Should HIV-positive women have babies? The answer is a resounding “yes” for women from well-resourced areas, and a reserved “probably not” for the remainder, if we follow the guideposts set by several presentations made on Monday. Positively Pregnant: HIV-positive Women and Pregnancy showcased studies from six countries on five continents.

The first, from the US, was titled “You can even possibly have a child: reproduction in the lives of HIV-positive women.” The women surveyed were said to initially perceive their diagnosis as a “death sentence” despite access to antiretroviral therapy, and the presenter went on to discuss how reproduction is tied to envisioning the future and mothering is a way of affirming a valued role and sustaining life.

“There is a subtle and sometimes overt assumption that you shouldn´t have a baby [if HIV-positive].” It was noted that a number of these mothers had had their children taken away from them by social services, and perceived this as a last chance to be a good mother, suggesting a somewhat marginalized study population, in sharp contrast to the millions of very mainstream HIV-positive women in poorly resourced areas.

A French study, “Pregnancy outcomes and follow up among HIV-infected drug users,” with 43% of the participants still using IV drugs, found very low rates of transmission with antiretroviral therapy. It was noted that pregnancy terminations that occurred were related to social factors, such as such as stability of relationships, rather than HIV status.

HIV-positive women’s use of and attitudes to antiretroviral (ARV) treatments during pregnancy in Australia documented yet a third population with access to treatment, sometimes imposed on their babies against their will: “If she was positive the doctors were going to start killing her with ARVs.”

Also presented was “Reproductive choices and the impact of the medical culture on female sterilization rates among HIV-positive pregnant women in Brazil.” The presenter noted that with an increase in HIV-positive women in stable relationships and a decrease in maternal to child transmission rates due to antiretroviral therapy, we need to ask what women want and what they get.

She then proceeded to show data for a public prenatal service with and without a referral hospital, concluding that the demand for sterilization is high among HIV positive women in both settings, but the likelihood of getting the procedure is dependent on the medical culture (greater availability in the referral hospital). Contrast this with the case of a 17 year old HIV-positive girl subject to sterilisation without her consent in Manila last year.

An Italian study, “Intrauterine insemination (IUI) in HIV serodiscordant couple for male HIV infection,” referred to over 4,000 cycles of IUI with sperm washing. The study concluded that the sperm are not the target of HIV, enabling HIV-positive men in this setting to have children with their HIV-negative partners.

Finally, the only study from a truly resource-poor setting, “Impact of perceived HIV risk, history of child loss and spontaneous abortion on desire for pregnancy among ever-married women in Zimbabwe,” was presented so briefly that all that came across was the high demand for children such that HIV did not decrease desire for pregnancy.

There was an entirely different tone to an earlier presentation on “Mothers to Mothers to Be (M2M2B),” a program in Cape Town in which HIV-positive mothers mentor other HIV-positive mothers. Women diagnosed HIV-positive in pregnancy are referred to the program from public health clinics, which are only able to provide pre and post test counseling.

At M2M2B, the mothers benefit from shared experiences, moving from feeling dejected and isolated after finding out they are HIV-positive to feeling good about themselves. Information and support are provided regarding infant feeding choices, baby care and how to live as an HIV positive mother. Nevaripine is provided to both mother and child for prevention of maternal to child transmission.

Working with a group of female entrepreneurs, the program has been able to incorporate an income-generating component in which the women make T-shirts and baby blankets. A local rotary club sponsor of the program stated, “If we improve the quality of women we improve the quality of our future.”

Samantha, a counselor with M2M2B, was interviewed about the program. “Being HIV-positive alone is hard. Being HIV-positive and pregnant can be too much. In other MTCT programs you only receive pre and post test counseling, no support. In our program, we work with the patient from the beginning through the baby’s PCR test at six months.”

The women continue to support one another, and some become mentors in the program. Asked if she thought any of the women would choose to have another child, she said “I don’t think so. I would not have had the one if I knew I was HIV-positive.” So far, there have been 87 babies born and only one has been HIV-positive. Samantha is about to start another job, going into the hospital and encouraging mothers to get HIV tested.

During a press conference on M2M2B, a reporter asked if there was a shortage of women to serve as mentors. “Unfortunately, there are too many qualified women,” she was told.

The cross-section of responses to HIV-positive women and pregnancy makes it clear that the desire to bear a child is universal. It also begs the disturbing question of why one woman seeks desperately for antiretroviral therapy and another’s newborn is subjected to it by court order, why one woman cannot receive desired sterilisation services while another is subjected to the procedure involuntarily.

With an estimated number of annual perinatal HIV infections in the US now at 280 to 370 (Tuesday poster exhibit) while almost half of all women in Botswana are now HIV-positive, the most profoundly disturbing question is whether anyone in resource poor areas will be left to have babies at all, and what we, as a global community, are willing to do about it.

AIDS 2002 Conference News produced by Health & Development Networks/Key Correspondent Team