HIV, unwanted pregnancy and abortion – where is the human rights approach?

Abstract

Abstract

The HIV/AIDS field is addressing how legal and policy restrictions affect access to health promotion and care, e.g., in relation to criminalization of HIV transmission, drug use and sex work. Work to address the reproductive rights of women living with HIV, particularly regarding unwanted pregnancy and abortion, has nevertheless lagged behind, despite its potential to contribute to broader advocacy for access to comprehensive reproductive health information and services for all women. It is in that context that this paper examines abortion in relation to the rights of women and girls living with HIV. The paper first presents findings from recent research on HIV-positive women’s reasons for seeking abortions and experiences with abortion-related care. This is followed by a discussion of abortion in relation to human rights and how this has been both addressed and neglected in policy and guidance related to the reproductive health of women living with HIV. The concluding remarks offer recommendations for expanding efforts to provide comprehensive, human rights-based sexual and reproductive health care to women living with HIV by including abortion-related information and services.

Résumé

Le secteur du VIH/sida analyse l’influence des restrictions politiques et juridiques sur l’accès à la promotion de la santé et aux soins, par exemple en ce qui concerne la pénalisation de la transmission du VIH, de la toxicomanie et du commerce du sexe. Le travail pour aborder les droits génésiques des femmes vivant avec le VIH, en particulier du point de vue des grossesses non désirées et de l’avortement, est néanmoins en retard, en dépit de son potentiel pour contribuer à un plaidoyer élargi en faveur de l’accès de toutes les femmes à des informations et des services complets de santé génésique. C’est dans ce contexte que l’article examine l’avortement en rapport avec les droits des femmes et des filles vivant avec le VIH. L’article présente d’abord les conclusions de récentes recherches sur les raisons ayant incité des femmes séropositives à avorter et leur expérience des soins liés à l’avortement. S’ensuit une discussion sur l’avortement dans la perspective des droits humains et la manière dont cela a été abordé et omis dans les politiques et les conseils relatifs à la santé génésique des femmes vivant avec le VIH. Les remarques finales proposent des recommandations pour élargir les activités afin d’assurer aux femmes vivant avec le VIH des soins de santé génésique complets et basés sur les droits humains en incluant des informations et des services relatifs à l’avortement.

Resumen

En el campo de VIH/SIDA se está investigando cómo las restricciones legislativas y políticas afectan el acceso a la promoción y los servicios de salud, por ejemplo, con relación a la penalización de la transmisión del VIH, el consumo de drogas y el trabajo sexual. No obstante, el trabajo para abordar los derechos reproductivos de las mujeres que viven con VIH, en particular referentes al embarazo no deseado y el aborto, aún está a la zaga, pese a su potencial de contribuir a que se abogue más a favor del acceso de todas las mujeres a información y servicios de atención integral a la salud reproductiva. En ese contexto, este artículo examina el tema de aborto en relación con los derechos de las mujeres y niñas que viven con VIH. Primero se presentan los hallazgos de recientes investigaciones sobre las razones por las cuales las mujeres VIH-positivas buscan servicios de aborto y sus experiencias con estos servicios. Después se trata el tema de aborto con relación a los derechos humanos y se analiza cómo esta relación ha sido abordada o ignorada en las políticas y orientaciones referentes a la salud reproductiva de las mujeres que viven con VIH. Las observaciones finales ofrecen recomendaciones para incrementar los esfuerzos por ofrecer servicios integrales de salud sexual y reproductiva, basados en los derechos humanos, a las mujeres que viven con VIH al incluir información y servicios relacionados con el aborto.

Key Words:

• HIV and pregnancy
• reproductive health
• abortion
• law
• advocacy

Since about the mid-2000s, the HIV/AIDS field has increasingly addressed how legal and political restrictions affect access to health promotion and care, e.g., in relation to criminalization of HIV transmission, drug use and sex work.^1–5 Such work is important for all people, regardless of their HIV status, as it contributes to improving the overall policy environment for provision of health care.

