ASUNTA WAGURA'S healthy baby boy has sparked considerable controversy in Kenya. As an HIV-infected woman and AIDS activist, Asunta's decision to conceive a child exposes an emerging feature of the global HIV/AIDS pandemic: increased access to life-prolonging treatment is affecting women's reproductive choices, and challenging ideas about the kind of services and policies required.
If we are to keep pace with the evolving pandemic, concerns about women's reproductive health must become an integral part of HIV/AIDS services and policies.
Outdated notions of the virus still prevail, Asunta told me when I saw her recently in Kenya: "It's still regarded with the old lenses -- you are positive, you're only headed to the grave. That has to change." For many women, both those who are HIV-infected and those who are trying to stay uninfected, integrating reproductive health and family planning services with HIV/AIDS programs provides an otherwise missing link. Women benefit from family planning to prevent unintended pregnancies, which carry with them the inherent risks of transmitting the virus to the baby and contributing to the burgeoning population of AIDS orphans. HIV-infected women who want to have babies stand a much better chance of safely doing so when they have access to information and services to prevent mother-to-child-transmission during pregnancy and infant feeding. Still others prefer to access HIV/AIDS information, testing, and services through maternal-child health services, thus avoiding the stigma associated with stand-alone HIV/AIDS services. Fortunately for women in Kenya, integration of reproductive health and HIV/AIDS programs is gradually moving forward . The Kenyan government and the U S AIDS program, as well as civil society groups, have recognized the importance of linking AIDS and reproductive health services. A recently launched U S health program in Kenya includes funding from both the U S AIDS program and a small proportion of family planning/reproductive health funds -- not as much as advocates of program integration would hope for and too little to achieve all the synergies that would be possible, but nonetheless a step in the right direction. Similarly, the Kenyan Ministry of Health recognizes the importance of using existing reproductive health infrastructure to address HIV in women and is supporting pilot programs to integrate family planning and HIV counseling and testing.
Asunta, whose organization, the Kenyan Network of Women Living with AIDS, provides services for HIV-infected women, understands that not every Kenyan woman can make the kind of informed choices that she could: "I am an empowered woman, and I make the decisions that I want regarding my life. . . Not every other woman is as advantaged as I am." A U S official in Kenya noted that HIV-infected women without access to appropriate information and services run the risk of endangering the health of their babies and themselves. "Women should be our most important focus for prevention, care and treatment interventions, and we ought to look everywhere we can to find them," the official said.
Many challenges remain on the path to integrating reproductive health and HIV services for women, and much is at stake for US global AIDS policy. Promoting linkages between these programs would be a useful strategy to expand entry points for women to access HIV/AIDS services, to increase the efficiency and cost-effectiveness of AIDS programs, to build greater sustainability, and to help to address the shortage of health care workers. With women increasingly bearing the brunt of the epidemic, especially in Africa, focusing on new opportunities to reach them is essential for the success of prevention, care, and treatment programs.
Asunta and her baby force nations to face the new challenges in crafting innovative and effective responses to global AIDS. She has shown the need to address the prevailing negative attitudes surrounding sexuality of women living with HIV/AIDS, whether they seek contraception or pregnancy. And her experience suggests that integrating reproductive health and HIV/AIDS programs is a key to provide women access the information and services they need to make informed decisions about their personal and reproductive lives. As she put it: "At the end of the day, we have to make information accessible to women -- that's part of empowerment."
Janet Fleischman is a senior associate of the Center for Strategic and International Studies HIV/AIDS Task Force.