Sarah MacCarthy

HIV and Pregnancy Intentions: Do Services Adequately Respond to Women's Needs?

Too little is known about how an HIV diagnosis and access to care and treatment affect womens childbearing intentions. As access to antiretroviral therapy improves, greater numbers of HIV-positive women are living longer, healthier lives, and many want to have children. Effectively supporting womens reproductive decisionmaking in the context of HIV requires understanding how pregnancy, reproduction, and HIV intersect and asking questions that bridge the biomedical and social sciences. Considering women to be at the center of decisions on health policy and service delivery can help provide an appropriate constellation of services. A clear research agenda is needed to create a more coordinated approach to policies and programs supporting the pregnancy intentions of women with HIV.

The HIV Care Cascade: Models, Measures and Moving Forward

This article seeks to identify where delays occur along the adult HIV care cascade (“the cascade”), to improve understanding of what constitutes “delay” at each stage of the cascade and how this can be measured across a range of settings and to inform service delivery efforts. Current metrics are reviewed, measures informed by global guidelines are suggested and areas for further clarification are underscored.

The pregnancy decisions of HIV-positive women: the state of knowledge and way forward.

Abstract Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women’s ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights. Résumé Malgré le nombre croissant de femmes vivant avec le VIH et touchées par ce virus, la recherche, les politiques et les programmes accordent encore trop peu d’attention à leurs besoins, leurs droits, leurs décisions et leurs désirs relatifs à la grossesse. Nous avons analysé les publications pour vérifier l’état actuel des connaissances et dégager les domaines sur lesquels il convient de se pencher. Il en ressort que les options contraceptives pour la prévention de la grossesse chez les femmes séropositives sont insuffisantes : les préservatifs ne sont pas toujours disponibles ou acceptables, et d’autres choix sont limités du fait de leur coût, leur indisponibilité ou leur inefficacité. De plus, la stérilisation contrainte des femmes vivant avec le VIH est fréquemment rapportée. Des lacunes persistent dans l’information en rapport avec l’efficacité, la sécurité et les meilleures pratiques concernant les technologies de procréation assistée. Les résultats néonatals suscitent en général plus d’attention que la santé des femmes avant, pendant et après la grossesse. L’accès à des services sûrs d’avortement et de post-avortement, déterminant pour permettre aux femmes de jouir de leurs droits génésiques, est souvent réduit. Il faut s’intéresser davantage aux professionnelles du sexe, aux consommatrices de drogues injectables et aux adolescentes séropositives. Les nombreux obstacles que rencontrent les femmes vivant avec le VIH dans leurs relations avec les services de santé génésique façonnent leurs décisions en matière de grossesse. Il est capital que les femmes séropositives participent davantage à la conception et la mise en łuvre de recherches, de politiques et de programmes relatifs à leurs droits et besoins en rapport avec la grossesse. Resumen A pesar del creciente número de mujeres que viven con VIH y son afectadas por éste, en las investigaciones, políticas y programas aún no se presta suficiente atención a sus necesidades, derechos, decisiones y deseos con relación al embarazo. Realizamos una revisión de la literatura para determinar el estado actual de conocimiento y destacar las áreas que requieren más atención. Encontramos que las opciones anticonceptivas para la prevención del embarazo en mujeres VIH-positivas no son suficientes: los condones no siempre son accesibles o aceptables y otras opciones están limitadas por su disponibilidad, eficacia o costo. Más aún, se informa un alto índice de esterilización forzada entre mujeres que viven con VIH. Aún existen brechas en la información relacionada con la eficacia, seguridad y mejores prácticas respecto a las tecnologías reproductivas asistidas. Generalmente se presta más atención a los resultados neonatales que a la salud de las mujeres antes, durante y después del embarazo. A menudo se restringe el acceso a los servicios de aborto seguro y atención postaborto, los cuales son esenciales para que las mujeres puedan realizar sus derechos sexuales y reproductivos. No se presta adecuada atención a las trabajadoras sexuales VIH-positivas, usuarias de drogas inyectables y adolescentes. Los numerosos retos que encuentran las mujeres que viven con VIH en sus interacciones con los servicios de salud sexual y reproductiva influyen en sus decisiones respecto al embarazo. Es imperativo que las mujeres VIH-positivas participen más en el diseño y la implementación de investigaciones, políticas y programas relacionados con sus necesidades y derechos referentes al embarazo.