Work to address the reproductive rights of women living with HIV, particularly regarding unwanted pregnancy and safe abortion care, is nevertheless lagging behind. It was not until 2010 as a result of women’s advocacy that the official program of the International AIDS Conference included a session on unwanted pregnancy and abortion.⁶ Three factors contributed to the lack of attention given to this reproductive health need.

First, most advocacy regarding reproductive health for women living with HIV has centered on issues that more easily garner political and international support: efforts to increase access to, and use of, contraceptives; development of female-controlled HIV prevention methods; measures to reduce vertical HIV transmission; and opposition to forced sterilization and coerced abortion.

Second, much of the attention to women living with HIV has been in the context of a “baby-centric” approach, with women mainly considered in the context of preventing vertical HIV transmission rather than in terms of their own overall reproductive health needs.^7–9 For example, as pointed out at the 2011 United Nations General Assembly High Level Meeting on AIDS, only 34% of pregnant women living with HIV were assessed in 2008 regarding their need for antiretroviral therapy to safeguard their own health.¹⁰

Third, vocal opposition to abortion has led to inconsistency by UNAIDS, the agency coordinating the United Nations response to HIV/AIDS, in addressing abortion in relation to women living with HIV.^11–13 United Nations agencies are bound by the terms of consensus statements by United Nations Member States and there is no consensus document calling for amendment of abortion laws; however, the International Conference on Population and Development Programme of Action and the Beijing Platform for Action both call on governments to ensure that abortion is safe where permitted by law. Moreover, United Nations agencies must provide evidence-based technical guidance on health issues even if this contravenes countries’ existing policies.¹⁴ UNAIDS is beginning to do this with regard to restrictive laws related to HIV transmission, sex work and drug use, but much less so regarding restrictive abortion laws.

Restrictive governmental policies on abortion also have affected the work of non-governmental organizations (NGOs). The Mexico City Policy (“global gag rule”), which governed the provision of financial aid by the United States government until 2008, mandated that NGOs could not receive US funding if they addressed abortion or provided abortion-related care. Organizations in various countries lost funds as a consequence¹⁵ and other NGOs avoided incorporating abortion care into their programs. A review of proposals submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria in its first seven funding rounds revealed that only two of 210 proposals with reproductive health components mentioned abortion, which may be a result of the perception that inclusion of this health care component would not be accepted.¹⁶

In that context, the following paper examines abortion care in relation to the rights of women living with HIV. The first two sections present findings from recent research on HIV-positive women’s reasons for seeking abortions and on their experiences with abortion-related care. The studies were found through searches over a two-year period on the Internet and in the ISI Web of Science, PubMed, Popline and Sociological Abstracts databases to identify literature addressing abortion in the context of HIV. The paper then discusses abortion from a human rights perspective and how this has been addressed in policy and guidance regarding the reproductive health of women living with HIV. The concluding section offers recommendations for expanding efforts to provide comprehensive sexual and reproductive health care to women living with HIV by including abortion-related information and services.

Reasons for abortion among women living with HIV

While many women living with HIV wish to have children, studies in various countries have shown that others do not plan or want to have children (or additional children).^17–23 However, UNAIDS has noted that unintended pregnancy rates among HIV-positive women range from 51% to 90% in reported research.²⁴

HIV-positive women’s motivations for terminating pregnancies partly coincide with those of other women: the pregnancy resulted from rape or incest;²⁵ they did not use or were prevented from using contraception, or their method failed, but they did not want a(nother) child;²⁶ the pregnancy occurred too soon after their last childbirth;²⁶ they did not want to bring a child into an abusive relationship;²⁷ they were not in a steady relationship and could not cope alone; they did not have sufficient socioeconomic resources to care for the child;^26–28 and/or they already had the number of children they desired.²⁷

