Topic: Sexual reproductive healths & rights of positive females in Pakistan
Issue: What are the SRHR needs of positive females in Pakistan
Like other Asian Pacific countries, Pakistan has low HIV prevalence, which stands below 0.09 percent among the general population, with higher prevalence rates documented among key populations of people who inject drugs (PWID) and transgender sex workers. Although there are no national statistics that document the rising prevalence among women in Pakistan, anecdotes by service providers in Voluntary Counseling and Testing centers suggest an increase in the number of women infected with HIV. With care and treatment for HIV/AIDS becoming more accessible, women, men, and young people living with HIV are feeling healthier, living longer, and planning for their futures, including making decisions about starting or expanding a family. HIV-Positive females have the same sexual and reproductive rights as all other females, including rights to information, rights to adequate services, and rights to make free and informed decisions about reproduction. All too often, programs in many parts of the world— including Pakistan—have failed to recognize these rights. Most HIV/AIDS intervention programs have focused largely on preventing mother-to-child transmission (PMTCT), while overlooking the rights of HIV-Positive females to fulfill their sexual and reproductive health (SRH) goals. Not surprisingly, HIV-Positive females are often unaware of measures to reduce the risk of transmission of infection to their children.
The sexual and reproductive needs and desires of HIV-Positive females, in Pakistan, may not be different than those of healthy women in Pakistan or other parts of the world. HIV-Positive females want to have safe and enjoyable sexual relations with their husbands, give birth to healthy children, and avoid unintended pregnancy. However, these women face considerable challenges to the exercise their sexual and reproductive rights and the achievement of their fertility goals. Stigma and discrimination acutely affect their access to comprehensive SRH services. Negative experiences with the health care system prevent HIV-Positive females from seeking health care and expose them to additional health risks.
The vertical structure of health service delivery in Pakistan results in providers being unable to provide services outside their domain. HIV/AIDS care givers are not trained in providing for the sexual and reproductive health needs of HIV-Positive females, while primary and secondary care providers who offer reproductive health services stigmatize HIV-Positive females and are not aware of their needs.
However, this reality can be changed. The change can begin by linking sexual and reproductive health services for HIV-Positive females with HIV care. Linking these two critical components of care will create a more comprehensive package of health services for HIV-Positive females. Training of health care providers and raising public awareness about HIV are essential for reducing stigma and discrimination against HIV-Positive females. Finally, HIV-Positive females need to be empowered to stand up for their sexual and reproductive health rights and to demand quality services.
Need For Policy Analyses Brief On The Subject
The rights of individuals to access SRH services, and to make their own decisions about their SRH care, have been well recognized and to have Sexual and reproductive rights apply to all individuals regardless of HIV status. Yet more often than not, the rights of HIV-Positive Females are not recognized or given priority. Gender inequality and some social and cultural practices often tightly restrict and sometimes control the decisions that women and girls can make regarding their sexual and reproductive choices. Due to poverty, HIV-related stigma, and discrimination, the access of HIV-Positive Females to critically needed information and services is severely curtailed, with dire consequences.
The close relationship between SRH and improved prevention, treatment, and care for HIV/AIDS, and their role in contributing to meeting various international commitments, are now widely recognized. Challenges to SRH and HIV/AIDS share the same root causes, including poverty, gender inequality, marginalization, and stigmatization. Therefore, ensuring access to SRH services for HIV-Positive Females contributes both to an effective global response to HIV and to the reduction of poverty and gender inequality.
Sexual and Reproductive Health and Rights, has been a neglected area, in Pakistan and up till now, fewer is known about existence of service delivery to cater the SRH needs of positive females. APLHIV through funding support of Asia Pacific Network of People Living with HIV/AIDS (APN+) undertook a rapid assessment in September 2015, which was the 1st ever an effort to document the issues and suggest a way forward to identify SRH needs of HIV-Positive Females. Based on the findings of the study a capacity building plan for positive females in Pakistan was developed. During the training session more focused discussion were undertaken to write the issues in form of policy analyses brief.
Sexual Reproductive Health Services
During the capacity building workshop 15 positive females who were willing to take part in discussion participated in the discussion for developing policy analyses brief. Out of fifteen  positive females six positive females reported availed ‘Maternal and Neonatal Care’ services, while another three  positive females received abortion related services, however none benefited from abortion preventive services.
Prioritized Sexual & Reproductive Health Services Needs
The participants of the discussion were inquired about three group of services i.e. SRH related services; services which fall in between the SRH & HIV and HIV exclusive services. Among sexual and reproductive health related services, eleven  participants, prioritized need for the gynecological examination, followed by maternal and neonatal care by eight  females, while breast examination by nine  females and cervical screening through Pap Smears by seven  females.
