Chapter XVI
International Issues

Suniti Solomon, MD;
Dorothy Kasonde, MBCHB, MMed;
Valdiléa Gonçalves Veloso dos Santos, MD, MSc;
Jean R. Anderson, MD

I. Introduction  TOP

Of the estimated 40 million individuals living with HIV/AIDS around the world, approximately 95% live in resource-constrained settings and have fragmented health care systems and of these, over 50% are women (UNAIDS, 2003). This represents what Peter Piot, the Executive Director of UNAIDS, has called the “increased feminization of the epidemic.” In a recent address to the World Bank, he said “Every year we see an increase in the number of women infected with HIV…Because of global inequality, women living with HIV/AIDS often experience more stigma and discrimination. And since women are the main care givers and source of household labour, their illness means the collapse of family community care systems and household protection.” (Piot, 2003). One of the legacies of HIV in the developing world and especially in women is the millions of orphans, estimated to comprise 15% of all children in the worst affected countries by 2010. Recognizing the global burden of HIV disease and the inequity in availability of resources, including antiretroviral drugs, and the resulting erosion of decades of progress in health and economic indicators, there has been a growing consensus that international response and collaboration are critical and growing political momentum. In the 2003 State of the Union address President Bush committed US$15 billion to fight HIV/AIDS over the next five years and in November 2003 the US Congress allocated US$2.4 billion to international AIDS activities for the 2004 budget year. These funds are managed by the Global AIDS Coordinator’s office by the newly appointed Ambassador, Randall Tobias. The Global Fund to Fight AIDS, TB and Malaria represents a partnership between governments around the world, civil society, the private sector, and affected communities to provide resources directly to resource-constrained countries to address their specific HIV care and prevention needs. The United Nations 3 by 5 initiative is led by WHO and UNAIDS with the goal of getting 3 million people on antiretroviral treatment by 2005.

This chapter includes a discussion of the special considerations and challenges for HIV+ women in three representative countries from three representative regions. While this cannot represent all countries and regions struggling with the HIV pandemic, each of the countries discussed presents a unique perspective on the HIV/AIDS pandemic from resource-constrained settings: India is the second most populous country in the world with over one billion people; although HIV prevalence there is currently only approximately 0.7%, this translates into almost 4 million persons living with HIV/AIDS and trends show prevalence to be increasing. It is one of the few countries that initiated HIV prevention activities in the very early stages of the epidemic. In 2002, India started prevention of HIV transmission from mother to child on a large scale using single dose nevirapine. In April 2004, there is planned a roll out of combination antiretroviral therapy (d4t, 3TC, and nevirapine) to all those who need it in the six states of India with the highest prevalence.

Zambia is a high-prevalence country (approximately 16%) in the highest prevalence region in the world, sub-Saharan Africa. Among Zambians 15-24 years of age, women are two-and-a-half times as likely to be HIV-infected as men (Zambia Demographic and Health Survey, 2001-2002). Each of these three discussions is anchored by women who have a long and distinguished history as care providers and/or advocates for women living with HIV in these three countries.

Brazil is a country with limited resources that has made the political commitment to provide antiretroviral therapy for all of its citizens with HIV infection and has seen decreases in morbidity and mortality equal to that seen in resource-rich countries.

II. India  TOP

In India 85% of women with HIV were infected through heterosexual contact and over 90% reported a single lifetime partner, generally their spouse (John, 1993; Gangakhedkar, 1997; Newman, 2000). Blood transfusion was the source of infection in almost 8% of women; single unit transfusions are commonly given during childbirth and abortion to manage hemorrhage. Common clinical manifestations in HIV-infected women include vaginal and oral candidiasis, pulmonary tuberculosis, skin lesions, genital ulcers, weight loss, and diarrhea.

There are a number of cultural beliefs and practices that present special challenges to HIV care and prevention. In India there are different values placed on the birth of a female and a male child. A woman’s primary social function is to assure caste community and continuity of property through the birth of sons. Only sons can perform certain rituals, such as funeral rites for their parents. Furthermore, parents must often pay large dowry amounts for their daughters’ marriage. This has resulted in overwhelming importance given to bearing sons, resulting in use of prenatal ultrasound commonly for sex determination with elective termination of female fetuses and a low overall female to male ratio of 100:144. Therefore, women begin life as devalued and considered a liability.

