenges have compelled activists to mobilize and demand that governments and international organizations take action.¹ The advent of antiretroviral therapy has turned HIV into a chronic disease in settings with reliable access to treatment, and has offered the possibility of longer and healthier lives for women living with HIV (WLHIV). At the same time, the success of the most effective prophylactic antiretroviral regimens for prevention of mother-to-child transmission (PMTCT) has changed the context within which women decide whether or not to have children.² Advances in HIV treatment and prevention technologies have thus expanded the realm of options for HIV-positive people, and in so doing, they have forced both the global community and local communities, in Brazil and elsewhere, to think in new ways about sexual and reproductive rights. Stepping up to this challenge means recognizing that all women – regardless of their HIV status – have the right to enjoy a sex life, if that is what they desire; to choose if, when, with whom, and how they’ll have children; and to exercise these choices safely and with minimal risk to their health.³

Research on the pregnancy intentions of WLHIV has identified numerous factors influencing their desires and decision-making, such as their health status; the cultural significance of motherhood; the availability of PMTCT programs; and the influence of partners, family and health care workers.⁴ At the same time, the ability of all women to achieve their childbearing intentions may be hindered by factors such as a lack of control over their own sex lives; precarious access to family planning methods; a lack of information about how to prevent pregnancy; gender norms that identify contraception as the woman’s responsibility; insufficient partner cooperation; and a lack of access to safe abortion.^5,6

When women are diagnosed with HIV, two dimensions of their sex lives often take on tremendous importance: preventing undesired pregnancies, and preventing the transmission of HIV to sexual partners and offspring. But contraception and HIV prevention do not necessarily overlap. The relationship between the two is quite complex; they possess distinct symbolic and cultural meanings that vary in accordance with women’s agency in specific contexts.⁷

Published data have documented high rates of unintended pregnancy among HIV-positive women,^8,9 suggesting that practicing family planning may be especially difficult for this population. In many countries, a limited range of contraceptive options is available, especially for WLHIV.⁶ In Brazil, obstacles to preventing unwanted pregnancies among WLHIV include a lack of family planning services tailored to their needs and limited access to contraceptive methods other than male condoms.⁷

When facing an unwanted or unplanned pregnancy, some women, including WLHIV, may decide to terminate it. Some of the few studies addressing women’s decisions and experiences in this regard indicate that there may be higher rates of induced abortion among WLHIV than in the overall female population.^9–12 Other studies indicate that having HIV may not alter the reproductive intentions of WLHIV, suggesting a major role for socioeconomic and cultural factors in decision-making.^13–16 The following paper seeks to shed light on this issue by presenting a qualitative study on the views and experiences of Brazilian WLHIV who sought to terminate pregnancies. The qualitative study builds on quantitative research by members of the same study group, addressing issues raised by our earlier comparison of WLHIV and women not living with HIV (WNLHIV)^* in relation to induced abortion.

HIV and women in Brazil

In Brazil, women represented approximately 35% of the 597,000 reported AIDS cases in 2010. Antiretroviral therapy is widely available and new cases of AIDS are decreasing rapidly among children under one year old as a result of PMTCT.¹⁷ The majority of WLHIV have low levels of education and income.¹⁷ The majority are housewives or are employed in less qualified jobs.¹⁸ In addition, studies have found that women’s vulnerability to HIV is directly associated with gender inequality, which reduces their ability to negotiate condom use with partners.^19,20

Abortion in Brazil

Brazil’s highly restrictive laws regarding induced abortion allow for it in only two situations: in the case of rape, or to save the woman’s life. Having HIV does not exempt a woman from these laws. Despite the legal context, induced abortion occurs frequently. The National Abortion Study estimated that one in five Brazilian women under age 40 had had at least one abortion in her lifetime.²¹ A comprehensive literature review conducted by the Ministry of Health in 2009 found that abortion in Brazil occurs predominantly among women who are between 20 and 29 years old; have eight years of schooling or less; are workers; and are not married.²² A similar profile was found in a literature review conducted by Menezes and Aquino in 2009.²³ In both studies, the most commonly cited method for inducing abortion was misoprostol, which is accessed through the “black market” in Brazil as its sale has been prohibited in pharmacies since 1998. In these articles, which focused on the general population, reasons for choosing abortion included the desire to delay maternity, a lack of financial resources to raise a child and concerns about relationship stability. These motives correlate with the findings of a review of international studies on the topic; the authors of that paper conclude that women’s principal motives for abortion relate to concerns about being able to guarantee a good quality of life to their offspring.²⁴

