Reproductive Considerations in ART: Implications and Guidelines

1. National Antiretroviral Guidelines and Reproduction Among Women Using ART BY Madina Apolot madina.apolot@gmail.com 0752662739

2. Genesis of the Presentation • The presentation is based on the experience from working with HIV positive people initiating ART in HBAC Tororo

3. Guidelines on starting ART: reproductive aspect The guidelines are quite elaborate • Before start of ART counseling should be provided on: • Critical need to maintain safe sexual practices to prevent HIV transmission and re-infection • Safer options for reproduction and infant feeding • Current or planned pregnancy and the access to contraceptive services • Pregnancy risks: contraception options and choices • Sexual risks: willingness to practice safer sex, disclosure of HIV sero status, use of condoms • After start of ART follow-up should be done on: • Pregnancy risks: at every visit inquiry should be made on missed periods

4. Guidelines assumption • When you explain to people especially women about dangers or implications of pregnancy, women automatically will take decisions to control or prevent pregnancy

5. HBAC approach • All clients are educated on various HIV/AIDS aspects before start of ART: • HIV/AIDS basic information. • Reduction of risk of HIV transmission. • Implication of pregnancy in women living with HIV/AIDS. • Pregnancy and Antiretroviral therapy. • Ideally clients are started on ART, only when they have a clear understanding of the aspects above

6. Out come of the HBAC process • Clients still desired to become pregnant • Clients became pregnant. • Cases of repeated abortions and miscarriages were reported. • All these happened in spite of HBAC’s efforts to provide the clients with information about risks of pregnancy as per the guidelines

7. A part from information, what factors influenced reproductive decisions? • Cultural beliefs that people hold about child bearing and the role of women and me in society. • A child for self identity eg a true adult is the one with children, a true woman is the one with children. • Children for security: • children are highly regarded as potential resources and assets in the family. • Children as an insurance against old age. • Security for women; for maintenance of marriage relationships, inheritance of property from husband and support from husbands

8. Factors influencing reproductive decisions cont. • Children for preservation and continuity of self, family, clan and society • Pressure to reproduce themselves so as to have themselves continuing to live even after death and hence have the society continue to exist. • Producing a son provides the opportunity of continuity of self and society. • To have children is to exist: it is the very basis of survival • The desire to have children normally supersedes any danger to the body associated with having children especially for Childless people.

9. What are some of the implications of these reproductive decisions? • The objectives of the guidelines (prevention of HIV transmission and prolonging life) will be less effective: • Primary HIV infection in case of discordant couples. • Risk of transmission of HIV to the baby • Deteriorating of health of mothers eg: pregnancy (morning) illness

10. Observations • Guidelines seem to be guided by the current dominant politics of gender in ARV provision and not research. • Guidelines do not reflect some important aspects that guide the decisions of people to reproduce.

11. Conclusions • In light of what I consider shortcomings in the guidelines isn't it time/necessary to revise them? • How does one mainstream the above aspects (which influence reproduction decisions in a specific cultural setting) to inform the national guidelines, when we are faced with varying cultures in Uganda? • Given the risks people are willing to take to reproduce themselves in some of these settings (despite our policy makers and academicians/researchers concerns) are we not faced with a huge knowledge deficit that justifies a major research undertaking in order to be more effective?