Infertility-related reproductive health knowledge and help-seeking behaviour in African countries

¹Correspondence address. E-mail: silke.dyer{at}uct.ac.za Data from African countries indicate that men and women attributeinfertility to traditional beliefs about health and diseaseas well as to biomedical causes, although appropriate knowledgeof the latter is frequently lacking. Infertility is a dreadedcondition and as a result help-seeking is often intense andpersistent. Most of the help-seeking is undertaken by womenand both traditional and modern biomedical health services areaccessed. There are, however, many barriers to effective andaffordable biomedical infertility care, many of which are relatedto poor resources and lack of infrastructure, and as a resultthe need for infertility treatment is often unmet. Advancesin the quality of care require greater commitment to the problemof infertility in African countries, the provision of healtheducation as an integral part of infertility management, theintegration of infertility services into reproductive healthcare programmes and defining the role of assisted reproductivetechnologies in low resource settings. At the same time theimportance of traditional health services in infertility managementshould be recognized.     

Ethical issues of infertility treatment in developing countries

¹ Correspondence address. Tel/Fax: +32-16-620767; E-mail: guido.pennings{at}ugent.be The provision of infertility treatment in developing countriesis controversial. Reports over the last decades have inculcatedin people from Western countries the belief that overpopulationis the major problem of developing countries. This paper willanalyse the different arguments advanced for and against providinginfertility treatment to resource-poor countries. There aretwo arguments in favour: reproductive autonomy and the hugeburden of infertility in these countries. Pronatalism, whichreigns in almost all developing countries, is to a great extentresponsible for the devastating effects of infertility. Thefive arguments against the application of infertility treatmentare overpopulation, prioritization of limited resources, preventionrather than cure, justice and equal access and risk of abuse.The importance of a person's reproductive autonomy demands thatefforts should be made to enable people to determine how manychildren to have. This is equally true in developing countries.However, given the enormous difficulties of resource-poor countriesto provide even the most basic goods, the contribution by societyshould be directed mostly at prevention and should depend ona strong cost reduction for assisted reproductive technology.     

Affordable assisted reproductive technologies in developing countries: pros and cons

¹ Correspondence address. E-mail: akandewole{at}yahoo.com Infertility in developing countries is pervasive and a seriousconcern. In addition to the personal grief and suffering itcauses, the inability to have children especially in poor communitiescan create broader problems, particularly for the woman. Infertilityservices in developing countries span the spectrum from preventionto treatment. From a societal and public health standpoint,prevention is cost–effective and is considered by manygovernments and public health care providers to be a priorityfor service delivery. While prevention remains paramount, takenalone it ignores the plight of infertile couples, includingthose with non-infectious causes of infertility. Two key argumentsare frequently used to challenge the development of new reproductivetechnologies in developing countries: overpopulation and limitedresources. Evidence supports the conclusion that there is acompelling need for infertility treatment beyond prevention.In many instances, assisted reproductive technologies (ART)are the last hope or the only means to achieve a child for couples.In an effort to make much needed ART to developing countriesaccessible and affordable, developing countries should lookto public–private partnerships. Governments have a responsibilityto ensure safe and effective services including the controlof standards for clinical procedures and the regulation of professionalpractice.     

False perceptions and common misunderstandings surrounding the subject of infertility in developing countries

¹ Correspondence address. E-mail: willem.ombelet{at}telenet.be ^{Although the consequences of the problem of childlessness aremore pronounced in developing countries when compared with Westernsocieties, local health care providers and international organizationspay little attention on this issue. The limited budgets forreproductive health care are mostly restricted to family planningand mother care. The most common misunderstanding is the ‘overpopulation-issue’.It is generally believed that the expected growth of the worldpopulation puts a real burden on the issue of infertility treatmentin resource-poor countries, although recent UN reports clearlyshow that in most developing countries the fertility rate isdropping significantly and will fall below the threshold of2.0 by 2050. It seems that the expected population growth indeveloping countries in the next decades is rather due to populationageing and not to high fertility rates. Another important issuesurrounding infertility in developing countries is the so-called‘limited resources argument’. Because the problemof childlessness is a major health problem in most developingcountries, a re-arrangement of the global reproductive healthcare budget should be requested from local governments and internationalorganizations taking into account the urgent need for a go-togetherof more successful family-planning policies and affordable simplifiedART methods.}     