Fourteen  participants voiced need for treatment services, followed by HIV preventive services by twelve  females and HIV treatment / Treatment monitoring by eleven  females.
Among SRH/HIV linked services, HIV Counseling & Testing (HTC) remained the most prioritized need, followed by Psycho-Social support and PPTCT services.
Additional Sexual & Reproductive Health Services Needs
Diagnostic services were identified to be the most wanted additional sexual & reproductive health need, followed by cost for transportation, nutritional support for children, medication for common ailments and regular medical checkups.
Sexual & Reproductive Health & HIV Linked Services
Participants had in depth discussions on two questions, whether they would prefer to avail, both SRH and HIV from the same health facility and / or from the same health care providers, and subsequently advantages and disadvantages of availing services from the same health facility and the health care providers. Preference for integrated SRH and HIV was recorded by twelve  participants and services delivery from the same health care provider by thirteen  participants. Reduced number of trips and transportation cost were identified as key reasons for integrated SRH & HIV services from the same facility, while opportunity for availing additional services and reduced stigma for HIV were cited as reasons for availing services from the same health care providers.
Suggestions For Improving Sexual & Reproductive Health Service Delivery
Reducing stigma, followed by improved attitude of health care providers and capacity building of health care providers on SRH were priority suggestions for improving SRH service delivery. Whereas training of health care providers on SRH, followed by involvement of NGOs in service delivery and availability of IEC material / Information on SRH were suggested as measures to improve SRH & HIV Integrated services.
Sexual Reproductive Health Rights
Out of 15 participants on six  were aware of their sexual and reproductive health rights. Awareness recorded about sexual and reproductive health rights, was even lower, than other rights.
Three  participants were aware about availability of mechanisms to prevent violence against women, while two  reported about existence of mechanism to safeguard about stigma and discrimination. However, all participants negated about existence of any sort of mechanism, where they can solicit their views about the quality of services, being delivered.
The sexual and reproductive health needs of HIV-Positive females, in Pakistan are not dissimilar to those of healthy women in other parts of the world. When they seek health care, HIV-Positive females want their provider to acknowledge their health condition and to provide quality guidance and treatment in a respectful manner. For HIV-Positive females in Pakistan, exercising those basic sexual & reproductive health and rights is a challenge. Widespread stigma and discrimination among health care providers and at the community level create significant barriers to accessing basic services and deprive many HIV-Positive females of realizing their sexual & reproductive health and rights and reproductive goals. Additionally, the current setup of vertical service delivery programs meant that staff trained to provide maternal and child health or family planning services are often unaware and untrained in the needs of HIV-Positive females. Likewise, providers who work in HIV-care centers are not trained in or aware of how to address the unique sexual and reproductive health needs of the HIV-Positive females that they serve.
These circumstances affect the ability of HIV-Positive females to access sexual and reproductive health services. Poor treatment by untrained or uninformed providers makes HIV-Positive females hesitant to seek additional services in the future. Moreover, unreliable access to information perpetuates misconceptions about HIV/AIDS and the options available to HIV-Positive females. The discrimination and stress these women experienced due to repeat rejection from health care providers not only violated their rights but also jeopardized their health and their chances of successful delivery of a healthy child. The multiple and interrelated needs of HIV-Positive females would be better addressed through an integrated model of service provision.
QUESTIONNAIRE FOR DISCUSSION
- Have you ever received any of the following services: –
- a. Family Planning
- b. Maternal & Newborn care
- c. Post abortion management
- d. HIV Testing & Counseling
- e. Management of OIs, STIs or any other co-infection
- f. Prevention of unsafe abortion
- What Sexual and Reproductive Health (SRH) services, would you like to get, along with HIV related services?
- a. Family Planning
- b. Breasts Examination
- c. Pap smears for cervical screening for pre-cancers / cancers
- d. Routine gynecological examination
- e. HIV prevention
- f. HIV monitoring and / or Treatment
- g. Treatment preparedness/treatment
- h. HIV counseling and testing
- i. Prevention and management of gender based violence.
- What other/ additional services, would you like to receive in addition to mention above?
- Do you prefer sexual and reproductive health and HIV services at the same facility, or do you prefer different facilities?
- Do you prefer sexual and reproductive health and HIV services from the same provider or do you prefer referral to another provider?
- If you make one suggestion for improving services at this facility, what would you suggest?
- Do you have any suggestions about the integration of sexual and reproductive health and HIV services?
- Are you familiar with your SRH rights? Can you name a few SRH rights?
- Is there is a mechanism in place that solicits of HIV-Positive Female about the quality of existing services?
- Are there measures in place to prevent violence against women?
- Are there any measures/mechanisms in place to safeguard against stigma and discrimination?