In ancient times India offered to the world the renowned treatise on sexuality The Kamasutra. Sexual imagery found a pride of place in temple sculptures and elaborate rituals covered marriage, nuptial nights, pregnancy, and childbirth, recognizing sex and reproduction as part of the social process. Such openness about sex and sexuality is now nearly absent. As a woman attains puberty, she is expected to maintain a culture of silence when confronted with issues of her own sexuality, preventing access to information. There is a great deal of pressure to maintain virginity until marriage. Many women engage in alternative and even risky sexual behaviors, such as anal sex, in an effort to maintain their virginity. When women do engage in sex, their ignorance and the continued culture of silence make them unable to negotiate safer sex practices.

As with virginity, motherhood is considered a virtue and using barrier methods or non-penetrative sexual practices is seen as an affront to the concept of motherhood. The worst offense a woman is held guilty of is the inability to bear children. Her life is reduced to violence, rejection, and misery. The pressure to have children is equally great among HIV serodiscordant couples. In one study from an HIV care center in south India, 44% of couples were serodiscordant for HIV, but many women were willing to risk acquiring HIV in order to conceive a child (Solomon, 2003). “I would rather be HIV positive than a barren woman,” said Aruna, one HIV-uninfected woman whose husband has HIV infection. “If my neighbor sees me as she goes out to work, she considers it so inauspicious that she will go back home to cleanse herself under the shower.” Parents-in-law of these women may extend threats that their sons will marry a second time and produce a child by his second wife.

Violence against women is a fact of life in India. A woman has the duty of pleasing her husband; if she refuses sex, she risks violence, abuse, and abandonment. These women tolerate their husband’s infidelity and abuse and submit to their demands to avoid further abuse, remaining in these relationships for fear of abandonment. The culture of silence is maintained and many view this violent relationship as “normal.” A woman is raped every 34 minutes in India and a woman is burnt to death over dowry every 93 minutes (UNIFEM, 2000).

AN INNOVATIVE PROGRAM FOR WOMEN

YR Gaitonde Center for AIDS Research and Education (YRG CARE) is an innovative program for women that offers a number of services to women with or at risk for HIV. Couples counselling and testing promotes open communication between genders and can reduce practices of blaming the woman and can encourage both partners’ involvement in decision-making, help them plan their future together, reduce risks and improve their quality of life. Family counselling is also offered to help other family members realise that the couple needs all their support to achieve a better quality of life.

In India marriages are not “made in heaven”. Parents arrange them, usually within the same caste and religion. The first step is to match horoscopes; if the majority of the houses in the astrological charts of the prospective groom and bride match, their parents meet and finally the couple are introduced to each other. This usually occurs when the man is 24–25 years of age and the woman is 18–21 years. At YRG Care there is a marriage counseling center where HIV seropositive men or women who are under pressure to marry are counseled, their needs assessed, and efforts made to introduce them to suitable partners.

There is a cohort of 1908 women followed at YRG CARE, of which 693 are HIV-negative married to husbands with HIV. These women are under great pressure from the parents-in-law to bear children, but neither the husband or wife is able to discuss HIV-related issues, including the need for safe sex, because of the stigma attached to HIV disease. Through counseling services at the center, these couples are given various options including adoption; artificial insemination using donor semen; antiretroviral therapy for the husband to reduce plasma viral load, in turn decreasing HIV transmission from husband to wife while trying to conceive; or artificial insemination with washed semen from the husband. This service allows these couples hope, while helping protect the woman both from rejection and from HIV.

Other services offered through YRG CARE include provision of at least one balanced meal daily to a woman and her husband when he is in the hospital through a novel scheme called “365 Good Friends,” in which people donate money on their birthday, sufficient for 50 meals. This saves the woman from having to cook and bring food from home to the hospital, as would usually occur. This initiative is presently assisted by the Andrew Ziegler Foundation, which is helping YRG CARE to find ‘Good Friends’ who will donate $100 towards daily meals to improve the nutrition of our patients.