The comparative Brazilian abortion study: how it led to the current study

In 2003, members of this study group initiated the first Brazilian study to compare characteristics of WLHIV and WNLHIV with regard to several aspects of their health, including induced abortion. We performed a cross-sectional analysis of 2,045 women’s public health care service users and 1,777 WLHIV users of specialized HIV health services in 13 Brazilian municipalities. Details of the study methodology can be found in Santos et al.²⁵

Study findings were initially published in Portuguese in 2009.^25,26 In brief, the findings showed that WLHIV and WNLHIV differed from each other in regard to certain demographic characteristics. WLHIV reported earlier sexual debut, and a larger proportion of WLHIV than WNLHIV reported having three or more lifetime sexual partners. Larger proportions of WLHIV also reported experiencing sexual violence and being diagnosed with sexually transmitted infections.

Among all women of reproductive age, a significantly higher percentage of WLHIV compared to WNLHIV reported having an induced abortion once in their lifetime: 17.5% and 10.4%, respectively (p<0.0001). This difference, which remained after adjusting for age and number of children, was no longer significant when adjusted for the number of lifetime sexual partners (13.3% for WLHIV versus 11.0% for WNLHIV; p>0.05).

We observed from the data that incidents of induced abortion increased with the age of women, and were higher among those who started their sex lives earlier, had a higher number of lifetime sexual partners, and reported episodes of sexual violence, without significant differences in the magnitude of the association effects between the groups. One variable was associated with induced abortion among WLHIV alone: the likelihood of abortion was lower for WLHIV who self-identified as white than for WLHIV who did not. In other words, factors associated with induced abortion were almost the same for WLHIV and WNLHIV. Importantly, factors associated with induced abortion – earlier sexual debut, a higher number of lifetime sexual partners and a history of sexual violence – were also among the factors that differentiated WLHIV from WNLHIV. (See 2009 articles for quantitative data.^25,26) The significance of this will be further explored in the discussion section.

Purpose of this article

The comparative study of WLHIV and WNLHIV raised issues that should encourage researchers and policy makers to recognize the complexity of abortion-seeking behavior among WLHIV. Findings suggest that factors influencing the decision to terminate a pregnancy may go far beyond simply HIV-related concerns. To further explore these factors a complementary qualitative study was designed to further the knowledge about women’s decision-making processes in relation to HIV and abortion. With this we hope to help policy makers and health care professionals to improve the reproductive health services offered to WLHIV. In this article, we present our study findings, then discuss how they provide greater insight into the results obtained in the earlier quantitative study.

Methodology

The qualitative study presented here investigates the extent to which WLHIV were motivated to seek abortion as a consequence of having HIV infection, and the extent to which the decision was part of a larger reproductive decision-making context that involved partners, financial resources for raising children, ideals in terms of family size and other factors described in the literature as being related to abortion. The article utilizes the theoretical framework proposed by Bajos and colleagues,²⁷ which situates women’s reproductive decisions as outcomes of complex and multi-determinate processes going beyond individual-level decision-making. In other words, we seek to understand the ways in which cultural, institutional and individual dimensions mediate the decision of a woman living with HIV to induce an abortion.