They also have reasons specific to their HIV status. One is fear of transmitting the virus to the baby, sometimes because they have suffered the illness or death of a child already and sometimes despite awareness of interventions to prevent transmission.^27–31 In this context, it is noteworthy that only 48% of pregnant women living with HIV around the world had access to effective regimens to prevent vertical transmission of HIV in 2010.³² Women also have reported fears of exposing a child to later stigma and discrimination²² or of leaving a child orphaned, thus imposing a childcare burden on remaining family members or leaving the child with inadequate care.^27–29 Some women have cited a need to use socioeconomic resources for their own health care and that of existing children, including HIV-positive children,^27,28,30 as well as a desire to focus on preserving their health without undergoing a(nother) pregnancy.^27,29,33

Women living with HIV are concerned about the issue of unwanted pregnancy not only because of the implications for their own health and wellbeing, but also because they care for daughters and other women confronting morbidity and life-threatening consequences of unsafe abortions.²⁶ For this reason, HIV-positive women in countries such as Botswana, Malawi, Namibia and South Africa have called for abortion to be legally available.^25–27,34

Abortion care for women living with HIV

Research among women living with HIV who sought abortions has revealed problems that they face with accessing services. In some instances, it is likely that all women seeking care encounter similar situations. In other cases, women reported the problems to be related to their known HIV-positive status.

Even in countries where abortion is permitted, women living with HIV may still be unable to access legal services. Women seeking abortions in India and Nepal reported being turned away from public and private health services, both when they revealed their sero-status and when they did not do so, indicating that access may be a problem for all women^30,31,35 Studies in India and South Africa have cited women who said they could not terminate pregnancies, either because they sought care too late or because health facilities delayed their request until it was too late.^23,27,36 Latin American women living with HIV who participated in focus groups organized by the NGO delegates to the UNAIDS Programme Coordinating Board reported that they were denied access to safe abortion because of noncompliance with existing protective laws.³⁷

Women may also receive faulty information and discriminatory treatment from health care providers. In a South African study, a few women were wrongly told that only one legal abortion is allowed per woman.²⁷ Reports from Namibia and South Africa cite women who said they were required to agree to sterilization in order to obtain a legal pregnancy termination.^38,39 Women in India and Nepal reported both verbal and physical abuse from health care providers, as well as providers’ refusal to use vacuum aspiration to complete the abortion procedure, in some cases because of the women’s HIV status.^30,31

Abortion and the rights of women living with HIV

Women’s right to terminate unwanted pregnancies in at least some circumstances has been affirmed by the international human rights system. To ensure that women living with HIV are enabled to access safe legal abortion for unwanted pregnancies, such guidance should be reflected in policy and programming documents regarding their reproductive health and rights.

One human rights treaty, the Protocol on the Rights of Women in Africa,⁴⁰ explicitly mentions a right to abortion; United Nations human rights bodies have also addressed abortion in relation to human rights. The United Nations Special Rapporteur on the right to health has explained that criminalization of abortion leads to violations of the rights to health, dignity, autonomy and freedom from discrimination.⁴¹ He further stated that governments must ensure that safe abortion and post-abortion care follow World Health Organization protocols, which would help guarantee women the right to the benefits of scientific progress. The United Nations Committee against Torture has expressed concern that total bans on abortion violate the right to be free from inhuman and cruel treatment,^42,43 while the Committee on the Elimination of All Forms of Discrimination against Women has stated that laws criminalizing medical procedures that only women need are a barrier to their access to appropriate health care.⁴⁴ The United Nations Human Rights Committee ruled that rights are also violated when abortion is refused in cases of rape.⁴⁵ When women are denied the opportunity to terminate an unwanted pregnancy, their right to decide whether and when to have children is also involved. Nevertheless, safe legal abortion care is only sometimes seen as an essential element of a human rights-based approach to providing reproductive health care for HIV-positive women.

Some NGOs have addressed abortion-related care in their HIV/AIDS-related policy guidance and program guidelines.^46–54 In 2010, NGOs advocated for inclusion of safe abortion in the outcome document for an African intergovernmental meeting on gender and HIV/AIDS, while in 2011 they took the same stance at the United Nations High Level Meeting on AIDS,^53,54 but both times governments failed to incorporate that language.^55–58

UNAIDS has a unique role in coordinating the work of 11 United Nations organizations in order to provide a consolidated approach to dealing with all aspects of the HIV/AIDS pandemic. The guidance issued by UNAIDS not only serves to inform the work of United Nations agencies, but also provides governments, academics and civil society organizations with a framework for research, policy and programming. Examples of UNAIDS publications issued between 1998 and 2011 unfortunately show inconsistency in its approach to addressing issues of pregnancy termination for women living with HIV.

