Medical Research Council
World Health Organization
Health Systems Trust
2011-2012 Education Sector HIV and AIDS: Global Progress Survey- Progression, Regression or Stagnation?UNAIDS
The Global Forum on MSM & HIV (MSMGF)
The importance of choice
During the 1990s, the era of Cairo and Beijing, when United Nations conferences led to new and progressive international agreements concerning women, South Africa responded by developing and implementing similar- progressive changes. During the first 100 days of Nelson Mandala's presidency, an announcement was made that primary healthcare would be free to pregnant women as well as children under the age of six. While this was a harsh additional workload for nurses, it provided services for ordinary women and made a difference to their lives.
South Africa's constitution makes provision for women's rights and is regarded as one of the most progressive in the world. Our Choice on Termination of Pregnancy Act is considered to be second to Ethiopia as one of the most progressive in making provision for women's access to abortion.
While only 55 percent of our designated abortion facilities are up and running, these services have reduced abortion-related maternal mortality by 90 percent. Changes in the international arena resulted in international agreements being met with changes in funding allocations and in programmes focusing on sexual and reproductive health and rights.
Recently, in reviewing the area of violence against women, as reported by Oxfam in 2007, the author's reflected the opinion that Women's health had become reduced to HIV. It is a harsh reality that HIV/Aids infects and affects women greatly. Of those infected, the majority are women, and women bear the load in caring for the affected, given entrenched gender relations in our society. As nurses we know how HIV has devastated our patient load and as women we often go beyond the call of duty to assist in our communities. As nurses HIV/Aids is a large part of our patient burden, but as mostly women we also bear the brunt of being infected and affected.
Funders and programmers have jumped into the HIV arena and there is a large amount of donor money in this area. At the same time as there has been an influence by these international agencies to constrict our agenda, there has been a limit on funding work that relates, for example, to abortion and sex workers.
This has resulted in a growing Aids treatment movement that does not easily engage in sexual and reproductive health and rights issues, given the sensitivities. Given the complexity of treatment in South Africa, the way to get a foot in treatment was to start doing what is termed 'Prevention of Mother to Child Transmission (PMTCT)'. This was the start of ARV treatment in South Africa. But if we stop a moment to reflect, it is important to consider how it has panned out. While not the intention of the treatment movement, this reality has enabled treatment for so-called 'unborn babies' but not mothers. In some reports PMTCT has similar language to the anti-choice groups, as they refer to 'saving the unborn child'. There are attempts to include treatment for pregnant women but it is not the over-riding assumption, and some doctors are still debating the WHO policy and the SA DOH policy regarding when it is acceptable to start HAART with women and pregnant women, as adherence issues am viewed as difficult.
The language of PMTCT has also reinforced an understanding that women, spread HIV, which is totally unhelpful and not entirely true. In many countries the language has been changed. The insistence of women activists in India has led to the term 'Prevention of Parent to Child Transmission (PPTCT)' or the prevention of vertical transmission, as it was originally termed. Language shapes our reality and it is important to think about our choice of words.
In exploring this area the issues of sexual and reproductive health and rights as part of the continuum of care have been neglected. Engagement between these sectors is often difficult. For example, women do not see being offered to choose to continue their pregnancy or terminate it as part of the continuum of care. From a patient's perspective, what is understood is that you will get treatment for your unborn 'baby' and if you are lucky and you are considered in need of it, you may get care. The option to terminate is not part of the continuum of care.
There have been anecdotal reports of women resorting to illegal abortions due to this gap in care. On the other hand, as this is not provided for in policy, there are reports too - anecdotal - of some nurses insisting that women have abortions and sterilisations this has been picked up in Kwazulu-Natal.
Other sexual and reproductive health and rights issues appropriate contraception for HIV-positive women, violence against women with the sexually transmitted infections syndromic management protocol, sexual and reproductive intentions and screening for cervical cancer - are left outside what is considered the 'treatment agenda'. With the recent announcements of the registration of the cervical cancer vaccine in South Africa, this would be important to consider and explore, as cervical cancer has been defined as an opportunistic infection. Appropriate treatment for lesbian women and acknowledging the continuum of sexual and reproductive intentions that women engage in is pretty much off the agenda.
There is much to explore in this policy area of women's health and I look forward to unpacking some of these issues each month in Nursing Update. If there are areas that you would like to see addressed, please write to the editor.