This meeting has opened up a range of issues and options and few solutions at present. The following options have been discussed by those in need – artificial insemination, sperm washing, surrogate motherhood and adoption; each one having its own legal and financial implications.
This is the first time I have been addressed as someone at-risk of HIV infection rather than just as the spouse of a person living with HIV. This leaves me acknowledging various issues; a new world that allows for a platform to address issues concerning persons at risk.
Through all these meeting presentations and deliberations, it seems to me that the male condom is the only likely and effective tool to prevent infection through sexual exposure. It also has the dual function of being able to prevent unwanted pregnancies. Yet to a couple in a serodiscordant marital relationship and/or a person at risk, effective techniques are sought that would prevent infections such as HIV and STI but allow for conception. We do require that as a CHOICE!
Issues concerning conception in women with HIV and those at risk of HIV are becoming increasingly relevant, with the current improvements in treatment options for HIV patients and their increase in life expectancy and better quality of life1,2. Little wonder now that persons with HIV or those at risk acknowledge their desire to have children. Reproductive technologies provide a logical way to minimize HIV transmission for HIV-concordant and discordant couples desiring pregnancy. This leads to a range of ethical, legal and social cultural issues.
Women at risk face a dilemma3. There is a need to have a child (or more children), and there is a fear of being at risk through unprotected sexual activity. Women are faced with situations when the male partner or spouse uses safer sex precautions to prevent the spread of infection. The woman is often left to make excuses for not being able to have a child, succumbing to parental pressures despite the risks, to avoid being branded with the term ‘barren’, hostility or rejection from relatives and neighbours, and ostracization at cultural and religious functions.
Family support and understanding have played an important role in coping with these issues and reducing the stigma and discrimination. Counseling and psychosocial support have assisted in reducing stigma within the family. At YRG CARE, there is much emphasis on counseling for the individual, his or her spouse/partner and the family4. Other aspects that are equally important are access to updated information and discussions with peers through self-help groups or support groups5.
This meeting has provided me with a platform to share my own coping mechanisms with regard to the fertility pressures and issues. Discussions on personal and sensitive issues were faced head on with a clear perspective of the future. At first, when we decided to marry despite our serodiscordant status, we had planned on not having a child, hoping that our love and affection for each other would be sufficient to keep us together. Being the person with the negative status can be quite stressful if there is no one to voice fears and concerns. Over the years, with the influence of HAART and a better quality of life and a brighter view of the future, we felt the strong need for someone who we could call our own, a little child who would smoothen our tears and fears away with a little smile. Our little boy has been all this and more. When the family offered us the youngest son of our departed brother, our joy knew no bounds. We leapt up and traveled afar to bring him home to us. Although there was much discussion and debate, especially about the legal implications with our families6,7, all have wished us well and have ever since supported us.
Despite all the support, there is always a nagging concern, will our families and friends continue to accept him as our son. Would our neighbours treat him well? Would the kids in our neighbourhood welcome him into their circle and allow him to join in their fun and frolics. Would we be good parents? Are we doing the child an unjust act by adopting him, when we know that someday he would lose a parent to the disease. We realized that we cannot know all the answers, and that biological parents are also often unsure of so many things, but are able to go ahead and plan for their future and deal with the ups and downs as and when they come. This is exactly what we do.
Through all this, we coped; we coped because we had support from our family and friends. Dr Suniti Solomon, director, guide and counselor of YRG CARE has been with us every step of the way. She was the one who not only encouraged us, but also made us aware of the reality and the problems that we would face. She cautioned us to be patient and understanding. Her advice has helped us to be aware that we care for our little boy and that he cares for us, and whatever the world says nothing can change that. Our little boy has a charming, warm and healing smile, and when he smiles at us, it pulls at our hearts.
Queries of women living with HIV or those at risk revolve around access to information and services, the potential cost of reproductive techniques, their possible reversibility, dual protection or single protection, the confidentiality of clinicians and the availability of support systems.
There is a need for greater insight into the direct and indirect effects of HIV infection and its therapies on reproductive health. There have been no such studies conducted in India. Future research is necessary to understand the emotional and sociocultural issues. Clinical studies are required to determine the utility of antiretroviral therapy in preventing seroconversion or minimizing the risk of HIV transmission associated with reproduction. The further development of assisted reproduction techniques that are reliable and cost effective is also essential. Finally, it is important to address and resolve the sociocultural challenges that surround reproductive decision-making in persons, especially women with HIV and those at risk.
1. Lo JC, Schambelan M. Special articles: Hormones and reproductive health – commentary – reproductive function in human immunodeficiency virus infection. J Clin Endocrinol Metab 2001; 86(6):2338–2343.
2. Bendikson KA, Anderson D, Hornstein MD. Fertility options for HIV patients. Curr Opin Obstet Gynecol 2002; 14:453–457.
3. Solomon S, Buck J, Chaguturu S, et al
. Stopping HIV before it begins: issues faced by women in India. Nat Immunol 2003; 4(8):719–721.
4. Solomon S. ‘Encounters That Help…’. India: YRG CARE 1999.
5. Brown HW, Vallabhaneni S, Solomon S, et al
. Attitudes towards prenatal HIV-testing and treatment among pregnant women in Southern India. Int J STD AIDS 2001; 12:390–394.