Diane Cooper

Fertility Intentions and Reproductive Health Care Needs of People Living with HIV in Cape Town, South Africa: Implications for Integrating Reproductive Health and HIV Care Services

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women’s fertility intentions. Gender differences were also apparent in participants’ key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.

HIV and pre-neoplastic and neoplastic lesions of the cervix in South Africa: a case-control study

BackgroundCervical cancer and infection with human immunodeficiency virus (HIV) are both major public health problems in South Africa. The aim of this study was to determine the risk of cervical pre-cancer and cancer among HIV positive women in South Africa.MethodsData were derived from a case-control study that examined the association between hormonal contraceptives and invasive cervical cancer. The study was conducted in the Western Cape (South Africa), from January 1998 to December 2001. There were 486 women with invasive cervical cancer, 103 control women with atypical squamous cells of undetermined significance (ASCUS), 53 with low-grade squamous intraepithelial lesions (LSIL), 50 with high-grade squamous intraepithelial lesions (HSIL) and 1159 with normal cytology. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multiple logistic regression.ResultsThe adjusted odds ratios associated with HIV infection were: 4.4 [95% CI (2.3 – 8.4) for ASCUS, 7.4 (3.5 – 15.7) for LSIL, 5.8 (2.4 – 13.6) for HSIL and 1.17 (0.75 – 1.85) for invasive cervical cancer. HIV positive women were nearly 5 times more likely to have high-risk human papillomavirus infection (HR-HPV) present compared to HIV negative women [OR 4.6 (95 % CI 2.8 – 7.5)]. Women infected with both HIV and high-risk HPV had a more than 40 fold higher risk of SIL than women infected with neither of these viruses.ConclusionHIV positive women were at an increased risk of cervical pre-cancer, but did not demonstrate an excess risk of invasive cervical cancer. An interaction between HIV and HR-HPV infection was demonstrated. Our findings underscore the importance of developing locally relevant screening and management guidelines for HIV positive women in South Africa.

Clients’ perspectives on HIV/AIDS care and treatment and reproductive health services in South Africa

Abstract Qualitative research was conducted with HIV-positive women and men of reproductive age attending HIV/AIDS care and treatment services at a public health clinic in Cape Town, South Africa. Focus group discussions were held with women (n = 4) and men (n = 4), and in-depth interviews were held with four men to explore perceptions and experiences of HIV/AIDS care and treatment and sexual and reproductive health (SRH) care. Respondents praised their HIV/AIDS care and treatment, reflected on how it improved their quality of life and contrasted this with suboptimal care at other public health facilities, including SRH services. Women wanted integrated services, especially for contraception and to reduce stigma. HIV-positive mens lack of experience with SRH services and antipathy towards attending “womens” health services were highlighted. Challenges to involving men in HIV/AIDS care and treatment and SRH services and measures to address this were identified.

Community attitudes towards sexual activity and childbearing by HIV-positive people in South Africa.

Abstract While the ability to lead a healthy sexual life and to choose whether and when to have children are well-established features of reproductive health and human rights, issues surrounding sexual activity and childbearing among HIV-infected women and men have received little attention in sub-Saharan Africa. We conducted a semi-structured, cross-sectional survey at 26 primary health care clinics in South Africa to investigate community attitudes towards sexual activity and reproduction by HIV-infected individuals. Of the 843 women interviewed, slightly less than half (43%, n=361) thought that people living with HIV/AIDS should remain sexually active if they choose, while 13% (n=113) said they thought that people living with HIV/AIDS should have children if they wished to do so. In multivariate analysis, negative attitudes towards both sexuality and childbearing were persistently associated with not knowing someone infected with HIV (p=0.001 and 0.043, respectively). These findings suggest that the sexual and reproductive health rights of HIV-infected women and men may be an important target as part of efforts to reduce HIV/AIDS-related stigma. Health policies and services are required to reinforce the reproductive rights of HIV-infected individuals in South Africa and other countries in sub-Saharan Africa where HIV is most prevalent.