YRG CARE also provides HIV and sexuality education to industrial employees. This has resulted in many requests to also conduct such programs for the employees’ family members and for women in the neighboring community. It was felt that such knowledge would empower these individuals in their efforts to prevent the spread of HIV.

There remain many challenges for HIV prevention and management for women in India. Girls must be provided with the same educational opportunities as boys, both in terms of general academics and in the area of sexuality. Because gender inequities and power dynamics inherently involve both sexes, it is important that men be included when addressing issues affecting women. It may be helpful to better educate and sensitize both young women and young men about sexuality and about gender with the goal of reducing risky behaviors and violence, while enhancing information-seeking behavior and female equality. . Another important source of power is access to economic resources and assets. Educational programs along with skills training programs and microcredit loan schemes can help women to achieve economic independence.

Women in sex work have historically been disempowered and are at risk for exploitation, violence, and infection. Programs that organize and mobilize sex workers have been successful in increasing the power of these women and their communities. Organizations from all over India have combined into The National Network of Sex Workers to improve social, economic, and health conditions. These programs must be strengthened and expanded. The development of female-controlled methods of HIV/STI prevention, particularly those that can be used in secrecy, should be a major research priority and has significant implications both for sex workers and for women in primary relationships. In one study 89% of men would allow their non-primary sexual partners to use microbicides to prevent HIV and STI transmission and only 42% would allow their primary sexual partners to use them (Srikrishnan, 2001).

Although over 48% of Indians are women, they represent less than 10% of individuals in the parliament, the State High Courts and Supreme Courts, and in Civil Service administration. Political representation of women will be important to further advance many issues relating to women’s health and empowerment (Rao Gupta, 2002).

Lack of access to health care prevents women from having control over their lives. Since it is often difficult to access services without the permission or monetary support of their husbands and in-laws, steps must be taken to provide services to women in convenient, low cost, and discreet environments. In YRG CARE 61% of men and 76% of women who needed antiretroviral therapy were not able to secure the drugs. In a family wherein both husband and wife require antiretroviral therapy and the finances are sufficient for one person only, the man is usually the one who accesses the medications. HIV-infected women are also less likely to have laboratory investigations such as CD4 counts or viral loads. The Government of India currently has a project funded by the Global Fund for AIDS, TB and Malaria for prevention of mother-to-child transmission (PMTCT) which will supply ARV therapy not only to prevent MTCT but also for treatment of parents with CD4 counts less than 200/mm3 in 11 centers in the country.

III. Zambia  TOP

It is estimated that some 1.2 million Zambians are living with HIV/AIDS and prevalence in women is 12.9%, with significantly higher rates in women as compared to men throughout most of the reproductive years. The prevalence rates for both men and women are two-fold higher in urban than in rural areas. Although awareness about HIV/AIDS is high, this does not translate into positive action for prevention and both uptake of voluntary counseling and testing (VCT) and condom use are low (Zambia Demographic and Health Survey, 2001-2002). Women are most often offered VCT during antenatal care, after a spontaneous abortion or stillbirth, with death or failure to thrive in a child, with presentation of a sick child or partner to the clinic, after death of a partner, or when seeking treatment for frequent illnesses.

In sub-Saharan Africa tuberculosis (TB) is the most common HIV-related opportunistic infection (OI) and a leading cause of death. TB has special implications for the health of women: a study of 775 maternal deaths at the University Teaching Hospital of Zambia (Ahmed, 1999) found that 255 were due to TB and in 92% of these cases the woman was HIV+. TB endometritis is a major cause of infertility. The most recent national statistics indicate that 70% of TB patients have HIV infection (Zambia Demographic and Health Survey, 2001-2002).