Between 2009 and 2010, in-depth interviews with 55 WLHIV of reproductive age were carried out in six of the 13 municipalities included in the 2003–2004 quantitative study. Study recruitment took place at specialized HIV health services in the selected cities and was conducted via invitations made to the women by professionals at these services. The inclusion criteria were being of reproductive age and having terminated a pregnancy at least once in their lives. Additionally, women were selected to ensure diversity in terms of race, age and sexual and reproductive trajectories. Within this group of 55 women, 23 had terminated a pregnancy after their HIV diagnosis. Seven study participants had unsuccessfully attempted to terminate a pregnancy after their HIV diagnosis. In line with this article’s goal of exploring how the decision to have an abortion after being diagnosed with HIV is related to HIV status, the following analysis focuses exclusively on narratives of women who either had an abortion or tried to have an abortion after their HIV diagnosis.

Interviews were coded using thematic codes to systematize the data and were analyzed with the assistance of MaxQda^©. This qualitative analysis software allowed us to transform literal transcripts into outputs that generated the categorical dimensions of our research. Each interview was considered as an autonomous experience, yet the comparative reading of the material allowed us to grasp common and differing perspectives related to abortion practices.

This study was approved by the Research Ethics Committee of the Reference and Training Center for STD/AIDS.

Findings

Overview of the study population

The study population was composed of 30 women aged 18–47 from the middle and working classes. Ten of the women were white and 20 were black or “mulatto.” Only a small number of women defined themselves as housewives. Fourteen had completed elementary school, while only two had graduated from college. In terms of their relationship status, nine did not have stable partners at the time of the interview, 10 had non-cohabitating partners and 11 had partners with whom they lived. There was diversity in terms of the number of lifetime sexual partners, with the majority of women having five or more partners throughout their lives. Only five women had had either one or two partners in their lifetimes. Four women defined themselves as sex workers. Two women did not have children, 13 had one or two children and 15 had three or more children. The time since the women’s HIV diagnosis ranged from two months to 20 years.

Women’s experiences relating to abortion, contraception and violence

The qualitative analysis of women’s narratives shows that the decision to terminate a pregnancy was complex and involved diverse factors. Study participants reported using various methods, with misoprostol, or “Citotec” (brand name) as it was called by this population, being the most common. Few women referred to having an abortion performed by a trained professional in a situation that would be considered safe. The abortion experience was described as traumatic primarily among the poorest women, who did not have access to safe abortion. These traumatic experiences were associated with being generally alone, in situations that were clandestine and unsafe, in both physical and psychological terms.

Of the 23 women who had terminated a pregnancy after being diagnosed with HIV, 14 had abortions for the first time after the diagnosis and nine had abortions preceding the diagnosis as well. The occurrence of abortion both before and after the diagnosis was more common among women with more than three lifetime sexual partners, including sex workers and women with two or more children.

The lifetime pattern of contraceptive use among the study population was characterized by inconsistent use of oral hormonal contraceptives and condoms, and by lack of knowledge of contraceptive alternatives. The occurrence of nonconsensual sex and of sexual and physical violence in their social and familiar relationships was particularly common in the women’s trajectories and was frequently mentioned in their narratives of condom non-use.

The role of HIV in decisions to terminate pregnancy

For many women who terminated pregnancies after learning of their HIV-positive status, having HIV was a highly important reason for the abortion. Factors that contributed to the women’s decisions included their fears about transmitting HIV to their children and the perceived negative consequences of following PMTCT protocols, for the women or for their babies.

“Because the child suffers a lot, tests, vaccines, you have to give them medicine. That whole thing, right? Doing this all of the time, plus the suffering of the child, you have to keep drawing blood from the baby until you see the result [of the HIV test]. This hurts me… Then I tried to take it out [to abort]. I took a pill [Citotec], tea, aspirin.” (34 years old, primary school incomplete, stable partner, abortion after HIV diagnosis)

Although many of the women interviewed knew that the correct application of PMTCT procedures can avert HIV transmission to the infant, they were still haunted by the possibility of having an HIV-positive child. They also reported worrying that they would be overburdened by the care that an HIV-positive child would require. These feelings appeared to be stronger among women whose pregnancies had occurred earlier in the HIV epidemic, before effective treatments were available:

