When I was studying medicine in Cuba, I didn’t have access to a kitchen, so I was always looking for someone from whom to buy cooked meals. Loli was one of the people I used to buy food from. As a student, I didn’t have that much cash, but I bought cooked meals from Loli and Loli made much needed cash.
When I met Loli she had been HIV positive for about eight years. She told me about the kind of support she got from the Cuban health system. When she was diagnosed with HIV she received an intense health workshop about what being HIV positive meant. She also received free HIV treatment, by law she could work only 20 hours but get paid 40 hours, she received extra food from the monthly government food distribution, she frequently saw her family doctor, and her health was closely monitored.
Clearly, institutional support was not enough, since she offered me her cooking services, but the fact that she looked and was healthy, and was not an AIDS patient after eight years of being HIV positive seems related to the support she got from the Cuban health care system and her family’s care. Loli was married, but her husband was not HIV positive because they always had protected sex.
As a medical student in Cuba I saw some flaws in the Cuban health care system, but I was, and still am, very impressed at the Cuban public health approach of preventing sickness rather than curing a contracted disease. In Loli’s particular case, preventive medicine seemed to have a positive impact on her health and well being for more than eight years. The Cuban public health plan included avoiding stress, having a healthy diet, and being able to access antiretroviral treatments.
In contrast to the Cuban approach of supporting an individual’s ability to live a full and healthy life, some organizations direct their global health efforts to simply preventing HIV positive women from getting pregnant. Project Prevention, formerly known as CRACK (Children Requiring A Caring Kommunity) plans to pay Kenyan women with HIV/AIDS to use long-term contraception, instead of working hard for these women’s access to health services, antiretroviral treatment, their right to have access to the whole range of family planning methods, and the right to bear children. The organization claims it has contacted a Kenyan doctor who will place contraceptive intrauterine devices (IUDs) in female HIV/Aids patients for only $7. The organization plans to pay these women US $40 for accepting the procedure, saying:
“For only 47 American dollars we have prevented future pregnancies that may result in infants born HIV positive who would suffer daily and most will die before age 5. All this human suffering is preventable.”
Project Prevention has a point. Human suffering is preventable. However, their shortsighted vision of how to prevent mothers and children from suffering shows how very little Project Prevention knows about the World Health Organization (WHO) holistic approach to preventing mother to child transmission (MTCT), which includes preventing unplanned pregnancies but focuses on:
- Preventing women from getting infected with HIV,
- Preventing HIV transmission from a HIV positive woman to her child, and
- Providing treatment, care and support to mother living with HIV and their children and families.
The WHO also estimates that, if its guidelines for antiretroviral drugs are implemented, the risk of MTCT is less than 5% in breastfeeding children and even lower in non-breastfeeding children. One of the challenges in implementing WHO guidelines is the limited access to health services for rural, low income women and lack of institutional support that women with HIV or women at risk of getting it have to overcome. Such is the case of HIV positive women in Kenya.
Kenyan women living with HIV face significant barriers to obtain adequate health care, a fact that Project Prevention appears to ignore. In 2008, the Center for Reproductive Rights produced a report, At Risk: Rights Violations of HIV-Positive Women in Kenyan Health Facilities, that explains in detail that the Kenyan government provides free antiretroviral (ARV) treatment for Kenyan women, yet women are unable to get HIV treatment because of the cost of taking required tests. In addition, HIV positive women suffer from stigma and discrimination at health care facilities. There have been cases of medical personnel referring to HIV-positive patients using derogatory terms, refusing to treat them, or isolating them away from other patients. Other obstacles preventing HIV positive Kenyan women from obtaining quality health care include inadequate pre- and post-counseling for HIV testing, inadequate HIV treatment counseling, lack of specialized care of HIV positive women, lack of equipment, supplies and infrastructure, and hygiene conditions.
Without appropriate treatment for HIV and access to health care, the insertion of an intrauterine device (IUD) on HIV positive women may put these women’s health at risk. The perforation of the uterus and Pelvic Inflammatory Disease (PID) are two potential IUD side effects. While rare, these side effects could be fatal in HIV positive women. It is for this reason that doctors recommend HIV positive women select an intrauterine device as a contraceptive method only if they have ongoing access to health services.
Choosing a contraceptive method that suits her needs is a right that every woman, HIV positive or not, should have. But as reproductive rights activist Marlene Gerber Fried says, real choice requires that a woman have the resources and support that would allow her to exercise any of her reproductive options. Women should feel entitled to choose a contraceptive method they feel comfortable with. In fact, the Center for Reproductive Rights and the United Nations Population Fund (UNFPA) have defended this reproductive right, saying:
“Not every contraceptive method will be right for every person; women and adolescents can realize this right only if they have access to a full range of contraceptive methods in a setting that allows them to make an informed choice as to the appropriate method for them.“
While IUDs should be one of the options offered to HIV positive Kenyan women, it is unethical to coerce these women, who for the most part live in absolute poverty and face significant barriers to health services, to get an IUD or not get any contraceptive at all in exchange for much needed cash. Rather than showing genuine concern for these women’s suffering, Project Prevention seems interested in preventing the reproduction of marginalized women.
Indeed, Project Prevention has advocated limiting the rights of ‘certain women’ to reproduce in the past. In the United States, Project Prevention works to prevent female drug users from getting pregnant by offering them $300 to get sterilized. Since this campaign was launched it has targeted communities of color and low-income communities. In addition, this sterilization campaign has shown little concern for women and their reproductive rights, and appears to be influenced by eugenics.
Lynn Paltrow, founder and Executive Director of National Advocates for Pregnant Women (NAPW) writes in an article explaining why the group actually undermines the wellbeing of children and families that,
“Although C.R.A.C.K.’s leadership vehemently denies that it is racist, their statements, statistics and practices strongly suggest that they in fact engage in class and race based targeting.”
It’s too early to call Project Prevention’s new focus on Kenya a sterilization campaign, but it does seem that their main goal in promoting long-term contraception among HIV positive Kenyan women is to prevent them from bearing children. It is true that the international community should be concerned about HIV transmission rates, and support HIV positive women in low-income countries, but it must do so while taking into account women’s reproductive rights and their well being. Bribing women who desperately needed money to accept the insertion of an IUD is not what I call reproductive justice.
Susana Sánchez, an international student from Costa Rica, works with PopDev as a Research Assistant. She came to the United States to complete her medical degree, and in the process became interested in the social problems that affect Latinos in the United States, particularly undocumented immigrants. She is a fourth-year student at Hampshire College, where she majors in immigration and gender studies. She loves to spend time with her family in New Jersey and dreams of the day she will return to her native Costa Rica to work on public policy and enjoy the country’s beautiful seashore.