Determinants of Sexual Activity and Its Relation to Cervical Cancer Risk among South African Women

BackgroundInvasive cervical cancer is the commonest cause of cancer morbidity and mortality in South African women. This study provides information on adult womens sexual activity and cervical cancer risk in South Africa.MethodsThe data were derived from a case-control study of hormonal contraceptives and cervical cancer risk. Information on age of sexual debut and number of lifetime sexual partners was collected from 524 incident cases and 1541 hospital controls. Prevalence ratios and adjusted prevalence ratios were utilised to estimate risk in exposures considered common. Crude and adjusted relative risks were estimated where the outcome was uncommon, using multiple logistic regression analysis.ResultsThe median age of sexual debut and number of sexual partners was 17 years and 2 respectively. Early sexual debut was associated with lower education, increased number of life time partners and alcohol use. Having a greater number of sexual partners was associated with younger sexual debut, being black, single, higher educational levels and alcohol use. The adjusted odds ratio for sexual debut < 16 years and ≥ 4 life-time sexual partners and cervical cancer risk were 1.6 (95% CI 1.2 – 2.2) and 1.7 (95% CI 1.2 – 2.2), respectively.ConclusionLower socio-economic status, alcohol intake, and being single or black, appear to be determinants of increased sexual activity in South African women. Education had an ambiguous effect. As expected, cervical cancer risk is associated with increased sexual activity. Initiatives to encourage later commencement of sex, and limiting the number of sexual partners would have a favourable impact on risk of cancer of the cervix and other sexually transmitted infections

Risk of invasive cancer of the cervix in relation to the use of injectable progestogen contraceptives and combined estrogen/progestogen oral contraceptives (South Africa)

Background: Cervical cancer is caused by specific types of the human papilloma virus (HPV), but not all infected women develop cancer. It has been hypothesized that hormonal contraceptives may potentiate the oncogenicity of HPV infection. Methods: In a case–control study of colored and black women in the Western Cape Province, South Africa, 524 incident cases of clinically evident invasive cervical cancer (stages lb–1V) were compared with 1541 controls, and with a subgroup of 254 HPV-positive controls. Findings: For injectable progestogen contraceptives (95% of which were depot medroxyprogesterone acetate) the overall relative risk, adjusted for confounding, was 1.0 (95% confidence interval 0.8–1.3); for combined estrogen/progestogen oral contraceptives the corresponding estimate was 0.8 (0.7–1.1). When the data were divided into categories of duration of use extending to ≥15 years, or according to age, ethnic group, or recency of use, there was no consistent evidence of an increased risk. The findings were unchanged when the cases were compared with the HPV-positive controls. Interpretation: The present findings suggest that neither injectable progestogen-only nor combined estrogen/progestogen oral contraceptives increase the risk of clinically evident invasive cancer of the cervix.

Women's Health Status and Use of Health Services in a Rapidly Growing Peri-Urban Area of South Africa

Womens health in South Africa and particularly women living in peri-urban areas is being influenced by three major factors. These include the political transition that is occurring in the country, urbanization and the international interest in womens health. Changes in the delivery of health care to the population, and in particular to women are being planned. It is therefore important that data are available for the purpose of planning and evaluation of health services. This paper describes a household survey in which 661 women were interviewed. Socio-demographic patterns of women living in a rapidly urbanizing area were determined and related to health status, use of health services and knowledge of the services. Poverty appeared to be an overriding factor affecting the health of the population. One third of the women were living in unserviced shacks. There was a high rate of unemployment and those who were employed worked in low status jobs and earned very little. Rates of reported acute and chronic illness were lower than described elsewhere in similar household interview surveys. A third of the acute illnesses were due to respiratory disease. Reported rates of diabetes and hypertension were low indicating undiagnosed disease in the area. Being a member of an alliance household-a mixture of family, friends and lodgers-was the main predictor of acute illness. For chronic disease, age and increasing educational status were the main predictors. Knowledge of services apart from those for cervical cancer screening was good. The latter improved with increasing education, urbanization and being a member of an alliance household. As many of the women lived in unserviced areas and had little or no income the provision of infrastructural services and development programs are essential if their health is to be improved. The existing health services need to be developed to provide a comprehensive primary care service with special attention being paid to the health of women. The service should be close to their homes and be affordable. The information gathered in this survey will be used to plan services for women in the area and will act as baseline data for evaluation.

Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study

BackgroundDespite abortion being legally available in South Africa after a change in legislation in 1996, barriers to accessing safe abortion services continue to exist. These barriers include provider opposition to abortion often on the grounds of religious or moral beliefs including the unregulated practice of conscientious objection. Few studies have explored how providers in South Africa make sense of, or understand, conscientious objection in terms of refusing to provide abortion care services and the consequent impact on abortion access.MethodsA qualitative approach was used which included 48 in-depth interviews with a purposively selected population of abortion related health service providers, managers and policy influentials in the Western Cape Province, South Africa. Data were analyzed using a thematic analysis approach.ResultsThe ways in which conscientious objection was interpreted and practiced, and its impact on abortion service provision was explored. In most public sector facilities there was a general lack of understanding concerning the circumstances in which health care providers were entitled to invoke their right to refuse to provide, or assist in abortion services. Providers seemed to have poor understandings of how conscientious objection was to be implemented, but were also constrained in that there were few guidelines or systems in place to guide them in the process.ConclusionsExploring the ways in which conscientious objection was interpreted and applied by differing levels of health care workers in relation to abortion provision raised multiple and contradictory issues. From providers’ accounts it was often difficult to distinguish what constituted confusion with regards to the specifics of how conscientious objection was to be implemented in terms of the Choice on Termination of Pregnancy Act, and what was refusal of abortion care based on opposition to abortion in general. In order to disentangle what is resistance to abortion provision in general, and what is conscientious objection on religious or moral grounds, clear guidelines need to be provided including what measures need to be undertaken in order to lodge one’s right to conscientious objection. This would facilitate long term contingency plans for overall abortion service provision.

‘He lacks his fatherhood’: safer conception technologies and the biological imperative for fatherhood among recently-diagnosed Xhosa-speaking men living with HIV in South Africa

This paper explores notions of fatherhood and their linkages to fertility desires and intentions among a treatment-naïve cohort of Xhosa-speaking male key informants living with HIV, aged 20–53 in Cape Town, South Africa. Analysis is based on an initial 27, and 20 follow-up, interviews with men who were part of a study that assessed the acceptability of safer conception and alternative parenting strategies among men and women newly diagnosed with HIV to inform an intervention. Grounded theory analysis revealed themes related to the cultural imperative of biologically-connected fatherhood. Certain safer-conception strategies aimed at minimising the risk of HIV transmission were perceived as threats to paternity. These findings suggest that understanding of social and cultural beliefs related to notions of paternity and fatherhood may inform the implementation of acceptable safer-conception options for HIV-positive men and their infected and uninfected female partners in a high-HIV prevalence, low-resource setting.

A qualitative exploration of HIV-positive pregnant women's decision-making regarding abortion in Cape Town, South Africa

HIV-positive womens abortion decisions were explored by: (i) investigating influencing factors; (ii) determining knowledge of abortion policy and public health services; and (iii) exploring abortion experiences. In-depth interviews were held with 24 HIV-positive women (15 had an abortion; 9 did not), recruited at public health facilities in Cape Town, South Africa. Negative perceptions towards HIV-positive pregnant women were reported. Women wanted abortions due to socio-economic hardship in conjunction with HIV-positive status. Respondents were generally aware that women in South Africa had a right to free abortions in public health facilities. Both positive and negative abortion experiences were described. Respondents reported no discrimination by providers due to their HIV-positive status. Most respondents reported not using contraceptives, while describing their pregnancies as ‘unexpected’. The majority of women who had abortions wanted to avoid another one, and would encourage other HIV-positive women to try to avoid abortion. However, most felt abortions were acceptable for HIV-positive women in some circumstances. Data suggested that stigma and discrimination affect connections between abortion, pregnancy and HIV/AIDS, and that abortion may be more stigmatised than HIV/AIDS. Study results provide important insights, and any revision of reproductive health policy, services, counselling for abortion and HIV/AIDS care should address these issues.