Sexually transmitted infections (STIs) are a major problem in sub-Saharan Africa in general, including Zambia. STI prevalence is 56% among sex workers in Zambia (Family Health International, unpublished data, 2003) The East, Central, and Southern African Commonwealth region has adopted syndromic management of STIs, in which immediate treatment is given for all major causes of certain presenting symptoms (e.g., genital ulcers), based on local information about etiologies of the symptom and drug susceptibility patterns. Etiologic diagnosis with cultures and other laboratory tests is not generally available. Syndromic management is cost-effective and encourages people to access treatment at all levels of care. However, it does not identify those individuals with asymptomatic infection, which is more common in women. Contact tracing may help identify sexual partners, especially wives, who may be asymptomatic. Presumptive treatment should be offered to all sexual partners of persons being treated syndromically.

Invasive cervical cancer is the most common gynecologic malignancy in Zambia and is considered an AIDS-defining condition in the presence of HIV infection. Rates of preinvasive cervical lesions are significantly increased in the presence of HIV and both prevalence and severity increase with progressive immunosuppression. Routine Pap smear screening is not generally available throughout Africa, in either urban or rural areas, and women usually present in advanced stages of disease. As antiretroviral treatment becomes more available, invasive cervical cancer may become a still greater problem as women with HIV live longer with their infection but still suffer the consequences of HPV infection and progressive cervical dysplasia.

Although malaria does not appear to be more severe or more prevalent in HIV-infected individuals in general, in HIV+ pregnant women HIV hinders the ability to control Plasmodium falciparum infection and peak parasite prevalence occurs earlier in pregnancy. While in the HIV-uninfected pregnant woman a single dose of sulfadioxine pyrimethamine (SP) is sufficient to clear parasitemia, two to three doses are required in the HIV+ woman (Schulman, 1999). Malaria is a principal cause of severe anemia and intrauterine growth restriction in pregnancy (Steketee, 1996); in the HIV+ woman anemia related to malaria is exacerbated by nutritional deficiencies or wasting, other infections, and HIV-related illnesses. Malaria is estimated to be responsible for more than 20% of all maternal deaths in sub-Saharan Africa. Placental parasitemia is increased in the presence of HIV and may increase risk of MTCT.

CHALLENGES TO PREVENTION AND TREATMENT:

• The environment of poverty (these issues apply to sub-Saharan Africa in general): Literacy and education levels are low, particularly for women, and these factors are associated with lower use of condoms (Zellmir, 2003; Zambia Demographic and Health Survey, 2001-2002). Because of high unemployment levels, women may turn to sex work in exchange for favors or money needed to feed and educate their children, further increasing their risk of acquiring HIV. Lack of clean accessible water increases the incidence of diarrheal diseases and risk of malnutrition in those with HIV. Overcrowding in households occurs with several generations in an extended family often living together in small houses because of unemployment and because of incorporation of AIDS orphans into these families. Women and girls in these settings may be at increased risk for domestic and sexual violence and for neglect of their own health care needs. In several countries in Africa there is civil unrest and war. This has led to increased HIV risk for women, who are vulnerable to rape and intentional impregnation. Where there have been peacekeeping soldiers from high-HIV prevalence areas sent to low-prevalence countries, women in those countries have been at increased risk for contracting HIV. Women who are refugees from war and drought or famine are also at increased risk for HIV because of their vulnerability to violence and to sexual coercion and because of extreme economic dependence. Finally, health care infrastructures and resources are inadequate for the diagnosis and management of HIV disease and other general health conditions.
• Violence against women and sexual violence occurs in 4.4% of ever-married women (50% in the last 12 months). (Zambia Demographic and Health Survey, 2001-2001)
• Cultural issues (many of these issues apply to other countries in Africa, not just Zambia): Women are care providers but their work is not considered in monetary terms. When the husband dies his relatives come to claim the property because the woman did not contribute money for the purchase of land, house, or household goods. Because of their lack of monetary resources, women are economically dependent on their partners. They have no bargaining power to negotiate for safe sex, as the man will go outside the home for sex. Married women who demand the use of condoms are accused of not trusting their husbands and female condoms cannot be used without the permission of the husband. Even with condom use, some men believe they can be made sick if the semen does not flow out, so they make a small hole at the tip of the condom. It is believed that wives who are faithful cannot get HIV or other STIs. Often, even if a man receives STI treatment or HIV testing, his wife will refuse, as she will be blamed for bringing disease to the marriage. Certain sexual practices increase the risk of HIV infection for women. Dry sex is considered more pleasing and women use herbs or other substances to dry the vaginal mucosa, increasing risk of trauma during intercourse and risk of HIV transmission. Female genital mutilation is commonly practiced in many areas throughout Africa in order to reduce the woman’s libido, as it is believed that a respectable woman does not enjoy sex. Infertile couples seek the wife’s sister as a surrogate mother without regard to HIV status. In many African cultures polygamy is practiced and legally supported; it is commonly believed that a man will become impotent if they are in a monogamous sexual relationship. “Sexual cleansing” after the death of the husband is practiced in some Zambian communities. With this practice the widow is expected to have sex with her husband’s chosen relative in order to remove the husband’s shadow from the woman’s body; otherwise, any man who has sex with the widow will die. In South Africa sexual assault of children has increased dramatically because many men believe that they can be cured of HIV by having sex with a child. Older men (who may already be HIV-infected themselves) often seek out very young women or girls because they believe that older women are likely to be HIV+. In one study, 66% of women had unprotected sex in their last sex act with a non-regular partner.
• Stigma: Stigma concerning HIV is widespread throughout Africa and leads to a vicious cycle of fear and denial. The consequences of this cycle include discrimination, rejection, increased risk of HIV transmission, and decreased likelihood that infected individuals will appropriately access care and treatment for HIV and related opportunistic infections, such as TB. Health care providers who worry about stigma or fear becoming infected through work activities may have problems with disclosure of VCT results to patients (Zambia Nursing Council, 2001) and may be unwilling to care for those known or suspected to have HIV. Stigma is cited as the primary reason for the low VCT uptake in PMTCT programs. In most hospitals doctors and nurses will not write HIV as the cause of death on a death certificate because of stigma.

