Prevention of HIV Perinatal Transmission: The Role of Sexual and Reproductive Health Services for Women Living with HIV

With the evolution in prevention, diagnosis, and treatment of HIV/AIDS, ending the infection as a public health threat worldwide has become a real possibility included within the United Nations Sustainable Development Goal Project 2030. However, some countries and even entire regions are not on track to reach this target due to increased new infections in young populations. Young women (15–24 years) represent 48% of the new HIV cases globally. Research shows these women have significant unmet sexual and reproductive health (SRH) needs, with high rates of unplanned pregnancies, increased HIV perinatal transmission (HIV-PT) risk, and higher maternal morbidity and mortality. Granting access to SRH services based on rights for women living with HIV is a cost-effective alternative to reducing new infections in children by promoting respect for women’s reproductive options. This chapter addresses the role of SRH services based on rights for women living with HIV within HIV-PT. It also summarizes the new “Consolidated Guideline on Sexual and Reproductive Health and Rights of Women Living with HIV”; designed by the World Health Organization as a global recommendation for SRH programs and services that promote gender equality and human rights for women living with HIV.


Introduction
In the last decades, the HIV/AIDS picture has changed notably with global health policy accomplishments for prevention, diagnosis, treatment, and followup, improving people's quality of life and turning the overwhelming prognosis of a fatal disease into a chronic, treatable condition. The progress in the control of HIV/AIDS has stimulated a debate on the possibility of ending it as a public health threat by 2030, and it has become a substantial element of the United Nations third Sustainable Development Goal Project 2030 (SDG-3.3). The goal is to decline new HIV infections and AIDS-related deaths by 90% between 2010 and 2030 [1].
Despite all the public health advances related to HIV, there are countries and even entire regions that are not on track to reach the global target due to new infections. In 2019 the Joint United Nations Program on HIV/AIDS (UNAIDS) reported 1.7 million people with newly acquired HIV infections. Eastern Europe and Central Asia registered a 72% rise in new HIV infections since 2010. New HIV infections have also risen in the Middle East and North Africa by 22% and 21% in Latin America. Certain regions like Eastern and Southern Africa are exceptions to these rates, with a sustained 38% reduction in new infections since 2010 [2].
A third of new HIV infections affect young populations. With the change in transmission trends during the past two decades, more women have become infected by sexual transmission within high-risk partners. They currently represent more than half of the people living with HIV worldwide and 48% of the new cases reported each year. Health risks for acquiring HIV infection are especially acute for adolescent girls and young women aged 15-24 years, and AIDS persists as the fourth leading cause of death in middle and low-income countries [3]. The risk for acquiring HIV, especially in young women and adolescent girls, arises from multiple reasons, including unfavorable health social determinants such as economic dependence; poverty; lack of education and formal work opportunities; adolescent marriage; intrafamily and institutional violence, and limited access to Sexual and Reproductive Health Services based on Rights (SRHSR) like family planning and adolescent-friendly health services among others [4].
Women living with HIV (WLHIV) have significant unmet sexual, and reproductive health (SRH) needs leading to high rates of unplanned pregnancies. Research shows that these necessities are even three times higher than women without HIV and increase the number of new HIV infections in their children due to HIV perinatal transmission (HIV-PT); and higher maternal morbidity and mortality. Studies also show that these unmet needs increase the number of unsafe abortions and unwanted sterilizations, due to health providers and patient's misinformation about HIV and pregnancy [5,6].
To accomplish the SDG-3, the elimination of HIV-PT is a must. Globally, in 2019, 1.8 million children were living with HIV, with 95,000 AIDS-related deaths and 150,000 new infections. Even though new HIV infections among children have declined by 52% since 2010, some countries, especially in concentrated epidemic settings, have maintained stationary HIV-PT rates for the past ten years, far away from the elimination goals. HIV-PT is still considered a public health problem representing the impossibility of health systems to end a preventable disease with immense repercussions for children's lives, families, and the community [7]. In HIV-positive populations, studies have shown a close relationship between women's SRH and HIV-PT prevention. Granting access to SRHSR for WLHIV is a cost-effective alternative to reducing new infections in children by promoting planned and desired pregnancies and promoting respect for WLHIV's reproductive options as part of the United Nations International covenant on rights [8].
The present chapter addresses the relevance of SRHSR for WLHIV within HIV-PT reduction. The first part explores aspects of women's vulnerability to acquire and live with HIV and the relationship of these determinants with SRH. The final part summarizes the 2017 World Health Organization's (WHO) "Consolidated Guideline on Sexual and Reproductive Health and Rights of Women Living with HIV," related to the HIV-PT prevention recommendations based on rights [9].