“In 1990… soon after I discovered I had [HIV], I discovered that I was also pregnant. At that time, the doctors said that there wasn’t anything they could do and that there was a 50% chance that my child would be born infected. [They said] that… if my child was born infected, that it would be difficult for him to live more than three years. So I became desperate, not because of the possibility of him being born infected, but I became desperate knowing that I would love him, raise him for three years and then have to bury him. This was my nightmare, whether I would not have the courage to close the lid of the coffin on my son. I wouldn’t be able to handle it.” (44 years old, completed primary school, stable partner, 5 children, abortion after HIV diagnosis)

Relationships with partners and family members

Despite the importance of the HIV diagnosis in terms of their decision to abort, for the majority of women, this was only one of many personal, social and emotional reasons. The following statement illustrates some of the factors women took into account:

“I am already 42 years old, understand? I was thinking, my God… I am going to have a child at 42, and when I’m 50, the child is going to have a lot of energy, and I am going to have to be 100% and I don’t feel like I have the resistance any more… I also was thinking, it could bring me problems, bring problems for my child… There are various things. The financial life, personal life, emotional life, everything. But I’ll tell you something. With all of the fear that I had, with everything, if the guy had been cool, someone I could’ve counted on, I would’ve left it [not terminated the pregnancy].” (43 years old, primary school incomplete, stable partner, 2 children, abortion before and after HIV diagnosis)

At the same time, the narrative above draws attention to the importance of partnership. Having a partner who could share the responsibility of raising a child was often reported to be a fundamental factor in the decision to continue or terminate the pregnancy.

“[My partner] was nuts and he drank a lot. Then I got pregnant, so I got rid of it [interrupted the pregnancy]. I begged and prayed to God. I beat my belly. For God’s sake, I can’t have that child, I can’t have that child. But I did not talk to him [the partner]; he was an alcoholic.” (47 years old, primary school incomplete, without a stable partner, 4 children, abortion after HIV diagnosis)

The influence of the family also emerged as an important dimension of the decision to have an abortion. This was frequently connected to the absence of a partner or to a partner’s perceived lack of support.

“If I had had a person who had talked with me, helped me, even now, during my second attempt to abort. If I had a person who had said: ‘I am going to give you something, whatever you need, you can count on me,’ but no, no one said that, not from my family or from his. His family even said, ‘Now you are going to have to figure out how to take care of the child and work.’ Since I already knew what kind of man I had, he didn’t even buy the baby’s layette, I was the one who had to get it, used, from friends.” (24 years old, primary school incomplete, stable partner, 4 children, unsuccessful abortion attempt after HIV diagnosis)

In addition, women considering abortion often recognized their mother and mother-in-law as central figures in the decision-making process. This appeared to be related to the possibility that childcare would fall upon the grandmothers if the child’s mother needed to work, if the mother couldn’t or didn’t want to raise children, or if the father abandoned the family. However, family members did not always encourage abortion; sometimes they were against it. For example, one woman reported being persuaded by her mother to stop trying to terminate a pregnancy after multiple unsuccessful abortion attempts, noting that her mother even promised to raise the child.

The influence of health services and health professionals

The decision to have an abortion also involved the participation of health services and health professionals. Interviews highlighted the refusal of health professionals to support the sexual and reproductive health demands of WLHIV and to acknowledge that many HIV-positive women become pregnant and choose to abort because they do not want to have a child at that moment. Health professionals, especially gynecologists, were described by women as only emphasizing the need to prevent pregnancy. When faced with the reality of a pregnancy, even an undesired one, health professionals reportedly assumed that the woman would have the child and only focused on preventing mother-to-child transmission of HIV. Thus, women were not provided with the necessary support to be able to decide whether or not to continue their pregnancies in a conscious and informed way.

On the other hand, the women’s narratives describe different responses from health professionals facing the concrete reality of an abortion in process. In these cases, the professionals appeared to develop more flexible positions. For example, one woman described how a physician’s attitude about her abortion attempt changed after he learned that the woman was HIV-positive.