The 1998 international guidelines on HIV/AIDS and human rights issued by UNAIDS and the Office of the High Commissioner on Human Rights state that laws should ensure women’s rights, including access to safe and legal abortion.⁵⁹ A 2000 protocol for identifying discrimination against people living with HIV mentions mandatory sterilization and abortion as a form of discrimination but does not address denial of legal abortion.⁶⁰

In its guidance for legislators and human rights institutions, UNAIDS has given differing advice. A 1999 handbook for legislators, issued by UNAIDS and the Inter-Parliamentary Union, mentions the need for legislation to prevent coerced abortion and to facilitate free reproductive choice, birth control and abortion.⁶¹ A 2007 handbook for parliamentarians by UNAIDS and the Inter-Parliamentary Union mentions forced abortion as a human rights violation, and states that “reproductive rights require governments to minimize restrictions on reproductive liberty and maximize access to resources that enhance autonomous reproductive decision-making,” but does not mention abortion in this context.⁶² A handbook for national human rights institutions, published in the same year, also mentions forced abortion as a human rights violation but does not refer to reproductive choice or decision-making at all.⁶³

UNAIDS officials have also addressed abortion differently in speeches at high-level venues. An address by the UNAIDS executive director at the opening of the United Nations Commission on the Status of Women in 2009 deplored sex-selective abortion as a form of gender discrimination,⁶⁴ while a speech by the executive director in 2011 to the Vatican’s Pontifical Council for Health Care highlighted the case of a woman living with HIV who was forced to have an abortion.⁶⁵ On the other hand, at a parliamentary breakfast on the occasion of the G8/G20 meeting in 2010, the UNAIDS deputy executive director stated that “reproductive health requires a comprehensive approach, including contraception, family planning and, yes, access to legal, safe abortion.”⁶⁶

The 2009 UNAIDS action framework for addressing women, gender equality and HIV states that HIV-positive women do not have access to the full range of reproductive health services but only mentions pregnancy termination in relation to coerced abortion.⁶⁷ The 2010 operational plan for implementing the framework notes that the reproductive health components of HIV services fail to consistently provide emergency contraception and safe legal abortion services, yet does not include recommendations on how to remedy this.⁶⁸ UNAIDS’ 2010 report on the global HIV epidemic notes that countries with high HIV rates among young women also face challenges in addressing unintended pregnancies and unsafe abortions.⁶⁹ The agency’s 2011–2015 strategy remarks that attitudes and laws in many societies “stifle public discussion of sexuality – for example, in relation to … abortion and sexual diversity.” However, in explaining how it will build synergies with the reproductive health community, UNAIDS only addresses work to provide pregnant women with antiretroviral therapy, antenatal care and full access to contraception.³²

In 2011, UNAIDS, the United Nations Population Fund and UN Women consulted influential leaders regarding the sexual and reproductive rights of women living with HIV and were told that gender-responsive, integrated HIV and sexual and reproductive health and rights services must include management of unsafe abortion complications and safe abortion where legal.⁷⁰ Nonetheless, UNAIDS’ subsequent report on planned work with UN Women to link HIV and reproductive health services only mentions eliminating coerced abortion.⁷¹ Terminology guidelines issued by UNAIDS in 2011 define sexual and reproductive health programs and policies as including prevention of unsafe abortion and post-abortion care but do not mention safe abortion.⁷² At the same time, a 2011 UNAIDS publication highlighting innovative community interventions to achieve sexual and reproductive rights for women through the HIV response features work addressing abortion in Malawi, Namibia and South Africa,⁷³ and another UNAIDS publication from that year states that “access to effective contraception and safe abortion must be recognized as a human right.”⁷⁴

In summary, UNAIDS followed up on its strong 1998 guidance document, which stated that women living with HIV should have access to safe legal abortion, by sometimes addressing this need in policy and programming documents, sometimes only addressing the human rights violations implicated in coerced and forced abortion, and sometimes failing to address abortion at all in action plans to integrate HIV and reproductive health services. As the lead agency in the field of HIV/AIDS, UNAIDS should more consistently promote access to safe legal abortion for women living with HIV, bringing its efforts up to par with the work taking place with regard to HIV and criminal law.