INNOVATIVE INITIATIVES

• In village initiation ceremonies traditional women counselors (“Alangizi”) are being trained to incorporate couple counseling to promote HIV knowledge and use of condoms.
• The Forum for African Women Educationists (FAWE) has trained teachers to counsel girls, many in boarding schools during their adolescent years, about HIV/AIDS, and advocates for pregnant girls to remain in school and to return to school after giving birth.
• Home-based care (HBC) is supported by faith-based and community organizations to provide care within the home for chronically ill persons using community volunteers. These programs offer VCT, spiritual care, help in writing wills, assistance with chores, administration of medicine, and assistance with personal hygiene. Although volunteers were at first stigmatized, they now have the respect of the community and are often called upon for advice because of their knowledge about HIV and care.
• Programs that provide access to water and sanitation have incorporated HIV awareness and basic hygiene information.
• PLWHA networks have started income-generation activities at various centers, with money raised used to improve nutrition and help pay school tuition for children.
• An initiative in Southern Africa supported by Family Health International, including partnerships with international and local non-governmental and community-based organizations, provides commercial sex workers in border areas with HIV information, condoms, VCT, and STI treatment.

IV. Brazil  TOP

It is estimated that approximately 623,000 individuals are living with HIV/AIDS in Brazil (Szwarcwald, 2001); women account for 30% of cases reported and are now the fastest-growing segment of the population in terms of AIDS cases. The male:female ratio for AIDS has fallen from 24:1 in 1985 to 2:1 in 1997 and among adolescents is now 1:1. (Brasil, 2003). The HIV/AIDS epidemic began to explode in Brazil in the 1980s when the country was emerging from a military dictatorship and in the midst of a redemocratization process. In 1988 the country’s new constitution recognized health as a constitutional right for all citizens; this facilitated the adoption of the prevention and care policy that characterizes the Brazilian approach to fighting HIV/AIDS and paved the way to the successful implementation of universal and free access to highly active antiretroviral therapy (HAART) for all HIV-infected citizens in Brazil. Currently more than 115,000 people have had access to free ARV treatment provided through government financing and generic versions of a number of ARV agents are produced by several publicly-owned companies. Since the introduction of HAART, a sharp decline in the incidence of AIDS and an 80% decrease in AIDS-related mortality has occurred in Brazil, similar to that seen in the most developed countries (Levi, 2002; Gotlieb, 2003). The median survival after a diagnosis of AIDS has increased from 5.8 months for patients diagnosed between 1982 and 1989 (Chequer, 1992) to 58 months for those diagnosed in 1996 (Marins, 2003). The decrease in hospitalizations has saved more than US$2.2 billion from 1997 to 2001, more than offsetting the US$1.8 billion invested in fighting HIV/AIDS during the same period. Today Brazil provides technical assistance on HIV/AIDS to Portuguese-speaking African countries.

