In-depth: The Treatment Era: ART in Africa

SOUTH AFRICA: HIV-positive and pregnant - weighing the risk

Photo: IRIN

AIDS councillors hear varied reasons from women as to why they want to conceive Credit: IRIN

NAIROBI, 6 December 2004 (IRIN In-Depth) - As anti-AIDS drugs become available to more South Africans, a growing number of HIV-positive women are choosing to become pregnant in spite of their status.

Although it is generally accepted that all women have the right to bear children, society finds it harder to accept when women living with the virus exercise that choice.

Admittedly there are risks involved. In the absence of intervention, an estimated 15 to 30 percent of mothers with HIV will transmit the infection to their baby by the time it is born, according to the World Health Organisation. A single dose of Nevirapine, given to mother and baby, halves the chances of infection during labour, when the risk of transmission is highest.

"Initially people assumed that if someone knew their HIV-positive status, then pregnancy was a 'no-no'. But the reality is that most of these people are young women in their prime, who want to have babies," Dr Pumla Lupondwana, a research doctor at Chris Hani Baragwanath hospital in Johannesburg, told PlusNews.

Lupondwana is conducting a study on resistance to Nevirapine at the perinatal HIV research unit based at the hospital. She estimated that about a third of the 250 women participating in the trial had made a conscious decision to fall pregnant. In fact, an increasing number of women were second-time mothers who had been diagnosed HIV-positive during their first pregnancy.

"They've been exposed to Nevirapine, and they know all the risks involved," she said.

The reason for having a baby varies. According to Lupondwana, some may want a child they can leave behind as "some form of legacy or reminder". For some women, a new partner might insist on having a baby, with the woman too afraid to disclose her status. But pressure from the community, and fear of stigma and discrimination were other reasons, she explained.

HIV-positive Theodora's (last name withheld) third child will be one year old this month. Theodora was diagnosed during her second pregnancy and received Nevirapine, but the baby died a week later from meningitis.

In April last year she conceived again, after she had become resistant to Nevirapine during her second pregnancy. "I had wanted to wait a bit longer, but I really wanted this baby - there was this hole inside me after the first one died. I knew this was my last chance," she said.

In a study presented at the 2004 International AIDS Conference in Bangkok, Thailand, South African virologist Dr Lynn Morris showed that although there was high resistance to Nevirapine six weeks after a woman had taken a single dose, this dropped to 14 percent after six months.

Resistance to Nevirapine decreases the drug's effectiveness and makes it difficult to treat the baby if it is born HIV-positive.

After consulting with her doctor and undergoing CD4 count and viral load tests (which measure the strength of the immune system and the amount of HIV in the blood), Theodora had a safe pregnancy and her baby was born HIV-negative.

"I ate more fruit and vegetables, and did all the things you should be doing anyway when you are pregnant and negative. But for the whole nine months I was being eaten up with worry, thinking about all the risks."

Most HIV-positive pregnancies are usually trouble-free, unless the mother is at an advanced stage of the disease and has a compromised immune system, Lupondwana said.

Of concern to Lupondwana and her colleagues, however, is the fact that most of the women are practising unsafe sex, despite receiving extensive family planning advice.

"Some might have planned to have the babies, but most of these women are having unplanned pregnancies because they are not using any form of contraception, or their partners refuse to use condoms," she commented.

Sharon Ekambaram, an AIDS activist and former PMTCT coordinator of the lobby group, the Treatment Action Campaign, pointed out that the country's prevention of mother-to-child transmission of HIV (PMTCT) and antiretroviral (ARV) rollout programmes had failed to take this into account.

"These programmes are missing the point by not addressing the woman's inability to disclose to their spouse or partner and negotiate safer sex. These women are forced to hide the fact that they are on treatment, just to avoid disclosure," she said.

Theodora, for example, admitted that she was "alone in my HIV status". When she found out she was pregnant the first time, her partner told her not to take an HIV test. "I went behind his back and tested because I wanted to know for myself. I didn't tell him the result and he still doesn't know," she said.

There are many women in a similar position at her support group meetings. "Their men don't want them to use condoms, and they are too scared to tell them about having HIV, so they just keep quiet," Theodora said. "When some women did gather the courage to disclose, the men would say 'if we both have it, then it doesn't matter - we don't have to use condoms.'"

With a CD4 count of 131, Theodora is on a waiting list to receive free ARVs and has not decided whether she will disclose to her partner. They are both unemployed and survive on a government child support grant.

"I really don't understand why I'm on a waiting list because, with all the stress I'm having, it [CD4 count] can go even lower - I don't even want to think of [dying and] leaving my children now," she said.

The latest UNAIDS report on the global AIDS epidemic estimates that in South Africa the number of orphans is expected to increase from 2.2 million in 2003 to 3.1 million by 2010.

According to the latest numbers from the Joint Civil Society Monitoring Forum, an NGO coalition set up to monitor the ARV rollout, about 18,500 South Africans are accessing ARV treatment.

Nevertheless, as an increasing number of people receive treatment and start living longer, government would "have to stay on top of their PMTCT programme," Lupondwana warned.

"More and more HIV-positive women will want to have kids - this is still a new issue that hasn't been adequately dealt with in the public sector. Healthcare workers cannot afford to be "judgemental" by treating women living with the virus, who choose to have babies, "as if they are crazy", she added.

Lupondwana cautioned that becoming pregnant when HIV-positive still has its risks, as it could compromise the woman's immune system. "But, at the end of the day, it is their choice to make."

The Treatment Era
ART in Africa

December 2004
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Links & References

The WHO 3 by 5 Initiative
www.who.int
The Global Fund to Fight HIV/AIDS Tuberculosis and Malaria
www.theglobalfund.org
The President's Emergency Plan for AIDS Relief
www.usaid.gov
World Bank AIDS site
www1.worldbank.org
Pan-African Treatment Access Movement
www.patam.org
WHO Prequalification Project
http://mednet3.who.int/
Eldis Resource on ARVs
www.eldis.org

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