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Kampala — IT was really painful for Anita to come to terms with the fact that she was HIV-positive. "At 23, fresh from university, my life was just beginning," she says regrettably. "At first I thought of going on an infection spreading spree, but I changed my mind.

"It is not worth it. Recklessness will kill you faster because you may acquire other strains or opportunistic infections in the process," she remembers the counsellor's words.

"I decided to build a wall against any possible relationship with a man," she discloses.

 But five years down the road, many things changed for Anita. She came to terms with her sero status and got into a stable relationship, but this came with consequences.

"I have risked two abortions and the last one almost killed me," she almost whispers. "I ruled out the dream of having a child once I discovered I was positive. But I never considered any family planning method, unfortunately," Anita adds.

While the risk of HIV-positive mothers transmitting the AIDS virus to their unborn children has been tremendously reduced through evolving medical interventions, research shows that many women still opt for abortion.

A 2004 Kampala-based exploratory study contained in the 2007 Guttmacher Institute report, 'Unintended Pregnancy and Induced Abortion in Uganda', says pregnant HIV-infected women are ambivalent about having children.

"Almost all pregnant women had at least one pregnancy since learning their HIV status," the report says. "Most did not want the pregnancy and half considered obtaining an abortion."

The report adds that the women's main concerns were about how the pregnancy could affect their health and whether the child could also get infected.

The attitude was not any different when it came to their spouses. "Almost all men wanted her to have an abortion. Some forced them by mistreating them or denying responsibility of the pregnancy," the study says.

"The majority of the HIV infected women also said that after learning their diagnosis, they reassessed the number of children they wanted. Some decided to have fewer than they had planned. Others did not want to have any more children at all."

With the introduction of Prevention of Mother To Child Transmission (PMTCT) programmes that include treatment of the mother with antiretroviral drugs, Caesarean birth, administration of nevirapine to the new born and the elimination of breastfeeding, the risk of perinatal transmission has been reduced from over 30% to 8%.

However, the mothers' fears are justified because the protection is not guaranteed. Besides, some of the children born to HIV-positive mothers have been left without a mother, a father, or both parents and this is a critical issue for all mothers: Do I risk infecting my baby, leaving her an orphan or both?

Dr. Saul Onyango, the former national PMTCT coordinator, now with the Uganda AIDS Commission, says they explain the risks, the possibilities to the mother and she takes a decision. "It is her right," he says.

"Our approach is informed decision based on comprehensive knowledge," Onyango argues. "That is why we have PMTCT programmes which are supposed to have a component of reducing unwanted plus mistimed pregnancies and family planning is the solution."

PMTCT has four arms; primary prevention of new infections especially among young people, prevention of unwanted and mistimed pregnancies for those already infected, prevention of mother-to-child infections for those who are already infected and get pregnant, then general care and support within the community.

"However, most of our PMTCT force is in prevention of mother-to-child infections in pregnant women," Onyango says. "We would achieve so much if we tried to balance all the arms, especially prevention of unintended or mistimed pregnancies by enhancing uptake of family planning."

The magnitude of the problem
According to the World Health Organisation (WHO), nearly 20 million unsafe abortions take place each year, 98% of them in developing countries with restrictive abortion laws.

WHO says about 25% of women who undergo unsafe abortions will likely face severe complications like overbleeding, infection, a perforated uterus, or ultimately, death. It adds that governments should ensure access to safe abortion services when the pregnancy endangers the mother's life, enhance post-abortion care and above all, access to family planning for HIV-positive mothers is essential because they are more vulnerable to ill health.

The 2007 Guttmacher report says an estimated 297,000 abortions are conducted annually. The study was not specific to abortion in HIV-positive mothers.

However, Onyango says: "We have no specific local study on abortion or family planning use in HIV-positive women, but abortions may be more common in this category because of stigma and fear of infecting the unborn child," he argues.

"There are also spontaneous abortions resulting from stress or deteriorating health. When you are HIV-positive, your immunity is low and you risk many opportunistic infections, among them malaria, which is the leading cause of spontaneous abortions.

"It also depends on the stage of infection and timing of the pregnancy. You may get pregnant when your viral load is high, thus the immune system fails you, automatically expelling the baby. But there are those who induce the abortion because they do not want to get pregnant, yet they are not using any family planning method," Onyango says.

"There are those who want babies because they hope he will be HIV-negative. Besides, no woman wants to face death without the chance of having a baby," he adds.