However, the reduction in AIDS deaths among women has lagged behind the reduction in deaths among men with AIDS, and this is true in all regions of the country (Fonseca, 2002; Gotlieb, 2003). The epidemic began later in women and women with HIV continue to experience delays in diagnosis and treatment. Health care providers may be less likely to think about HIV infection in women and women themselves often do not perceive themselves to be at risk. In a study conducted in Sao Paulo, 53% of HIV-infected women interviewed did not perceive themselves to be at risk before learning of their HIV status and, of those who did perceive themselves at risk before testing, 29% believed they were at risk only after their partners became ill (Ventura-Filipe, 2000). Women may also prioritize the health care of their children and infected partners over that of their own care, potentially postponing care and compromising adherence to antiretroviral therapy.

Once women are diagnosed with HIV, health care providers are frequently not prepared to provide the needed support with HIV-infected women reporting limited receptiveness for discussing sexuality and childbearing wishes with their providers (Paiva, 2002). Furthermore, the fact that gynecologic care and family planning services are often located in places separate from those providing HIV/AIDS care is a barrier to integrated care for women.

The most frequent clinical manifestations in a cohort of 297 women with HIV/AIDS followed in Rio de Janeiro included oral candidiasis, weight loss >10%, vaginal candidiasis, recurrent bacterial sinusitis, tuberculosis, and multidermatomal herpes zoster. Tuberculosis, Pneumocystis carinii pneumonia, and espophageal candidiasis were the most common AIDS-defining illnesses (Grinsztejn, 2001). In the same cohort, prevalence of sexually transmitted infections (STIs) were high, including HPV (51.2%), syphilis (10.8%), hepatitis B (14.7%), and trichomoniasis (9.8%). Among HPV-infected women, 92% were infected with oncogenic subtypes. Vaginal candidiasis was identified in 20.9% and bacterial vaginosis in 18.2%. (Grinsztejn, 2001). The high rate of HPV infection has special relevance in Brazil, since cervical cancer is still a major cause of morbidity and mortality and is the most frequent cancer in Brazilian women, with approximately 20,000 new cases of cervical cancer and 6000 deaths due to cervical cancer each year. Overall, survival and disease progression rates appear to be similar in HIV-infected women and men, with initially observed differences largely explained by differences in stage of disease, access to care and treatment, and initiation of timely therapy.

Because of gender and social inequities and prejudices, Brazilian women continue to face enormous barriers in prevention of HIV; it is difficult to discuss safer sex with partners and women have very little bargaining power when trying to introduce and sustain condom use. Frequently, women who do use condoms use them primarily for contraception, not as a means to prevent sexually transmitted infections or HIV, and HIV-infected women who use more effective contraceptive methods are less prone to use condoms (Fernandes, 2000; Magalhaes, 2002). In a cross-sectional study designed to assess safe sexual behavior among heterosexual couples, women who had known about their partner’s HIV infection for a longer period of time were less likely to report safe behavior than those who had recently found that their partner was HIV-infected (Guimaraes, 2001). The partner’s desire not to use a condom is a frequently reported reason for inconsistent use, even among HIV-infected women with HIV-uninfected partners. In a study conducted in Sao Paulo 25% of HIV-negative men did not use condoms even after knowing about their female partner’s HIV infection (Magalhaes, 2002). In 1999 the favorable results of an acceptability study conducted in six urban areas led the Ministry of Health to purchase and distribute female condoms free of charge, prioritizing HIV-infected women, commercial sex workers, and women attending selected reproductive health services. In 2002 a total of 4 million female condoms were purchased for distribution.