Responding to Her Question: A Review of the Influence of Pregnancy on HIV Disease Progression in the Context of Expanded Access to HAART in Sub-Saharan Africa

In 2007, sub-Saharan Africa was home to over half of all women living with HIV. The vast majority of these women are of reproductive age, which raises concerns about the high incidence of pregnancy. As access to antiretroviral treatment is rapidly scaled up, two important questions must be answered: (1) Does pregnancy impact HIV disease progression?; (2) Does pregnancy modify the highly active antiretroviral therapy (HAART) response on HIV disease progression? A systematic review of the biomedical literature was conducted and seven relevant studies were identified. To date, it appears that there is no effect of pregnancy on HIV disease progression. Furthermore, initial studies in high-income countries suggest that pregnancy may positively modify the HAART response. These findings, however, must be interpreted with caution as it remains unclear how other factors, such as adherence, may influence the relationship between pregnancy, HIV disease progression, and HAART.

Human rights in health systems frameworks: What is there, what is missing and why does it matter?

Abstract Global initiatives and recent G8 commitments to health systems strengthening have brought increased attention to factors affecting health system performance. While equity concerns and human rights language appear often in the global health discourse, their inclusion in health systems efforts beyond rhetorical pronouncements is limited. Building on recent work assessing the extent to which features compatible with the right to health are incorporated into national health systems, we examine how health systems frameworks have thus far integrated human rights concepts and human rights-based approaches to health in their conceptualisation. Findings point to the potential value of the inclusion of human rights in these articulations to increase the participation or involvement of clients in health systems, to broaden the concept of equity, to bring attention to laws and policies beyond regulation and to strengthen accountability mechanisms.

Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition.

Late presentation to HIV/AIDS services compromises treatment outcomes and misses opportunities for biomedical and behavioural prevention. There has been significant heterogeneity in how the term ‘late presentation’ (LP) has been used in the literature. In 2011, a consensus definition was reached using CD4 counts to define and measure late presenters and, while it is useful for clinical care, the consensus definition has several important limitations that we discuss in this article.

Making the invisible, visible: a cross-sectional study of late presentation to HIV/AIDS services among men who have sex with men from a large urban center of Brazil.

BackgroundLate presentation to testing, treatment and continued care has detrimental impacts on the health of HIV-positive individuals as well as their sexual partners’ health. Men who have sex with men (MSM) experience disproportionately high rates of HIV both globally and in Brazil. However, the factors that inhibit linkage to care among MSM remain unclear.MethodsWe conducted a cross-sectional study of HIV-positive MSM (n = 740) enrolled in HIV/AIDS services in a large urban center of Brazil from August 2010 to June 2011. Descriptive, bivariate and multivariate statistics were conducted using STATA 12 to examine the relationship between a range of variables and late presentation, defined as having a first CD4 count <350 cells/mm3.ResultsWithin the sample, the prevalence of LP was 63.1%. Men who self-identified as heterosexual (AOR 1.54 and 95% CI 1.08 - 2.20) compared to men who self-identified as homosexual and bisexual were at increased odds of late presentation. Additionally, men age 30 and older (AOR 1.56, 95% CI 1.01 – 2.43) compared to individuals age 18–29 experienced increased odds of late presentation among MSM.ConclusionsThe prevalence of LP in this population was higher than noted in the global literature on LP among MSM. Heterosexual men and older age individuals experienced substantial barriers to HIV care. The stigma around same-sex behaviors and the current focus of HIV prevention and treatment campaigns on younger age individuals may limit patients’ and providers’ awareness of the risk for HIV and access to available services. In addition to addressing HIV-specific barriers to care, developing effective strategies to reduce late presentation in Brazil will require addressing social factors - such as stigma against diverse sexualities - to concretely identify and eliminate barriers to available services. Only in so doing can we make currently invisible people, visible.

