I picked up a piece on the IRIN HIV/AIDS network this week that reported on a “cash for contraception” program that’s currently underway in Kenya. A US-based organization, Project Prevention, is reportedly offering Kenyan women living with HIV $40 (USD) to get intrauterine devices (IUDs), a long-term contraceptive. The idea behind the program, whose operations in the US and UK offer long-term contraception or sterilization to drug addicts, is to prevent mother-to-child transmission of HIV by incentivizing women living with HIV not to have children in the first place. Unsurprisingly, the human rights and public health communities are up in arms, and the Kenyan government says it’s looking into whether the program violates its anti-discrimination laws.
William Okoth, the program’s Kenya coordinator, discusses his (and presumably the program’s) views on mother-to-child transmission, which are extremely concerning–and dead wrong. He says:
HIV has been the longest disaster and only birth control amongst HIV-positive women provides an opportunity to end it…Why should you give birth to a child who will remain an orphan, or who is likely to die before his or her fifth birthday because the mother had infected them… prevent the suffering before it occurs.
Yes, there are 16.6 children worldwide who have been orphaned by AIDS. And there’s no denying the seriousness of pediatric HIV infections. But his argument suggests that every woman living with HIV will die and orphan her children, and that every woman living with HIV who gives birth will pass the virus to her child, when, without any medical intervention, the risk is around 30-40% (with intervention, the rate drops to under 5%, and if the woman is also on HAART for her own health, it can be under 1%). MTCT is not 100%, and suggesting so further increases stigma and discrimination against people living with HIV. At the risk of stats fatigue, here are some more (all from UNAIDS’ 2010 report):
There’s still so far to go in the fight against HIV/AIDS. But this is not the virus that it was in the 1980s or 90s, or even early 2000s, and it is no longer a death sentence in those places where antiretroviral drugs and health care can be accessed. Elimination of new infections among children is within our grasp, and the UN and other global bodies are calling for it by 2015.
Okoth also cites the importance of prevention of unintended pregnancies as one of the “four prongs” of prevention-of-mother-to-child transmission of HIV (PMTCT). And on this point, he’s not wrong: lack of access to or knowledge of family planning and contraceptives is a serious issue around the world, and informed family planning choices are key to eliminating new HIV infections among children. Furthermore, gender inequalities often mean that a woman does not have control over when she has children. When I worked in Sierra Leone, patients with newly-repaired obstetric fistulas were informed that they needed to wait a year before having sexual intercourse and at least two years before having another child to minimize the risk of another fistula, but most shook their heads when they were offered various forms of contraception. Their husbands, they explained, would abandon them if they did not get pregnant right away, and they could not tell their husbands that they could not have sex. Strong and widespread family planning and reproductive health education and access to contraception are key to PMTCT, maternal and infant mortality, and a host of other childbirth and other illnesses and injuries. They must, however, also provide women with the ability to make free, informed decisions about their bodies. Project Prevention’s program denies this right.
Specifically targeting women living with HIV and pushing cash on them has an extremely high risk of coercion and is, without question, discrimination. According to the US Government, 50% of Kenyans live below the poverty line and 40% are unemployed. I’d bet that the unemployment rate for women is higher, and would be especially high for a woman living with HIV, who may not be able to find work due to stigma and may not have the safety net of family, who may have abandoned her due to her positive status. For such a woman, $40 is a lot of money, and might be an offer she couldn’t refuse.
Project Prevention’s cash-for-contraceptives program denies women the right to make their own reproductive decisions and introduces an element of coercion into family planning practices. The program is discriminatory, increases stigma against people living with HIV, and is just plain wrong. Although more family planning and reproductive health education, greater access to contraception, and the reduction of MTCT are laudable goals, the ends do not justify the means in Project Prevention’s case. And the damage those means are doing along the way makes them reprehensible.
