A Changing Landscape

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HIV Today: A Changing Landscape

Rachel Snow began researching HIV/AIDS in 2001, and since then she’s seen the field shift from a focus on prevention to a growing concern with the capacity of health systems to manage the disease and cope with the complications it can generate—including tuberculosis, sexually transmitted infections, and reproductive health issues. An associate professor of health behavior and health education, Snow is currently engaged in two global HIV/AIDS studies:

To Have or Not to Have

When a woman lives in a society with endemic HIV/AIDS, what happens to her desire to have children? It’s an aspect of the HIV/AIDS epidemic few think about, says Snow, “and yet the right to reproduce among people who have HIV is unquestionable.” Thanks to the widespread availability of antiretroviral (ARV) therapies, it’s no longer difficult for men and women with HIV to conceive, and the risk of transmitting the virus to their offspring is extremely low. But in countries where HIV is endemic, it’s unclear how these developments are affecting personal decisions about reproduction.

In Uganda, for instance, where ARVs are widely disseminated, and the HIV-prevalence rate among adults has dropped from a high of 30 percent in the 1990s to just over six percent today, Snow and her research team have found “a pretty significant suppression of interest and desire for more children among HIV-positive women on ARVs.”

In a survey of 1,600 women in the city of Mbarara, in southwest Uganda, the researchers—including, at left, SPH Ph.D. student Massy Mutumba—found that HIV-positive women were far less eager to have children than their HIV-negative counterparts.

Snow and her team are trying to understand the phenomenon. Do HIV-positive women in fact want fewer children, and if so, why? Does it matter if a spouse is HIV-positive, or if there’s an HIV-positive child in the household? Does the availability of contraceptive technologies make a difference?

Snow says it’s critical that countries like Uganda have adequate family- planning counseling, methodologies, and technologies—coupled with well-developed ARV-delivery systems—so that HIV-positive people “have the opportunities, technologies, and power to have the number of children they want to have and believe they can care for—whether it’s six or whether it’s two.”

Testing

Antiretroviral drugs can drastically lower the spread of HIV/AIDS, especially in the early stages of the infection, when the viral load is particularly high. But if people don’t know they’re infected, they can’t get into ARV treatment, and that’s got scientists worried, because in several countries in southern Africa where HIV is endemic, young men appear not to be getting tested.

Snow and her research team have found that in South Africa, females get tested for HIV at a rate three times higher than younger men. Similar numbers have turned up elsewhere in the region—in Lesotho, Namibia, and Swaziland. But farther north, in countries like Kenya, Uganda, Tanzania, and Ghana, there’s far less disparity in HIV-testing rates among men and women.

Why the difference? Snow suspects it may have to something to do with “masculinity and the legacy of apartheid.” She notes that vast numbers of young men in countries with disparate HIV-testing rates work in South Africa, “so this may be linked to labor migration.”

She and her team are analyzing demographic and health surveys in more than 20 African countries, in an effort to determine and address the underlying causes of the problem. In terms of a herd effect, Snow says, getting people on ARVs is the best means of prevention—and that process can’t start until they’re tested.<

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