HIV Infection As a Factor of Discrimination in Access to Healthcare for Pregnant Women

According to data of AIDS Federal Center [1] 798,866 people with HIV infection, including more than 290 thousand women(36.7%) were registered in Russia by 31.12.2013. In 2013, there were almost 15,000 deliveries from women with HIV infection diagnosis, more than 5,000 pregnant women first learned about their diagnosis at the examination during pregnancy.

Discrimination Faced by HIV-Positive Women

First of all, women live in fear of disclosure, because society still has a negative attitude to HIV infection. Even doctors discriminate against HIV-positive patients; they deny carrying out abortions or IVF (in vitro fertilization) due to HIV infection. Infectiologists often do not take into account the specificity of women’s health when prescribing the ART (antiretroviral therapy).

Many of existing support programmes are targeted at pregnant women and last till thederegistration of the child at AIDS Centre, whereas support programmes to maintain adherence to treatment during this period are not available for women with young children.

HIV-positive women are deprived of the right to be legal adopters, trustees and guardians.

Access to Breast Milk Substitutes (BMS)

According to Methodological Recommendations MR 3.1.0087-14 of the Federal Supervision Agency for Customer Protection and Human Welfare of Russia (Rospotrebnadzor), to prevent vertical transmission of HIV-infection the complete avoidance of breastfeeding and transition to breast milk substitutes during the entire nursing period is practiced in addition to antiretroviral drugs for mother and child. [2]

In Decree of the President of Russian Federation No.761 dated June 1, 2012 “On National Strategy of Actions in Interests of Children for 2012-2017”, in section “Measures for governmental support of disabled children and children with disabilities” it is stated: “Expanding prevention of vertical transmission of HIV infection, including mandatory prenatal examination of pregnant women regardless of their registration at the place of residence and their citizenship, free provision of nursing HIV-infected mothers with formula milk for baby feeding, with the attraction of funds provided for realization of “Health” national priority project”. But in fact, it turns out that the distribution of formula milk is decentralized and therefore providing the newborns with it in sufficient quantities is not always possible. In addition, the region not always can provide a woman with formula milk which is better suited to her baby.

According to the results of E.V.A. Noncommercial Partnership [3] monitoring conducted in August-September 2014 (over 70 HIV-positive women from 22 regions of the Russian Federation who became mothers in 2013-2014 were involved in the survey), only65% of respondents knew about the possibility to get free BMS for their children, and only 40% used this opportunity. Only a quarter of them received formula milk in full, for half of them the received packages were not enough for 6 months (i.e. till introduction of complementary feeding), another quarter had to give up the provided formula milk as it was unsuitable. Each fifth of those who had the necessary data to receive BMS did not do this because of the complexity of documents processing. Women in Krasnoyarsk Territory, Moscow, Volgograd, Irkutsk, Leningrad, Moscow, Nizhny Novgorod, Novgorod, Novosibirsk, Samara, Saratov, Sverdlovsk, Tomsk and Ulyanovsk regions, in St. Petersburg, in the Republics of Karelia and Tatarstan, in Khanty-Mansiysk Autonomous Region, i.e. almost in all cities where monitoring was carried out, did not receive formula milk in a volume sufficient for 6 months feeding or did not receive it at all.

Pregnancy, HIV Infection and Narcotics

In 2013 in the Russian Federation there were registered 345,015 injectable narcotics users, 17.2% of them were women [4].Injectable narcotics are still the main way of HIV infection spreading in Russia: 57% of all new cases in 2013 [5]. Simultaneously, the occurrence of HIV among women is growing from 36% of all cumulative HIV cases in 2011 [6] to 36.7% in 2013 [7]. However, the dynamics of HIV spreading in a group of narcotic-dependent women is unknown. According to studies, the majority of women who use narcotics are of childbearing age (18-45 years).Up to 11% of all pregnant women in Russia use narcotics [8].

A separate problem is the spread of HIV infection among pregnant narcotic-dependent women. The number of HIV-infected women in Russia, whose pregnancy ended by a delivery increased from 2011 to 2013 by 23%: from 11,694 in 2011 to 14,394 in 2013. [9]The official Russian statistics do not mark maternal narcotics addiction [10]. Nevertheless, a study carried out in 2007 showed that every third among HIV-infected pregnant women (32.3%) used injectable narcotics.[11] These data indicate a high level of HIV infection among drug-addicted women of childbearing age.

