1. T Mukotekwa 1, D Patel, B Engelsmann 1 1 Organization for Public Health Interventions and Development Trust (OPHID), Harare, Zimbabwe Zimbabwe National HIV&AIDS Conference, Harare, 5-8 Sept 2011+ Subsequent pregnancies among known HIV positive women - A Reproductive Health Right: Perspectives from HIV Positive Men and Women

2. Background  HIV epidemic in Zimbabwe is maturing  HIV related services have been more widely available for many years  1,200 PMTCT sites with 350,590 ANC bookings/2010  512 OI/ART sites with 326,241 clients on ART/2010 More women of reproductive age aware of their HIV positive status prior to pregnancy More women of reproductive age alive and in good health to contemplate second pregnancies More women experienced healthy pregnancy outcomes despite HIV positive status

3. Issues  PMTCT sites begin to see their clients with subsequent pregnancies  Mixed feelings among health care workers on how to handle these subsequent pregnancies  Little is known about the reproductive needs and intentions of this specific subgroup 3

4. Description  Murambinda Mission Hospital, Buhera district (Manicaland Province), one of the pilot sites of the national PMTCT programme, has provided PMTCT services to its clients since 2001  Care and treatment services include  Comprehensive post HIV diagnosis support (New Life) centres  Psychosocial support groups for PMTCT graduates  OI/ART clinic 4

5. Description  Increasing trend of subsequent pregnancies among HIV positive women who had gone through its PMTCT program noted in Murambinda.  In 2008:  1065 women booked for antenatal care in the district hospital  170 ANC bookings tested HIV positive  22 positive women transferred to ANC from OI/ART clinic  98 out of the resultant 192 HIV positive women in ANC were on ART  39 (20%) had previously accessed ANC + PMTCT services (“subsequent pregnancies”) 5

6. Description  Focus group discussions were held with two psychosocial support groups for PMTCT clients/graduates and their spouses (2010)  23 women  9 accompanying spouses  42 other men from support groups  Information collected on reproductive perceptions and needs to support HIV positive women 6

7. Lessons learned HIV education through PMTCT or OI/ART services (treatment literacy support) significantly enabled women to exercise their reproductive health rights “the counsellors tell us that if your CD4 count gets higher it is safer to have a child” 7

8. Lessons learned Increased access to triple therapy and combination ARV prophylaxis for PMTCT increased confidence of HIV positive men and women to anticipate a healthy outcome in a subsequent pregnancy “ARVs are here and our problems are not that big now” After being initiated on ART, they felt confident “to let nature take its course” 8

9. Lessons learned Gaps however identified in full understanding of risk among discordant couples Most subsequent pregnancies consciously planned to fulfil social obligations “My husband died. I just got married again. I need another child to cement the new relationship ” 9

10. Lessons learned Few subsequent pregnancies a result of cited family planning method failure “just found myself pregnant” Perceived attitude problem among health care workers attending positive women presenting with subsequent pregnancies “you continue to spread HIV because you are having unprotected sex” 10

11. Conclusions 11  Beneficial effect of HIV education at different service delivery points, indicating quality counseling  Few gaps: In depth counseling for discordant couples required  Education of health care workers to address attitudes problem (translating theoretical knowledge as provided in HIV education into attitudes and care behaviour)

12. Recommendations  Anticipation of and early planning for subsequent pregnancies in PMTCT clients (part of F/U services)  Greater efforts needed to sensitize health care workers and assistant personnel to appreciate reproductive needs of HIV positive persons 12

13. Acknowledgements Financial support (USAID, UKAid, EGPAF) Implementing partners (Kapnek, Zapp) Provincial and district health executives Murambinda Mission Hospital Psychosocial Support Groups Murambinda Hospital Mothers 13

14. THANK YOU 14