Women and HIV
An estimated 20.1 million women were living with HIV worldwide at the end of 2020, representing approximately 55% of all HIV infections [10,11]. Also, almost half of the estimated 1.7 million new HIV infections in adults for the same year globally were among women. HIV infection remains the leading cause of death among women of reproductive age [12]. Most women acquire HIV through heterosexual relations with high-risk partners. In sub-Saharan Africa, 59% of people with HIV are those, and those aged 15 to 24 years are eight times more likely than their male peers to be infected [13]. In the Caribbean, young women are twice as likely to be infected as men. In Eastern Europe and Central Asia, injecting drug use (IDU) and sex work are the primary drivers of the epidemic. One-third of women acquired HIV infection by injecting drugs, and 50% from partners who inject drugs. Latin America's epidemic concentrates among men who have sex with men (MSM), but more than 20% of the region's MSM also report having sex with women [14,15].

Risk factors for HIV acquisition in women
Women have differential vulnerabilities to HIV acquisition studied in different contexts. Below are some of the core biological, behavioral, and social determinants risk factors related to the heterosexual transmission that individually and synergistically contribute to these HIV infection rates among women globally.

Biological risk factors
Research has presented evidence about the relationship between the female reproductive tract, the immune system inflammatory response, and the vaginal microbiome, decreasing or increasing women's vulnerability to HIV infection. Interestingly, there is a unique balance between the female mucosal immune system and the hormonal system at the cellular level. This balance intends to protect women from genital infection while permitting an embryo's survival [16][17][18].
Genital tract inflammation (infection, microscopic abrasions that result from sexual activity, douching, or other causes) also increases women's susceptibility to HIV infection [19]. Different studies demonstrate the importance of the vaginal microbiome in maintaining the acidic environment that protects against HIV and suggests that lower genital tract infections can promote HIV acquisition among women [20,21].

Behavioral risk factors
The risk of heterosexual acquisition of HIV varies from as low as one per 1000 contacts between uninfected and infected individuals to one transmission per three contacts. Factors including male circumcision status, HIV viral load concentration; sexually transmitted infections; alterations of vaginal flora, and anal intercourse increase women's risk and contribute to the variation in these estimates of transmission. Factors such as hormonal contraception may also affect HIV acquisition risk. Sexual partners' participation in concurrent sexual relationships, especially MSM, and age disparity with intergenerational relationships between young women and older men, increase individual women's risk of acquiring infection and help spread HIV throughout the population [22][23][24][25].

AIDS Updates -Recent Advances and New Perspectives
Sexual violence represents a significant risk for HIV infection acquisition among women [26,27]. In HIV prevalent settings, women who experience intimate partner violence are 50% more likely to acquire HIV than women who do not have these experiences. In medium and low-income settings, gender-based violence is common for women and increases their risk for HIV acquisition. This risk is related to genital injury due to forced intercourse with an infected partner, limitations to negotiate safer sexual behaviors, and patterns of sexual risk-taking among women who experienced abuse during childhood or adolescence. War, migration, displacement, and conflict situations also increase women's risk of experiencing sexual violence, including rape and HIV acquisition [28,29].

Social determinants of health as risk factors
Research shows how women's HIV risk acquisition is consistently associated with disadvantageous economic security, education, and other structural determinants prevalent in medium and low-income settings. A systematic literature review from eighteen countries performed in Latin America showed that most women who became HIV infected were young, less-educated, working in informal jobs, and users of public health services. Besides the structural health determinants related to HIV, these women also faced barriers to accessing contraceptive alternatives and SRHSR imposing a limit to their capacity to make autonomous reproductive decisions [30,31]. Gender inequality is an essential structural factor underlying usual risk factors associated with HIV acquisition. Women's unequal educational, social, economic, and political status represents an inherent disadvantage; unequal power limits their ability to negotiate at a relationship and family level. Also, there is a high prevalence of violence, and women who experience trauma, abuse, or other forms of sexual violence are at increased risk for HIV acquisition [32].

