Eastern European Alliance for Reproductive Choice REPRODUCTIVE CHOICE FOR HIV- INFECTED WOMEN Prof. POSOKHOVA S.P. UKRAINE УКРАЇНАУКРАЇНА

July 2008 e Total: 33 million (30 – 36 million) Western & Central Europe [ – 1.0 million] Middle East & North Africa [ – ] Sub-Saharan Africa 22.0 million [20.5 – 23.6 million] Eastern Europe & Central Asia 1.5 million [1.1 – 1.9 million] South & South-East Asia 4.2 million [3.5 – 5.3 million] Oceania [ – ] North America 1.2 million [ – 2.0 million] Latin America 1.7 million [1.5 – 2.1 million] East Asia [ – 1.1 million] Caribbean [ – ] Adults and children estimated to be living with HIV, 2008

July 2008 e Estimated adult and child deaths from AIDS, 2008 Western & Central Europe8000 [4800 – ] Middle East & North Africa [ – ] Sub-Saharan Africa 1.5 million [1.3 – 1.7 million] Eastern Europe & Central Asia [ – ] South & South-East Asia [ – ] Oceania1000 [<1000 – 1400] North America [9100 – ] Latin America [ – ] East Asia [ – ] Caribbean [ – ] Total: 2.0 million (1.8 – 2.3 million)

The number of HIV-infected people in Ukraine increased at about 1.5% of the population ( )  80% of all HIV-infected people are in the reproductive age  50% are women The number of HIV-infected people in Ukraine increased at about 1.5% of the population ( )  80% of all HIV-infected people are in the reproductive age  50% are women УКРАЇНАУКРАЇНА HIV in Ukraine Population in Ukraine is 46,3 million

Reproductive rights Women with HIV have a right to decide about their reproductive choice European multicentral study found that 22% of HIV positive pregnant women had terminated a pregnancy since their HIV diagnosis, and 29% of them reported more than one pregnancy If HIV-infected woman chooses not to have children, she should be able to make informed, voluntary decisions about contraception and then received her method of choice.

Family planning and HIV-related services Integrating family planning and HIV/AIDS services aimed to: Ensure that HIV-positive women receive available family planning information and services Support the reproductive rights and fertility choices of HIV-positive women Prevent new HIV infections by encouraging dual protection Prevent unintended pregnancies of HIV-positive women and girls of reproductive age Treat sexually transmitted infections Reduce HIV transmission from mother to child Decrease the number of AIDS orphans

Reproductive Health in HIV- infected women We examined 870 HIV-infected women in family planning center during 2 years. We diagnosed: Chronic inflammatory gynecological diseases – 25% of women Cervical pathology – 31.7% (cervical cancer – 0.8%) STI: syphilis – 3.5%, trichomoniasis – 12.5%, herpes symplex – 8.5%, HPV- 12.5%, chlamydiosis – 18%

Family planning methods

Contraception for HIV-infected According to WHO’s Medical Eligibility Criteria for Contraceptive Use (2008) – most contraceptive methods are considered to be safe and effective for HIV positive women, both asymptomatic HIV and AIDS. Therefore, the consistent use of condoms is recommended not only for preventing HIV transmission, but also for preventing unintended pregnancies. Dual protection option – consistent use of condoms with one’s of another effective method of contraceptive

Barrier methods Current data suggest that male and female condoms are highly effective in protecting against pregnancy and STI’s. Our data showed that only 42.3% of HIV- infected couples used male condoms and less 1% of HIV-infected women used female condoms. These data showed lack of knowledge in HIV- infected people about the possibility re-infection of HIV and STI’s

Barrier methods Other barrier methods are generally not recommended for women with HIV Frequent use of spermicides containing nonoxylon-9 may increase risk of re-infection because N-9 can disrupt the lining of the vagina, making it more vulnerable to infection. N-9 offers no protection against STI’s. Giaphragms and cervical caps are not recommended for women with HIV.

Intrauterine device (IUD) Under the revised WHO guidelines, most HIV- infected women generally can initiated and use IUD and the levonorgestrel-releasing intrauterine system, and IUD users who became infected with IUD may continue using the device. The only exceptions are for insertions among women who developed AIDS and are not received ARV drugs or women with AIDS who are not responding well to ARV treatment

Hormonal methods The WHO recommends that HIV-infected women can safely use hormonal contraceptive – including combined oral contraceptives (COC), the injectables DMPA and implants (Norplant) According our data only 15% of HIV –infected women use hormonal methods These data explain not only the low awareness of women, but their inaccessibility due to the high cost of contraceptive

Emergency contraception (EC) For women living with HIV who suffer from sexual violence, access to emergency contraception may be vital. In general, women living with HIV and discordant couples still seem to have far too little knowledge of emergency contraception. For example, in Ukraine, qualitative studies conducted in our clinic attendees showed that only 1% of women and men living with HIV had some knowledge of EC or how to access it.

The number of abortion in HIV- infected women About 2.5 million women who become pregnant each year worldwide are HIV-positive. Very little research has been done on whether HIV-positive women have an increased risk of morbidity following abortions than HIV-negative women. Among HIV-infected women, the risk of complications was associated with immune status for surgical abortion

HIV and abortion Both MVA and medical methods of abortion are safe if provided according to international standards. For pregnancies up to 12 weeks gestation, MVA should be the preferred method overD&C HIV infected women may experience more complications than their HIV negative peers, due to the risk of infection, sepsis and haemorrage, anaemia.

The number of abortion in HIV- infected women in Ukraine

Medical abortion for HIV-infected women Our data showed the lack of knowledge about medical abortion is widespread, not only among HIV positive women, but also among service providers, policymakers. It has been suggested that medical abortion might be a preferable alternative to surgical abortion for HIV-positive women

Summary HIV-infected women face few restrictions on their use of modern contraceptive methods. Furthermore, use of effective contraception can play a key role in preventing HIV-positive births. For termination of pregnancy for HIV-infected should be used only safe methods of termination, as medical abortion or vacuum aspiration.

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