Rights of PLHIV

to
Sexual and Reproductive
Health Services
 Session Objectives
In this session we will learn about:

1. The Sexual and Reproductive Health(SRH) needs of PLHIV

2. Why we need to talk about the Rights of PLHIV to SRH services

3. What are the SRH services currently available to the PLHIV

4. Challenges in addressing the SRH needs of the PLHIV

5. Advantages of integrating SRH into HIV Care services

6. SRH needs of women living with HIV and DTG based ARV regimens.
Sexual and Reproductive Health(SRH) needs of PLHIV
The SRH needs of the PLHIV are as per the following subgroups

1. Based on age of PLHIV: 3. Based on preference for sexual partners

• Adolescents • Same sex partners (homosexual)
• Adults • Different Sex partners(heterosexuals)
• Elderly • Having a combination of above
(Bisexuals)

4. Based on HIV status of sexual partner

2. Based on the gender
• Both the partners are HIV
• Male
positive(concordant couples/partners)
• Female • One partner is HIV negative and the
• Transgender other is HIV positive(discordant couples/
partners)
 The need to talk about the Rights of PLHIV to SRH services
• The core principles of Sexual and Reproductive Health are:

• Promotion of reproductive health

• Voluntary and safe sexual practices

• Knowledge of reproductive choices for individuals and couples

• Right to make decisions on timing of marriage and family size

• In the era of life-long ART, viral load suppression and “Undetectable is equal to Un-
transmissible” (“U=U”), the PLHIV have the same rights to SRH services as HIV
uninfected individuals, based on the core principles of Sexual and Reproductive
health.
 The SRH services currently available to the PLHIV
• Adolescent Reproductive & Sexual Health (ARSH) Clinics under the National Rural Health
Mission which can be accessed by all adolescents, irrespective of their HIV status

• Suraksha Clinics” for STI/RTI care provide screening and comprehensive case management of
Sexually Transmitted Infections (STIs) and Reproductive Tract Infections (RTIs)

• Essential Package of PPTCT Services under NACO

• Family Planning and safe abortion services

• Ante-natal Care and maternal Health Services

• Services for protection from violence

• Screening for Cervical cancer & HPV vaccination

 Challenges in addressing the SRH needs of the PLHIV

• The health system often fails to take into account the sexual and reproductive health
needs of PLHIV.
• In many places existing laws and policies fail to support people living with HIV to
achieve their sexual and reproductive needs
• Stigma and discrimination faced by the PLHIV accessing the health care services
• Lack of linkage between SRH centres and counselling centres
• Inadequate support from family and community
• The services are currently being provided under different national programs.
 Advantages of integrating SRH into HIV Care services
• Integrating SRH and HIV services will improve SRH outcomes of PLHIV
• Such integration recognizes the importance of empowering people to make informed
choices about their own SRH
• Comprehensive, rights-based family planning services are a core component of an
integrated SRH and HIV services package
• Enables Couples (both concordant & discordant) to pursue their fertility goals:
• planning for safer pregnancies
• spacing desired pregnancies
• preventing unintended pregnancies
• Enable PLHIV practising high risk behaviour to discuss their SRH needs without fear of
stigma or discrimination.
 Right to Sexual and Reproductive Health

• In 2016, the United Nations Committee on Economic, Social and Cultural Rights (CESCR)
defined the right to Sexual and Reproductive Health (SRH) as an “integral part of the
right to health”.
• Reproductive rights of HIV-positive individuals include:
• Knowledge about available contraceptive methods
• Ability to choose the number of children they wish to have including the decision of
not having children
• Counselling services about family planning methods (no coercion to adopt them)
• Easy access to Temporary and Permanent family planning methods
 SRH Services for Women living with PLHIV

The seven components of SRH services for women

living with HIV comprise of:
• Violence against Women services
• Sexual health Counselling and support
• Care for Sexually transmitted infections (STIs)
• Screening and Prevention of Cervical Cancer
• Ante-natal Care and maternal Health Services
• Family Planning and Infertility services
• Safe abortion services

Source: WHO Consolidated Guideline on Sexual and Reproductive health and rights of women living with HIV,
2017
 Protection from Violence and Creating Safety
• PLHIV who disclose any form of violence by an intimate partner (or other family member) or sexual
assault by any perpetrator should be offered immediate support.
• Health-care providers should, as a minimum, offer first-line support when the PLHIV disclose violence.
• First-line support includes:
o Being non-judgmental and supportive and validating what the PLHIV is saying
o Helping them access information about resources, including legal and counselling services
o Assisting them to increase safety for themselves and their spouse/partner/family members
o Providers should ensure consultation is conducted in private and with confidentiality
o Ensuring safe disclosure
• Mandatory reporting of intimate partner violence to police by health-care provider is not recommended.
• However, health-care providers should offer to report the incident to the appropriate authorities
(including the police) if the PLHIV wants this and is aware of their rights.