Contemplating abortion: HIV-positive women's decision to terminate pregnancy

Research on pregnancy termination largely assumes HIV status is the only reason why HIV-positive women contemplate abortion. As antiretroviral treatment (ART) becomes increasingly available and women are living longer, healthier lives, the time has come to consider the influence of other factors on HIV-positive womens reproductive decision-making. Because ART has been free and universally available to Brazilians for more than two decades, Brazil provides a unique context in which to explore these issues. A total of 25 semi-structured interviews exploring womens pregnancy termination decision-making were conducted with women receiving care at the Reference Centre for HIV/AIDS in Salvador, Brazil. Interviews were transcribed, translated into English and coded for analysis. HIV played different roles in womens decision-making. In all, 13 HIV-positive women did not consider terminating their pregnancy. Influential factors described by those who did consider terminating their pregnancy included fear of HIV transmission, fear of HIV-related stigma, family size, economic constraints, partner and provider influence, as well as lack of access to pregnancy termination services and abortifacients. For some HIV-positive women in Brazil, HIV can be the only reason to consider terminating a pregnancy, but other factors are significant. A thorough understanding of all variables affecting reproductive decision-making is necessary for enhancing services and policies and better meeting the needs and rights of HIV-positive women.

What's pregnancy got to do with it? Late presentation to HIV/AIDS services in Northeastern Brazil.

Despite the known benefits of early treatment initiation for individual morbidity and mortality, as well as for reducing the risk of transmission, late presentation (LP) to HIV/AIDS services remains a major concern in many countries. There is little information on LP from middle- and low-income countries and studies that do evaluate LP commonly disaggregate data by sex. It is rare, however, for researchers to further disaggregate the data by pregnancy status so it remains unclear if pregnancy status modifies the effects associated with sex. The study was conducted at the only State Reference Center for HIV/AIDS in Salvador, Brazils third largest city. LP was defined as a patient accessing services with a CD4 < 350 cells/mm3. Data were abstracted from the electronic medical records of 1421 patients presenting between 2007 and 2009. CD4 counts and viral load (VL) information was validated with data from the National CD4/VL Database. Descriptive and bivariate statistics were conducted to inform the multivariate analysis. Adjusted prevalence ratios (APR) were estimated using generalized linear models due to the high frequency of the outcome. Half of the sample (52.5%; n = 621) was classified as LP. Compared to the prevalence among pregnant women (21.1%), the prevalence of LP was more than twice as high among non-pregnant women (56.0%) and among men (55.4%). The multivariate analysis demonstrated no statistical difference between men and nonpregnant women (APR 1.04; 95%CI 0.92–1.19), but the APR of LP for nonpregnant women was 53% less than men (APR 0.47; 95%CI 0.33–0.68). These results highlight the importance of analyzing data disaggregated not only by sex but also by pregnancy status to accurately identify the risk factors associated with LP so that programs and policies can effectively and efficiently address LP in Brazil and beyond.

Engaging Human Rights in the Response to the Evolving Zika Virus Epidemic.

In late 2015, an increase in the number of infants born with microcephaly in poor communities in northeast Brazil prompted investigation of antenatal Zika infection as the cause. Zika now circulates in 69 countries, and has affected pregnancies of women in 29 countries. Public health officials, policymakers, and international organizations are considering interventions to address health consequences of the Zika epidemic. To date, public health responses have focused on mosquito vector eradication, sexual and reproductive health services, knowledge and technology including diagnostic test and vaccine development, and health system preparedness. We summarize responses to date and apply human rights and related principles including nondiscrimination, participation, the legal and policy context, and accountability to identify shortcomings and to offer suggestions for more equitable, effective, and sustainable Zika responses.