“I bought Citotec… inserted two, and took two. I felt pain… and was rushed to the maternity ward. I got there and the doctor examined me, and the pill came out. And then he said, ‘You took medication to abort.’ Then he called… social services, the police, everyone… The social worker came to talk with me, and I said to her, ‘I’m angry because I have the HIV virus, and I’ve already lost a four-month-old girl [to] the disease.’ Then she went and erased everything [about the abortion] and the doctor understood my reason, because if it depended on him, I would have been in prison until today.” (24 years old, primary school incomplete, stable partner, 2 children, unsuccessful abortion attempt after HIV diagnosis)

The women’s narratives indicated that some of the health professionals’ attitudes towards abortion changed when they knew the women’s HIV status. In the case described above, for example, although the doctor maintained the pregnancy, he did not press charges. It is worth emphasizing that health professionals’ slightly more flexible attitudes regarding abortion among seropositive women did not necessarily mean recognizing their right to terminate an undesired pregnancy.

Other life circumstances, including lack of desire for children

For many of the women interviewed, the decision to have an abortion after their HIV diagnosis was related to the virus, although generally also associated with other life circumstances, such as the desire not to have more children.

“I don’t care if it is a crime. It was me who will be stuck with a lot of kids, my daughter was only about a month old and I was pregnant again, what is this? Oh God forgive me… but I can’t have another child. There is a lot of things, taking medicine, going to the doctor, leaving [the kids] here, leaving there, and many other things. I feel bad about having three small kids, one of them still needing to be carried in my arms, and another in the belly. Go to the market, to the shopping mall, I feel bad about this. ‘Look at her with so many children, so young.’” (29 years old, completed high school, stable partner, 3 children, abortion before and after HIV diagnosis)

Reasons for having an abortion also included the context of the women’s pregnancy, which might have occurred under unplanned or unexpected circumstances. There were also references to women’s lack of access to quality sexual and reproductive health care, which would have helped them to have adequate contraception and to involve their partners in contraceptive practices.

“I didn’t want to have more children, but he showed up 10 days after the abortion, we had sex, and I got pregnant again, one on top of the other. Then I took the medication [to abort]…” (44 years old, primary school incomplete, without a stable partner, 5 children, abortion before and after HIV diagnosis)

For some women, the decision to have an abortion was more related to not wanting to be pregnant at that point in their lives, and wanting to prioritize other dimensions of their lives, like their jobs or professional careers.

“I didn’t want to have children, so if they gave me a car, I wasn’t going to accept it because it wasn’t the car that I wanted, it was that I didn’t want to have children. I was at the height, the height of my career, and I didn’t want to have a child. Look, God don’t punish me but if I could go back in time and not have any [children], I wouldn’t have had any.” (21 years old, completed high school, without a stable partner, 2 children, abortion before and after HIV diagnosis)

Discussion and conclusions

Study results point to a complex relationship between HIV infection, unwanted pregnancy and induced abortion in Brazil, confirming earlier quantitative study findings suggesting that the decision to terminate a pregnancy is not only influenced by HIV-related considerations.

In this qualitative analysis, HIV infection emerged as an important aspect of many women’s decision-making regarding abortion. However, even when being HIV-positive was clearly related to the decision to have an abortion, women always took into account other issues, such as their stage of life when the pregnancy occurred, the absence of partners and the absence of family support. While other authors have found many of these factors to be present in the decision to have an abortion among women not living with HIV,^23,24,28 we propose that in the case of WLHIV such factors become more relevant and are given significance by the real possibility of sickness or premature death.

Some factors that influenced women in our study to seek abortion, such as concern about transmitting HIV to their children or not being able to breastfeed, have also been identified in other studies of WLHIV. Particular issues include discomfort and fear in relation to the use of medication during pregnancy; women’s perceptions about what it means to be a “good” or “bad” mother in terms of not breastfeeding;^29,30 exposing the child to procedures that cause pain, like injections and medications; and fears related to their own health.³¹

The quantitative comparison of WLHIV and WNLHIV described in this paper’s introduction indicated that earlier sexual debut, higher number of sexual partners and history of sexual violence were the same factors associated with both HIV infection and induced abortion.^25,26 These findings are compatible with those of other authors who have noted a certain consistency in the reproductive behavior of WLHIV independent of their serological status.^13–16 The other authors’ findings suggest that being HIV-positive does not appear to alter pre-existing reproductive behavior patterns as these are shaped by the socioeconomic, cultural and health care context.