Advocacy for legal change in the HIV/AIDS field

Why is it important for UNAIDS and others working on HIV/AIDS to address abortion care for women living with HIV, including amendment of restrictive laws? Women living with HIV will not enjoy their full sexual and reproductive rights unless they are able to prevent and manage unwanted pregnancies through a full range of contraceptives, including female condoms, longer-acting methods and emergency contraception, as well as safe legal abortion. Advocacy and policy work on this in the HIV/AIDS field can strengthen and complement the work being done by organizations in the reproductive and maternal health field, to the benefit of all women and girls.

This requires a more vigorous women-centered and human rights-based approach to policies and programs for women living with HIV, similar to that being advanced in relation to other issues. For example, the Global Commission on HIV and the Law issued guidance regarding sex work, drug use, same-sex sexual relations, HIV transmission and violence against women. However, while a recommendation was made to stop coerced and forced sterilization and abortion among women living with HIV, it failed to call for revision of restrictive abortion laws so that HIV-positive women and girls (as well as all other women and girls) have access to comprehensive reproductive health care that can prevent unsafe abortions and their consequences.⁷⁵

UNAIDS states it is necessary to address punitive laws and policies, including criminal laws, because:

“Successful strategies for HIV prevention, treatment, care and support require supportive legal, regulatory and social environments that advance human rights, gender equality and social justice goals. Punishing and stigmatizing environments, in contrast, can increase people’s vulnerability to HIV infection, reduce access to and use of HIV services and other health and social services…” ⁷⁶

The same document names as examples of such laws and policies “legal and cultural barriers to sexual and reproductive health information and services” and “stigma and discrimination by health care workers (e.g. demeaning treatment, or denial of health care).” The denial of services and the provision of poor care to HIV-positive women seeking abortions are certainly manifestations of these issues.

Conclusions and recommendations

Enabling women and girls living with HIV to avoid the complications of unsafe abortions is a vital component of ensuring they have access to comprehensive reproductive health care. To achieve this, efforts to link HIV-related and reproductive health services must not only include access to contraceptive methods of their choice, non-discriminatory antenatal, delivery and postnatal care, and the provision of post-abortion care, but access to safe legal abortion as well. Health care providers must be able to discuss pregnancy termination in a non-directive and non-judgmental way and be able to refer women to safe legal abortion services. Those who provide abortion care should also ensure that their counseling includes provision of, or linkages to, HIV testing and support services for women living with HIV.

The research agenda to improve HIV-positive women’s ability to enjoy comprehensive reproductive health care needs to include additional research on the experiences of HIV-positive women in different countries in relation to unwanted pregnancy and abortion. A review of countries’ 2010 reports following up on the 2001 United Nations General Assembly Special Session on AIDS could provide an overview of national policies regarding HIV-positive women’s access to safe abortion care. Such studies should be complemented by clinical research documenting the effects of unsafe abortions among women living with HIV; assessing their experiences with different regimens of safe abortion care; and investigating whether these regimens should be adapted in any way to meet their needs. Studies should also determine how best to provide reproductive health counseling to HIV-positive women on dealing with failed contraception, accessing emergency contraception and seeking safe abortion care early in pregnancy if they wish to end an unwanted pregnancy.

To enable such an approach, advocates and agencies in the HIV/AIDS field should consistently include access to contraception, emergency contraception and safe abortion care in their work to ensure reproductive rights. Work on laws that impede access of people living with and affected by HIV to comprehensive health care should therefore also include advocacy to amend restrictive abortion laws and remove penalties for women who have had abortions. Such efforts will ultimately benefit not only women living with HIV but other women as well.