Poverty, lack of family or social support, sexual abuse, and domestic violence are problems frequently faced by women in Brazil and represent a major public health problem. These problems increase risk of acquiring HIV and other STIs and increase the likelihood that HIV-infected women will not receive the care they need. In interviews conducted among HIV-infected women being followed in Rio de Janeiro, domestic violence was reported by 24.2% and sexual abuse by 24.6%. The monthly family income was US$330 or less in over 60% of women, and 56% of women were unemployed at the time of the interview. Twenty-five percent of women had no support from family or friends and 20% had lost at least one child to AIDS (Friedman, 2002 ). In 2001 the Ministry of Health began to provide antiretroviral prophylaxis for victims of rape and a special training program to sensitize health care providers about violence against women was developed.

In the last several decades women’s access to and use of contraception has increased dramatically in Brazil, resulting in a sharp drop in the fertility rate from 6.3 in the 1950s to 2.3 in 2001 (IBGE, 2003). However, approximately 10 million women have unwanted pregnancies, either due to inadequate use of contraceptive methods or to a lack of knowledge and/or access to them. The high pregnancy rate among teenagers in Brazil, especially among those from poorer social strata, is of special concern. In 1998 32% of 15-year-old girls had had sexual intercourse and in 2002 adolescent pregnancies accounted for approximately 25% of all deliveries in the country. Some studies in Brazil suggest that the knowledge of HIV infection increases the prevalence of contraceptive use, including use of condoms, among women of reproductive age (Magalhaes, 2002; Santos, 2002). There was also a significant increase in dual method use after knowledge of HIV infection, with more than 70% of HIV-infected women choosing hormonal methods also using condoms; however, only 46% of women with tubal ligation also used condoms (Magalhaes, 2002). Nevertheless, HIV infection has not changed women’s desire to have children and with interventions available to prevent perinatal transmission of HIV and the increase in survival of HIV-infected people, many women with HIV are choosing to have children. If the health care provider adopts a judgmental attitude about childbearing in the context of HIV infection, this will represent a barrier for care for most HIV-infected women (Santos, 2002; Paiva, 2002).

The Ministry of Health has established the prevention of mother-to-child transmission of HIV as a top priority. Antiretroviral drugs for prophylaxis and treatment, infant formula, and referral for cesarean delivery are widely available (Veloso, 1999). However, in 2002 it is estimated that of the 17,000 HIV-infected women who delivered, only about 35% were identified and received ARV prophylaxis. Many doctors still do not offer HIV testing during prenatal care and test results often take too long to receive, resulting in many deliveries in women of unknown HIV serostatus and missed opportunities to prevent mother-to-child transmission. In a cross-sectional study conducted between November 1999 and April 2000 in 12 Brazilian cities highly affected by the HIV/AIDS epidemic, 77.5% of 2,234 postpartum women who were interviewed reported being HIV tested and the HIV test acceptance rate was 92.5%. However, 49.1% reported that they did not receive counseling about HIV prevention during prenatal care and over 50% did not receive explanations about the meaning of their test results (Veloso, 2002). Considering these barriers to diagnosis of HIV and counseling about HIV prevention during pregnancy, and because 95% of all deliveries in Brazil take place in hospitals, the use of rapid HIV testing in labor has become a major strategic intervention for prevention of mother-to-child HIV transmission (Santos, 2001; Nogueira, 2001). However, the overall low quality of prenatal care, as reflected by an unacceptably high maternal mortality rate (161–260/100,000) and incidence of congenital syphilis (24/1000 live births) (Brasil, 1993), remains a primary barrier to both prevention of HIV and appropriate care and treatment for women with HIV living in Brazil.

It is of utmost importance for Brazil that health care providers be better trained and sensitized about gender issues in order to provide a high quality of care and to address unmet needs. The integration of HIV/AIDS care with gynecologic, obstetrical, and family planning services and the availability of social support must be improved so that women in Brazil can be freed from many of the competing needs and other barriers they now face which prevent them from taking full control of their lives, including prevention of HIV and other sexually transmitted infections and access to HIV care and treatment.

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