While in agreement with this general idea, our data suggest the importance of adding another point to the discussion. It may be that among women of reproductive age, both HIV infection and induced abortion are associated with similar contexts of vulnerability.³² HIV infection, unplanned pregnancy and subsequent abortion are all to some extent related to women’s lack of control over their bodies and sexuality. The lack of control often results in the non-use or incorrect use of condoms and contraception. Therefore, other factors relevant to reproductive decision-making, such as limited access to reproductive health services and social and gender inequality, as described in a recent study by Orner and colleagues,⁶ may also be associated with HIV infection.

If this is true, it helps to account for why an HIV diagnosis would not necessarily cause changes in pre-existing behaviors. HIV infection is a major life-altering event, but the changes that it introduces into sexual and reproductive practices depend on other factors that are not necessarily the same for all women. Our findings illustrate this point. While WLHIV who sought abortions often reported that their HIV infection stood out as a quite important factor, additional factors such as relationships, financial security and other life priorities took on different levels of significance for different women.

Understanding the complex circumstances that determine women’s sexual and reproductive practices, especially in the context of HIV infection, requires an analytical approach that goes beyond the individual dimension.²⁷ Contraceptive practices, pregnancy and abortion among WLHIV are influenced by multiple factors that act on various levels, including structural, social, interpersonal and individual. Examples of these factors range from beliefs and values concerning motherhood among WLHIV, access to health services, providers’ degree of social acceptance of people living with HIV, as well as providers’ attitudes about the reproductive rights of WLHIV, including the right to obtain an abortion.

While our study findings call attention to the potential role of health considerations and social and financial constraints in influencing decisions about abortion, some WLHIV in our study reported wanting to terminate pregnancies simply because they did not wish to be mothers, or preferred to have children at a later stage of life. These perspectives provide a reminder that the discussion about rights in relation to abortion should not be exclusively based on compassion for women who face specific hardships, but should recognize the right to abortion under any circumstance because it is a human right.³³

Research projects have called attention to the numerous benefits of integrated HIV/AIDS and reproductive health services. Integrated services provide streamlined care to WLHIV and result in better HIV and reproductive health outcomes.³⁴ Based on our finding that HIV infection and reproductive decisions and practices share similar contexts, we emphasize that health services should address these issues together.

Among the factors that contribute to women’s vulnerability to both HIV and unwanted pregnancy, the difficulty many health providers face in openly discussing the desires and sexual and reproductive needs of women and men living with HIV – beyond the mere prescription of condom use in all sexual relationships – stands out. This could be addressed through concrete interventions such as provider trainings and the restructuring of health care services. Such trainings must reinforce the ideal of reproductive and sexual rights as the fundamental basis of health care. Services must be structured to provide a place where women and men can find the necessary information and support for their decision-making.

Lastly, it is important to point out that our findings emerged from within the specific context of Brazil, where HIV prevention and treatment interventions are widely available. Nonetheless, our findings reflect a context in which HIV services do not generally incorporate reproductive and sexual health care, and in which safe abortion is not accessible for the great majority of women. Caution should, however, be exercised in translating these findings to other contexts.

This limitation notwithstanding, our research provides some important clues about how HIV infection and other factors may jointly influence women’s decisions about pregnancy termination. At the same time, many questions remain, pointing to the need for further studies on the relationship between HIV infection, sexual practices and reproductive outcomes in Brazil and elsewhere. Future research should include comparative designs that explore the intersections of the various contexts and dimensions surrounding these factors at specific points throughout women’s lives.

Acknowledgements

This research was supported by the Brazilian National Council for Scientific and Technological Development (CNPq 22/207 and 57/2008) and the Ministry of Health.

Notes

* We use the acronym WNLHIV to refer to all women who do not know their serological status, or who tested HIV-negative at some point in their lives.