Differential HIV acquisition risks in young women
The standard definition of young women includes all those falling within the ages of 15-24 years. Between these ages, young women undergo significant transitions in lifestyle, maturity, and legal rights, which place them at different vulnerabilities for HIV acquisition. Young women are more susceptible to HIV infection than older women. Some biological factors may explain this age-variability in vulnerability. For example, the immature cervix has a more significant proportion of genital mucosa exposed to HIV, highly susceptible to infection. They also have relatively high levels of genital inflammation, which have consistently been reported to increase HIV acquisition risk [32,33].
Vulnerabilities in youth often are incremented by the interaction of the effects of social disparities and sexual behaviors. Choosing a sexual partner, early sexual debut, teen pregnancies; early school dropout; and sexual violence increase adolescent girls and young women's vulnerability to acquiring HIV infection and maintain them in cycles of poverty and dependency. Young women, on average, have their first sexual encounters during their teenage years: in sub-Saharan Africa and Latin America, about 60% of young women are sexually active by the time they reach the age of 18. However, unprotected sex between adolescents can result in pregnancy, HIV transmission is not frequent. In contrast, sex with an older man is more likely to result in HIV acquisition and pregnancy. Data show that women who start their sexual life at a young age have an older first sexual partner and have experienced sexual coercion [33][34][35].

Living with HIV
WLHIV must face complex lives with profound physical and psychological consequences. HIV/AIDS represents a dangerous triangle as these women must meet their condition in different roles, as a patient, as a mother, and as a carer of partners, parents, or orphans with AIDS. In middle and low-income settings, WLHIV also live painful lives of exclusion. They are rejected by their family, friends, and partners. With low access to education and work possibilities, thousands have lost their lives, and many more have been unable to fulfill them [35][36][37].
Since it was first identified, HIV has been linked with some kind of "sexual misbehavior," contributing to the high level of stigma and discrimination associated with the infection [38]. Women are often more susceptible to the stigma related to HIV and are frequently referred to as "transmitters" [39,40]. Discrimination discourages them from seeking the vital medical and psychological care they need during the illness. HIV stigma in women is associated with feelings of uncertainty and loss, low self-esteem, fear, anxiety, depression, and even suicidal ideation [41][42][43].
Different systematic reviews have examined stigma and discrimination in WLHIV, revealing the constant fear related to their medical condition and the painful effects of stigmatization and discrimination, including social rejection, denial, even violence within family and community. The rejection and discrimination extends to institutional violence by health care professionals. These studies also highlight that women face higher levels of discrimination from society just because they are women [43][44][45].

Sexual and reproductive health in WLHIV
According to the United Nations Population Fund (UNPFA), SRH implies that people can have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so. There are essential links between HIV/AIDS and women's SRH. For many, HIV represents the most challenging SRH issue; frequently diagnosed during pregnancy, HIV infection in women arises the necessity to cope with many fears and uncertainties related to SRH like death, guilt, side-effects from treatment, pregnancy, and delivery complications, HIV-PT, childbearing, and breastfeeding [46]. WLHIV have a high risk for unplanned pregnancies, reported as three times higher than in women without HIV. The consequences of unplanned pregnancies can be profound, placing WLHIV at greater risk of death during the pregnancy and postpartum period and leading to lower antiretroviral therapy (ART), adherence and higher attrition rates in prenatal care, and higher risk for HIV-PT [47].
One of the most basic SRH interventions is family planning, an important HIV prevention strategy for women. For WLHIV, contraceptive counseling is recommended by UNAIDS to prevent HIV-PT, advocating for planned and desired pregnancies and avoiding unplanned pregnancies. WLHIV who want and plan their pregnancies have better treatment adherence and lower risk of perinatal transmission and complications [48].
Barriers to access SRH represent a lost opportunity for HIV prevention, followup, and counseling. A lack of comprehensive SRHSR means that women cannot take care of their SRH rights and increases the risk of HIV infection or HIV-PT due to unplanned pregnancies. Studies show that barriers to access SRH services take many forms, including denial of access to services, non-integrated services implying different appointments for HIV and SRH, discrimination and institutional violence from service providers, and poor-quality services [49].
Within some settings, procedures related to SRH still are performed without consent, including sterilization and abortion. These interventions also deter women from accessing services and are usually associated with complicated relationships with healthcare providers who do not fully understand childbirth and HIV laws and misinterpret information about HIV-PT preventive measures during pregnancy, delivery, and postpartum [50,51]. Gender-based violence acts as an important barrier to the uptake of HIV testing and counseling, to the disclosure of HIV-positive status, and antiretroviral treatment (ART) uptake and adherence. Fear and violence lead women to avoid disclosing their HIV status, causing them to miss medical appointments and lose HIV care and follow-up [52,53].

