Kingston, Jamaica (2010 Features): Janelle* is determined that before her 23rd birthday, she will have her second child. The 22 year old is HIV positive.

"I don't know how long I am going to live," she says candidly.  "Yes, there is medication to make me live longer with HIV now, but opportunistic infections can come anytime.  I know I have HIV, so I want to have my child early so I can be around for him/her as long as possible."

Janelle has a five-year-old daughter and lives with her 20-year-old boyfriend who does not have a child.  "My partner is aware of my (HIV) status.  He wants kids and I always said I wanted two kids; so why should I let my being positive (HIV) stop me from having two kids?" she asks.

As antiretrovirals become more widely available in Jamaica, a significant number of women living with HIV are opting to have children, a situation many never thought possible five years ago.  However, many positive women report that their reproductive health rights are not always respected by health personnel.

Twenty-nine year-old Erica,  became pregnant last year, her first pregnancy since being diagnosed with HIV five years ago. "They (health officials at the clinic where the pregnancy was confirmed) made me feel that I had no right to become pregnant. They told me directly that I would be putting my child at risk and asked me if I had thought about how it would affect my child to know that its mother has HIV," she says 

In the Caribbean, which has the highest HIV prevalence outside of sub-Saharan Africa, an estimated 50 per cent of HIV positive persons are women. The need to address the sexual and reproductive health rights of HIV positive women is all the more significant because three quarters of people living with HIV in Jamaica are in their reproductive age.

Dr. Debbie Carrington, Care and Treatment Coordinator for People Living with HIV at the Ministry of Health in Jamaica, says Erica should not have been told that she has no right to get pregnant because she is HIV positive.

"We try to prevent unwanted pregnancy in HIV positive women just as we do in those without HIV, with counselling and family planning services primarily in the primary care health centres. When women who are HIV positive get pregnant, we try to prevent their babies from getting HIV."

GAPS IN HEALTH SYSTEM UNDERMINE REPRODUCTIVE RIGHTS

The Health Ministry's policy position, however, does not always translate effectively into practice.

Dr. Tina Kong, a medical doctor at the public sector Comprehensive Health Centre in Kingston for 16 years, admits that while public health clinics in Jamaica should provide a comprehensive range of services on sexual and reproductive health to patients, this does not always happen.

"Contraception services in clinics are integrated in thought but not in action.So if you go to the family planning clinic, you will hear everything about contraception, but if you are at your general clinic or STI clinic (at the same facility) you may not hear much about contraception." Dr Kong explains.

She says some health care providers at the clinic who counsel patients, are still not properly trained to do so. Chronic staff shortage means staff has to spend less time with patients, limiting the amount of information that can be passed on.

In a clinic that has 2,000 patients, approximately 70 per cent are women of reproductive age. Dr. Kong says she sees just as many HIV positive women who are pregnant as those who don't have the virus. Further, the same factors that would influence someone without HIV to get pregnant also influence those with the virus.

ATTITUDE ALSO A BARRIER
Despite this recognition, when HIV positive women in Jamaica request information about methods of contraception other than condoms, they are met with overt disapproval.  It is felt that their attempt to access information or access services means they intend to engage in unprotected sex.

"Ideally, all HIV positive persons should be using condoms, then they might not be so concerned about pills. It also safeguards them from re-infection with the virus.," Dr. Carrington stated.

Jamaica's National Family Planning Board says supporting women to exercise their reproductive rights regardless of their HIV status is a basic human right. 

However, Mrs. Joy Crawford, Manager, Support Services at the Jamaica AIDS Support for Life (JASL), which provides treatment, care and support services to almost 2,000 members, says, "Positive women don't have a difficulty if they don't disclose their (HIV) status.  However, once they disclose their status, the conversation switches from contraception to why they are even having sex when they are (HIV) positive. Almost 90 per cent of them are offended by this reaction, as, once they make the decision to be sexually active they feel they now have the right to protect themselves and have a family." 

Approximately 90 per cent of her clients are males and females of reproductive age

"This means women will be forced to access family planning where they don't get counselling - over the counter or borrowing from a friend. Counselling has many benefits, including how some family planning methods could affect ARV treatment adherence regimen. Counselling would also inform them of the services available to them if they get pregnant, including assistance if complications develop when using contraceptives," she says.

Mrs. Crawford says approximately 25 per cent of women clients want to have children.  She said over the past year, there has been a significant increase in the number of HIV positive clients who become pregnant. 

"This increase could be due to an increase in knowledge of children being born without HIV.  They now know that the chance of the child being negative is higher," Mrs. Crawford reveals.

Jamaica's Prevention of Mother To Child Transmission (MTCT) initiative has been hailed as a success under the National HIV/STI programme. Between January and June 2007, approximately four out of every five HIV-infected pregnant women received antiretroviral medication to prevent mother-to-child-transmission of HIV. The provision of this medication, and provision of formula for HIV positive mothers to reduce transmission via breastfeeding, has supported the decline in cases of mother to child transmission in recent years.