Her decision may seem odd to a casual observer, but for many women like Mandisa the choice is not a simple one. Her plight reflects a disturbing new twist in SA's rampant HIV/AIDS epidemic, which the United Nations (UN) estimates has infected more than 5,3-million South Africans. Health workers are seeing more and more women who are falling pregnant knowing that they are infected with the disease. Mandisa, who asked that her surname not be used, found out about her HIV status after her first baby fell ill and her local clinic suggested she have a blood test.
Three years later the little girl was dead and Mandisa's husband wanted another child. She agreed, but neglected to tell him that she had HIV. "She did not tell her husband because she was afraid of being chased away," says Patricia Qolo, who co-ordinates a counselling programme for HIV-positive mothers and other expectant mums in Cape Town's Khayelitsha township.
Statistics are hard to come by, but cases like Mandisa's are on the rise and are expected to increase further as HIV testing becomes more widespread, says Dr Mitchell Besser, who founded the counselling programme where Qolo works. With only limited access to AIDS drugs, this phenomenon is likely to boost the already high number of children orphaned by AIDS.
The UN estimates that during the past three years the number of South African children who lost one or both parents to AIDS ballooned by 80% to 1,1-million. At Johannesburg's Chris Hani Baragwanath hospital, researcher Pumla Lupondwana estimates that a fifth of the 250 HIV-positive women in her nevirapine resistance study planned their current pregnancies. All were counselled during previous pregnancies, and were aware of the ris ks they and their babies faced, she says.
Lupondwana concedes that many South African women do not intend to fall pregnant. Their babies are the results of rape, failed contraception, or partners who refuse to use condoms. But many HIV-positive women are choosing to get pregnant. Some say they want to leave a legacy behind them when they die, others feel the pressure of communities that accord less value to women who are childless.
Qolo has no figures to prove it, but she believes the fashionable clothes sported by some of the young unemployed mothers attending her clinic suggests they are falling pregnant to obtain child welfare grants. If a woman really wants a baby, and is told that there is a 15% chance her baby will be infected with the disease, she focuses on the 85% chance that her child will be healthy, says Qolo.
But why, if there are so many AIDS orphans, don't women who want babies simply adopt? "In our culture adoption is not accepte d at all, says Qolo, "and even HIV-positive women want to make their own babies." Lupondwana says the 200 women in her study who did not plan their current pregnancies had all received family planning advice during previous pregnancies. "But she just crosses her fingers and hopes nothing goes wrong," she says.
Many poor women are not using contraception because they are afraid to tell their partners that they have HIV, she says. But disclosure is risky. Few of the women in Lupondwana's study are financially independent, and revealing their illness could mean rejection by lovers, friends and family and possibly the loss of their homes. Contrary to popular perception, women such as Mandisa are not necessarily mortgaging their future jeopardising their longterm health to secure a better deal today, says Besser.
Most HIV-positive pregnancies are surprisingly normal, with little measured health risk to the mother, unless she is at an advanced stage of the d isease with a compromised immune system. "With good planning you can hugely reduce the risk of having an HIV-positive child," says Prof Gerard Theron of the University of Stellenbosch's obstetrics and gynaecology department.
If an HIV-positive pregnant woman receives no AIDS drugs, has a natural birth, and breastfeeds her baby, there is a 20%40% chance the child will get the virus, according to the World Health Organisation. If, as is the case for the majority of HIV-positive pregnant women in SA, the only available drug treatment is single dose nevirapine (a dose to the mother during labour and another to the baby shortly after birth), the transmission risk can be cut to about half these figures. More complex drug regimens can bring the transmission rate well below 2%.
A short course of AZT for the mother from the 28th week of pregnancy, a single dose of nevirapine during labour, and a dose of nevirapine given to the baby after birth is one example. Most women using public clinics and hospitals only have access to nevirapine, which is not without risks.
Scientists have known for some time that even a single dose of nevirapine causes virus mutations in the mother that are resistant to the drug, a scenario few women in Lupondwana's study are likely to have considered. Resistance means the drug is less effective, and limits the options for tackling mother-tochild transmission in subsequent pregnancies or slowing HIV's inexorable march in the woman's body. It also limits the options for treating the baby should it be born HIV-positive. Resistance to the first line of attack means a potentially costly switch to different medicines.
Western Cape for example, has already begun to change its preferred infant treatment from nevirapine to kaletra, says Mark Cotton, a paediatrician at Tygerberg Hospital. The implications of a reduced drug arsenal are profound, not only for the mother and child, but also from a health policy perspective.
The sheer scale of the HIV epidemic makes changing treatment guidelines more challenging than switching drugs for diseases such as malaria, which affect only a small, relatively localised population. SA's HIV case load tops 5,3million in contrast, there were only 11918 recorded cases of malaria in the 2003-04 season.
Even with the best possible medical supervision, a small proportion of the babies born to HIV-positive pregnant women will be infected with the virus. Life expectancy for these children varies widely, and is not well understood, say local researchers. "We have (HIV-positive) kids of nine, 10, 11 who have never been on treatment, and others who die in their first year of life," says Lupondwana.
Ultimately the decision to fall pregnant, whether HIV-positive or not, rests with women , says Besser. My advice to HIV-positive women who want to get pregnant is not that different to the advice I'd given someone with a chronic condition such as diabetes talk to your doctor, and get your disease under control before conceiving. (Source: Business Day, 4 October 2004).