Sexual and Reproductive Health based on Rights (SRHR), a guideline for WLHIV
WLHIV do not have equitable access to quality health services in some settings and face multiple forms of stigma and discrimination. They are disproportionately vulnerable to violence, including violations of their sexual and reproductive rights [6,7]. In 2017, the WHO, in response to requests from different organizations worldwide, and seeking to bring together new and existing recommendations and good practice statements related to the SRHR of WLHIV into one document, developed the new "Consolidated Guideline on Sexual and Reproductive Health and Rights of Women Living with HIV." This effort was meant to help countries plan, develop and monitor programs and services promoting gender equality and human rights acceptable and appropriate for women living with HIV [9].
The consolidated guideline advocates for a comprehensive, woman-centered approach to SRHR, from women's perspectives, their families, and communities. This approach maintains the guiding principles of gender equality and human rights. The base for developing this WHO guideline was a global survey conducted to assess the SRHR of WLHIV to prioritize their values and preferences. The survey is the largest performed to date and included 945 WLHIV from 94 countries [54]. The starting point of the guide is where a woman knows her HIV diagnosis. From there, it covers critical issues for providing SRHR-related services to support more effective health interventions and better health outcomes.
The guideline addresses new evidence-based good practice statements establishing the close relationship between SRHR and HIV within the framework represented in Figure 1. The core is grounded in a woman-centered approach (pink circle), the enabling environment strategies (outer purple circle), and the health interventions needed (central blue segments).
A woman-centered approach to access health services involves considering WLHIV as active participants and beneficiaries of good-quality, efficient, and reliable health systems capable of responding to their needs, rights, and preferences. They are also meant to promote gender equality and women empowerment for decision-making as the core for the achievement of SRHR.
The enabling environment strategies for WLHIV encompass eight activities to assist them in overcoming service uptake barriers, stimulate SRHSR use, and encourage continued engagement: promotion of healthy sexuality across the life course, from adolescence to menopause, with SRHR and HIV programs to meet women's health priorities in all epidemic contexts, including psychosocial support interventions, such as support groups and peer support [55]; facilitation of economic empowerment and resource access to reduce WLHIV inherent vulnerabilities; integration of SRHSR and HIV services to increase access to and improve retention in care and services; protection from intrafamily and institutional violence due to HIV diagnosis disclosure; social inclusion; promotion of community empowerment, and implementation of supportive laws and policies to access justice for violence victims and pregnancy termination decisions [56].
On a second front, for the specific health-related interventions relevant to the SRHR of WLHIV the guideline recommends the creation or improvement of health services (such as sexual health counseling and support for WLHIV), intended to provide self-efficacy and empowerment tools around sexual and reproductive health and rights; the prevention of sexually transmitted infections, and training of healthcare providers in sexual health based on rights knowledge. The guideline also suggests creating preventive services for violence against women supporting safe HIV diagnosis disclosure without stigma and discrimination [57]. Finally, regarding HIV-PT, the guideline recommends implementing friendly family planning services to provide comprehensive reproductive counseling. It advocates for planned and desired pregnancies avoiding unplanned pregnancies, with easy access to modern contraceptive methods based on the respect of sexual and reproductive options and rights of WLHIV, and safe abortion services for women who want a voluntary abortion. Within antenatal care and maternal health services, preventive strategies for HIV-PT, including antiretroviral treatments, delivery, and breastfeeding, are also emphasized [58,59].

Conclusions
Women's differential vulnerabilities to HIV acquisition have been studied in different settings and are associated with disadvantageous economic security, education, and other structural determinants of health. HIV/AIDS affects especially young women who represent almost half of the new cases every year worldwide. Research has shown that WLHIV have significant unmet SRH needs, including differential SRH counseling, psychological support, protection from intrafamily and institutional violence, and family planning. HIV-PT is related to WLHIV's unmet SRH needs and access barriers. Lack of quality family planning counseling and low availability of modern contraceptive methods increase the risk of unplanned pregnancies and HIV-PT due to poor ART adherence and high attrition rates in prenatal care prenatal. WLHIV have better treatment adherence and a lower risk of HIV-PT and complications when pregnancies are planned and desired.
Additionally, SRH unmet needs in WLHIV are related to structural barriers and limitations to access good-quality services, imposing a limit to their capacity to make autonomous SRH decisions based on rights and leading to social exclusion, stigma, and discrimination. To improve the use and access to SRHS among WLHIV, the WHO released in 2017 a new guideline with evidence-based recommendations from a women-centered approach. The objective was to promote an enabling environment for WLHIV, with safe preventive interventions preserving healthy sexuality across the life course. It advocated for support for these women in making informed SRH decisions addressing restrictions and barriers from the inalienable right to women's health and wellbeing and as an essential part of the health strategies aimed for these populations.
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