Adapted from :WHO Consolidated Guideline on Sexual and Reproductive health and rights of women living with HIV, 2017
 Sexual Health Counselling and Support
• Sexual health Counselling and support
• Adolescents and young people living with HIV are often poorly informed about their
SRHR.
• They need comprehensive sexuality education, including information about how
pregnancy, STIs and HIV transmission occur,
• They need to be empowered to recognize, avoid or report violence and sexual
coercion
• Brief sexuality communication (BSC):
• Recommended for the prevention of sexually transmitted infections among adults and
adolescents in primary health services
• Training of health-care providers in sexual health knowledge and in the skills of BSC is
recommended
• Adolescent-friendly Clinics under National Rural Health Mission project-ARSH clinics
ARSH: Adolescent Reproductive and Sexual Health program under NRHM

Source: https://nrhmmeghalaya.nic.in/sites/default/files/arsh_4.jpg
 Care for Sexually Transmitted Infections (STIs)
Suraksha Clinics: screening and comprehensive case management of STIs/RTIs
Critical components of Care For Sexually Transmitted Infections:
• Counseling and education of patient and sexual partner(s): STI/RTIs, genital cancers, safer sex
practices, importance of sexual abstinence during treatment period
• Syndromic Management of STI/RTI : Colour coded kits (kit 1 to kit 7)
• Adherence to treatment: Complete course, Follow-up after 7 days and assess for treatment
failure /re-infection
• Partner Treatment: Treat partner(s) where ever indicated
• Condom promotion: Provide condoms, educate about correct and consistent use
• Referral: Testing for HIV, Syphilis and Hepatitis B
• Immunization against Hepatitis B can be considered
 Screening for Cervical Cancer
• Cervical cancer is the second most common cancer in women living in low- and middle-income
countries.
• Cervical cancer is preventable and curable if detected and treated early.
• Women living with HIV are likely to develop persistent HPV infections with multiple high-risk
HPV types at an earlier age
• They have more rapid progression to pre-cancer and cancer than women not infected with HIV.
• Women living with HIV are at 4–5 times greater risk of developing cervical cancer
• WHO recommends that women living with HIV be screened as soon as they are diagnosed with
HIV (regardless of age)
• Reaching these vulnerable women at high risk of developing cervical cancer will need
prioritization of integrated preventive, screening and treatment services
 Recommendation on HPV vaccine
• WHO recommends the Human Papilloma Virus (HPV) vaccine for girls in the age group of 9–14
years, aiming for 90% coverage by 2030
• For girls receiving first dose of HPV vaccine before the age of 15 years, a two-dose schedule(at 0, 6
months) is recommended.
• If the interval between the two doses is shorter than five months, then a third dose should be
given at least six months after the first dose
• The maximum interval between the two doses is suggested to be no greater than 12-15
months.
• For girls receiving first dose of HPV vaccine at or after the age of 15 years, a three-dose schedule(0,
2, 6 months) is recommended
• Immunocompromised and/or HIV infected females aged 15 years and older should also receive
the vaccine and they would need three doses (at 0, 1–2, and 6 months) to be fully protected.
Essential Package of EVTHS Services in India
Routine offer of HIV counselling & testing with “opt-out” option
Ensure Involvement of spouse & family members (“Family Centric” approach)
Provide ART to HIV positive pregnant and breast-feeding women
Perform plasma viral load testing at 32-36 weeks to determine the risk of HIV transmission to the baby
Promote Institutional deliveries of positive pregnant women
Provision of Care for STI / RTI, TB and Opportunistic Infections
Nutritional counselling & psychosocial support to positive pregnant women and future family planning
Counselling and support for exclusive breastfeeds as the preferred option; continue breast feeding as per
guidelines
Antiretroviral prophylaxis to infants up to minimum six weeks
Integrate follow-up of HIV-exposed infants into routine healthcare services including immunization

Strengthen community follow-up and outreach through local community networks to support pregnant
PLHIV and their families
 Family Planning and Contraception
• Family planning is essential in promoting the well-being and health of families , including People
living with HIV, their families and their communities.
• In order for health workers to provide high-quality contraceptive services, contraceptive
programmes need to include certain elements, such as:
• choice among a wide range of contraceptive methods;
• evidence-based information on the effectiveness, risks and benefits of different methods;
• technically competent, trained health workers;
• provider–user relationships based on respect for informed choice, privacy and confidentiality
• an appropriate constellation of family planning services available at the same premises as the
ART centre
• Access to all available Contraceptive methods without discrimination
Temporary Family Planning Methods
Permanent Family Planning Methods under the National Family planning Program

Female Sterilization: Bilateral Tubectomy

Male Sterilization: Bilateral Vasectomy

Source: Family planning Brochure for ASHA

https://humdo.nhp.gov.in/wp-content/uploads/2017/07/ASHA-Leaflet.pdf
 Safe abortion services
• WHO recommends that safe abortion services should be the same for women living with
HIV, who want a voluntary abortion, as for all women.
• WHO suggests that women living with HIV who want a voluntary abortion can be offered a
choice of medical or surgical abortion, as for all women, based on the prevailing country law.
• Abortion services should be free of coercion and offered in a respectful and non-
judgemental manner
• Health workers offering abortion services:
• must respect the rights of the women living with HIV
• should facilitate access to safe abortion services, if desired by the woman
• ensure that the women make the choice for themselves