Pregnancy is a powerful incentive for women to discontinue the use of narcotics and to begin treatment of drug addiction. At that there are no special recommendations for provision of narcotic dependency treatment during pregnancy in the Russian Federation. None of the existing standards for drug dependency treatment of the Ministry of Health of the Russian Federation include specialized care during pregnancy. Meanwhile, the need for specific recommendations for drug dependency treatment of pregnant women is stipulated by the fact that some drugs used for treatment of opioid withdrawal syndrome have negative impact on the fetus and therefore they are incompatible with the state of pregnancy, and the use of other drugs is allowed only if the benefit to a mother outweighs the potential risk to her child.

The procedure of medical assistance on “Addictology” profile approved by the Ministry of Health of the Russian Federation No. 929n dated November 15, 2012 [12] also provides no organization of special care for pregnant women undergoing drug dependency treatment. The exception is the recommendation to include the position of obstetrician-gynecologist to staff standards of a chemical dependency treatment centre or a chemical dependency treatment clinic at a rate of one specialist per 100 beds for women [13].

Most often this group of women is outside the field of view of social and health care services, and the help-seeking woman is first asked for the documents, then the procedure of parental rights termination is initiated, and recommendations to have an abortion (or to sign papers for surrender of child) are given.

Recommendations

 

• To ensure the confidentiality of any information on the patient’s condition including on his/her HIV status.

• To develop educational programmes for health care and social workers on social and medical aspects of work with HIV-positive mothers, taking into account recommendations and experience of non-governmental organizations.

• To remove a legislative restriction on HIV-positive people rights to adoption and guardianship.

• To consider the possibility of organization and carrying out of an informational campaign to encourage adoption of HIV-positive children.

• To establish a system of low-threshold access to BMS for HIV-positive mothers.

• To develop and accept protocols and standards of treatment for female injectable drugs users (IDUs), pregnant women, nursing mothers and women with small children, as well as for women having a socially significant diseases (HIV-infection, tuberculosis, hepatitis).

• To open specialized state rehabilitation centers for pregnant women and women with children.

• To introduce into the practice of regions organization of patient schools for pregnant women living with HIV infection (PLHIV) and IDUs, including those with the motivation for engaging in the programme.

• To adopt protocols/standards/recommendations on obstetrics, gynecology, preservation of sexual and reproductive health for female IDUs and PLHIV.

• To open offices for family planning in AIDS centres; to instruct female IDUs on methods for pregnancy planning.

• To increase the competence of obstetricians and gynecologists for management of pregnancy of female IDUs. To work on formation of more tolerant attitude of medical staff of the obstetric services to female IDUs. To provide female IDUs with free diagnostics of pregnancy.

 

Author: Natalia Sidorenko, E.V.A.

http://evanetwork.ru/

 

[1] http://www.hivrussia.org/

[2] It is also important to note that recommendations of the Rospotrebnadzor contradict the recent recommendations of the World Health Organization, which recommends continuing breastfeeding till the baby reaches the age of 12 months, subject to ARV therapy of a mother and a child during the whole period of breastfeeding. http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf?ua=1

[3] http://evanetwork.ru/netcat_files/userfiles/Monitoring%20ZGM.pdf

[4] Based on the data from the letter of the Federal State Statistics Service to the EVA, NP No. 08-08-3/2746-DR dated 18.07.2014.

[5] The Federal AIDS Centre. Reference. “HIV infection in the Russian Federation in 2013”. http://hivrussia.org/doc/docs.shtml

[6] The Federal AIDS Centre. Reference. “HIV infection in the Russian Federation in 2012”.

[7] The Federal AIDS Centre. Reference. “HIV infection in the Russian Federation in 2013”.http://hivrussia.org/doc/docs.shtml

[8] Obstetrics. National manual. (2009) Ed. by Aylamzyan. Available athttp://med-books.by/books/Aylamzyan_Natsionalnoe_rukovodstvo_Akusherstvo.pdf

[9] Based on the data from the letter of the Federal State Statistics Service to the NP, EVA No. 08-08-3/2746-DR dated 18.07.2014.

[10] Ibid.

[11] Akatova N.Y., Stepanova Y.V., Miller B. Effectiveness of Monitoring Indicators to Prevent HIV-Tansmission from Mother to Child // Infectious Diseases. – 2007. – p. 17.

[12] Order of the Ministry of Health No. 929n dated November 15, 2012 “On Approval of Medical Care on “Addictology” Profile. http://www.rg.ru/2013/04/25/narkologiya-dok.html

[13] Annex No.19 to the Procedure http://cdnimg.rg.ru/pril/77/23/08/27503_pril.pdf

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