HIV and abortion – a human rights challenge
On International Safe Abortion Day (28 September), we give an overview of the link between HIV and abortion and the need for broader sexual reproductive health rights for women.
Women vulnerable to unintended pregnancy and unsafe abortions are the same women who find themselves vulnerable to HIV in the world’s poorest countries. Epidemics of gender inequality, poor access to health services and HIV are closely intertwined. So why is increasing access to sexual reproductive health rights (SRHR) services so challenging?
What is SRHR?
First of all, it’s important to distinguish what we mean by SRHR in its broadest sense. This summer, the Guttmacher–Lancet Commission presented a new holistic definition of SRHR which encompassed more than disease prevention and family planning. It included the right to make decisions governing one’s own body and sexuality, and the right to pursue a safe and pleasurable sexual life. It addressed sexual and gender-based violence, engaging men in their own health and integrating SRHR into other key health services.
Their recommended basic SRHR package now includes prevention, detection, and counselling for gender-based violence, infertility, cervical cancer and sexually transmitted infections (STIs), plus comprehensive sexuality education, safe abortion care, and counselling and care for sexual health and wellbeing. This is alongside traditionally recognised SRHR services for contraception, HIV and maternal and newborn care.
This re-definition of SRHR is important in light of increasingly prevalent regressive attitudes and policies which threaten women’s health worldwide.
The Global Gag
It's impossible to talk about SRHR in the context of global health without mentioning the Global Gag (also known as the Mexico City Policy). This US policy prevents foreign NGOs that receive US funding from providing safe abortions as a method of family planning – even if they use non-US funds to do so.
In short, no foreign organisation receiving bilateral global health funding from the USA can “perform or actively promote abortion as a method of family planning”. They are also unable to offer referrals or give advice on abortion as part of a family planning package – even where it is legally available.
Why is this an issue? Quite simply, research shows us that restrictive abortion policy increases the amount of women accessing unsafe abortions, resulting in more women dying. In terms of HIV programming specifically, it threatens to derail efforts to promote a women-centred approach to sexual and reproductive health rights services for women which focuses on rights and equality - where service integration is critical.
Giving women and girls the power to decide when they want to have a family is not only a basic human right, but a vital means to break cycles of poverty across lower income countries, by giving women the opportunity to stay in school and pursue better economic opportunities. Promoting the sexual and reproductive health rights of young women and girls is critical for reducing new HIV infections in this group who carry the largest burden of HIV, and particularly in sub-Saharan Africa.
But there is a large unmet need for contraceptives in low resourced contexts. In sub-Saharan Africa, less than a quarter (23.4%) of women report using contraception in 2017. Globally, an estimated 84% of unintended pregnancies are due to an unmet need for contraception. While increasing access to modern contraceptives so women can maintain control of their sexual health is important, other structural issues such as gender-based violence, inability to negotiate safer sex, early and forced marriage, a lack of comprehensive sexual health education, lack of agency, and low economic status can also contribute to unwanted pregnancies and HIV.
Stigma surrounding abortion and regressive policies mean that many women cannot access abortions if they want one, instead reverting to unsafe ‘backstreet’ abortions. Just under half (45%) of all abortions each year are considered unsafe. Around 97% of these occurred in developing countries in Africa, Asia and Latin America, say the World Health Organization (WHO).
Implementation and integration
Preventing HIV, unwanted pregnancies and unsafe abortions requires political will and cultural change. Governments need to ensure that the enabling environments exist that are conducive to women accessing SRHR services, through legal, policy and structural reform.
In their analysis, the Guttmacher–Lancet Commission call for health systems to be improved through interventions such as task shifting and by integrating services, particularly HIV. Accessible education and communication about SRHR should continue to be pushed, as well as taking advantage of technology and innovation.
Dr Bela Ganatra, lead author of the Lancet study and a scientist in the WHO Department of Reproductive Health and Research commented: “When women and girls cannot access effective contraception and safe abortion services, there are serious consequences for their own health and that of their families. This should not happen. But despite recent advances in technology and evidence, too many unsafe abortions still occur, and too many women continue to suffer and die.”
“Increased efforts are needed, especially in developing regions, to ensure access to contraception and safe abortion.”