Source: WHO Consolidated Guideline on Sexual and Reproductive health and rights of women living with HIV,
2017
Current DTG Data In Pregnancy & Newborn: Botswana Tsepamo Study
• The Botswana Tsepamo Study conducts birth outcomes surveillance study at government hospitals
throughout Botswana, covering ~70% of all births.
• Prevalence difference of Neural Tube Defects by ARV and HIV Exposure Categories in 2018, interim analysis
was rate of 0.94%. Till April 2020, prevalence in study had declined to 0.19%.
• Results since April 2021 to March 2022 are compiled in table on Prevalence Difference of Neural Tube
Defects by ARV and HIV Exposure Categories
Exposure group vs. comparison group Prevalence difference (%) (95% CI)
DTG at conception vs. non-DTG at conception 0.00 (-0.07, 0.10)
DTG at conception vs. EFV at conception 0.03 (-0.05, 0.12)
DTG at conception vs. DTG started in pregnancy 0.04 (-0.06,0.14)
DTG at conception vs. non-DTG started in pregnancy 0.04 (-0.07,0.13)
DTG at conception vs. women without HIV 0.04 (-0.01, 0.13)
Conclusion: Prevalence of NTDs among infants born to women on DTG at conception has declined to 0.11% and does
not substantially differ from other exposure groups. Data support existing WHO guidelines that recommend DTG as
first-line for use in all adults, regardless of reproductive potential
Source: Update on neural tube defects with antiretroviral exposure in the Tsepamo Study, Botswana
Available at: https://programme.aids2022.org/Abstract/Abstract/?abstractid=12759
ART Initiation in Women of childbearing age or potential

• Note: Women of childbearing age or potential, should be provided appropriate

information and counselling about immense benefits as well as slight risk related to
use of DTG, in order to make an informed choice about DTG use.

Linkages to contraceptive services is essential in Women in reproductive age group,

who consent to initiation on TLD regimen.
Counseling WLHIV on Sexual and Reproductive health issues
ART Initiation in Pregnant and Breast feeding WLHIV

Under the national programme, it is recommended to provide lifelong ART for all
pregnant and breastfeeding women living with HIV, where all pregnant women
living with HIV receive a “Fixed Drug Combination (FDC)” triple-drug ART regimen
regardless of CD4 count or clinical stage, both for their own health and to prevent
vertical HIV transmission and for additional HIV prevention benefits.

Presently as per the national guidelines, Tenofovir + Lamivudine + Dolutegravir

(TLD) is the preferred regimen for pregnant women.

Source: Chapter-2.5, National Guidelines for HIV Care and treatment, 2021
 Specific Counseling needs of PLHIV
• Counsellors and Doctors need to:
• Discuss risk of sexually transmitted infections with the PLHIV and counsel them on correct and
consistent use of condoms
• Emphasize risk of infection with drug resistant strains of HIV as additional reason to use barrier
contraceptives, even if the partner is also HIV positive.
• Counselling needs of PLHIV will be different for those who do not want children from those who want
children and these will be based on the HIV status of the partner.
Partner Status Counselling needs of PLHIV who do not wish to have children
HIV Positive(Concordant Recommend:
couple)  permanent methods of family planning
 Long term contraception
HIV Negative(Discordant In addition to above:
couple)  Recommend screening test for the spouse
 Strongly advocate condom use
 Counselling needs of PLHIV who wish to have children

Partner status Do not have children Have other child/children

HIV Positive
 Advise that women should preferably  Understand their need of having another
(Concordant
couple) conceive after attaining 20 years of age child (their own choice/family pressure etc.)
 Understand their need for having a child  Encourage child-spacing – recommended
(their own choice/family pressure etc.) gap of 3-5 years between two children
 Discuss the benefits of a small family

In addition to above: In addition to above:

HIV Negative
(Discordant  Recommend HIV testing for the spouse  Recommend HIV testing for the spouse
couple)  Suggest seeking medical help  Suggest seeking medical help

Reinforce the importance of adherence to ART and Viral Load suppression in PLHIV who wish to have children
HIV-SRH Counselling Guide
 The way forward..

• Health services providing equitable access to sexual and reproductive health services,
for not only the PLHIV but also their sexual partners and families

• Adolescent and youth-friendly clinics and services should be promoted and made easily
accessible to young PLHIV

• Schools and other public institutions should provide protective environments and
policies for young PLHIV

• Comprehensive and age specific sexual and reproductive health education should be
provided for all adolescents, young people, including those living with HIV
 Key Points
• The SRH needs of the PLHIV may vary based on the age, gender and HIV status of
the sexual partner/spouse.
• The PLHIV have the same rights to SRH services as HIV uninfected individuals, based
on the core principles of Sexual and Reproductive health.
• HIV positive women of childbearing age or potential should be fully informed of the
potential increase in the risk of neural tube defects with use of DTG and given the
choice of opting out of DTG based regimens.
• However, if an HIV positive woman is identified to be pregnant after the first
trimester, DTG should be initiated or continued for the duration of the pregnancy &
lifelong thereafter.
• Integrating SRH and HIV services will improve SRH outcomes of PLHIV
Thank You