Medical and socio-cultural aspects of infertility in the Middle East

³ Correspondence address: E-mail: giserour{at}thewayout.net The Middle East (ME), an area rich in history and traditionwith >300 million population, includes 18 heterogeneous countriesconcerning resources, income per capita, available healthcareservices, population density, growth rate, birth rate, totalfertility rate and life expectancy. There is a high prevalenceof infertility in the ME because of post-partum infection, unsafeabortion, iatrogenic tubal and pelvic infertility, tuberculosis,schistosomiasis and high incidence of male factor infertility.It is argued that in the ME, the solution to the problem ofinfertility is its prevention, and population control shouldtake precedence over infertility treatment. However, for a successfulfamily planning program and adoption of small family norms,couples should be reassured that they will be helped to achievepregnancy should they decide so. Prevention and treatment ofinfertility are of particular significance in ME because a womansocial status, her dignity and self-esteem are closely relatedto her ability to have children. Also there is gender sufferingof infertility in the ME. One of the stumbling blocks to acceptanceof assisted reproductive technology (ART) as a line of treatmentof infertility was the unacceptability to the main religiousgroups of the involvement of a third party in the act of procreation.Practices of ART in the ME have many common features and littledifferences. A mechanism had to be found to provide low-costART to the needy.     

The interface between medically assisted reproduction and genetics: technical, social, ethical and legal issues*

¹⁹ To whom correspondence should be addressed at: Department of Medical Genetics, University of Turku, Kiinamyllykatu 10, FIN-20520 Turku, Finland. E-mail: hkaaria{at}utu.fi^* Reprinted from European Journal of Human Genetics (2006) 1–58 with permission. The views expressed in this study do not necessarily reflect those of the European Commission (EC). The interface between assisted reproductive technologies (ART)and genetics comprises several sensitive and important issuesthat affect infertile couples, families with severe geneticdiseases, potential children, professionals in ART and genetics,health care, researchers and the society in general. Geneticcauses have a considerable involvement in infertility. Geneticconditions may also be transmitted to the offspring and hencecreate transgenerational infertility or other serious healthproblems. Several studies also suggest a slightly elevated riskof birth defects in children born following ART. PGD has becomewidely practiced throughout the world for various medical indications,but its limits are being debated. The attitudes towards ARTand PGD vary substantially within Europe. The purpose of thisarticle was to outline a framework for development of guidelinesto be issued jointly by European Society of Human Genetics (ESHG)and European Society of Human Reproduction and Embryology (ESHRE)for the interface between genetics and ART. Technical, social,ethical and legal issues of ART and genetics will be reviewed.     

Is affordable and cost-effective assisted reproductive technology in low-income countries possible? What should we know to answer the question?

¹ Correspondence address. E-mail: j.d.f.habbema{at}erasmusmc.nl Decision making on infertility treatment in low-income countries(LIC) assumes answers to quite a few questions: how should theinfertility problem be defined? How often does infertility occur?What is the burden-of-disease of infertility? What is the incomein LIC, and what can be spend on health care? How cheap shouldIVF be in order to be accessible to a considerable part of thepopulation? With what alternative health interventions shouldinfertility treatment be compared? How cost-effective shouldIVF be in order to compete with those other interventions? Thesequestions will be discussed. The emphasis is on the situationin Sub-Saharan Africa (SSA). It is concluded that a place forART in a health care package is not straightforward. Many ofthe questions are not or only partially answered. Moreover,cheap and effective ART has yet to be developed and tested.From the limited evidence available for each of the questions,it could be calculated that an IVF cycle should cost between50 and 75 dollar in order to be a candidate for the inclusionin a health package in SSA. This estimate can easily changeconsiderably when in the future the calculations will be basedon thorough research. Thus, a targeted research programme foranswering the open questions, especially on quality-of-lifeimplications of infertility in different societies, is the preferredoption for facilitating the future evaluation of ART in LIC.     

gp120-induced alterations of human astrocyte function: Na(+)/H(+) exchange, K(+) conductance, and glutamate flux

Many human immunodeficiency virus(HIV)-infected patients suffer from impaired neurological function anddementia. This facet of the disease has been termed acquiredimmunodeficiency syndrome (AIDS)-associated dementia complex (ADC).Several cell types, including astrocytes and neurons, are notproductively infected by virus but are involved in ADC pathophysiology.Previous studies of rat astrocytes showed that an HIV coat protein(gp120) accelerated astrocyte Na⁺/H⁺ exchangeand that the resultant intracellular alkalinization activated apH-sensitive K⁺ conductance. The present experiments wereconducted to determine whether gp120 affected human astrocytes in thesame fashion. It was found that primary human astrocytes express apH-sensitive K⁺ conductance that was activated onintracellular alkalinization. Also, gp120 treatment of whole cellclamped human astrocytes activated this conductance specifically.Furthermore, gp120 inhibited glutamate uptake by primary humanastrocytes. These altered physiological processes could contribute topathophysiological changes in HIV-infected brains. Because thegp120-induced cell physiological changes were partially inhibited bydimethylamiloride (an inhibitor of Na⁺/H⁺exchange), our findings suggest that modification of human astrocyte Na⁺/H⁺ exchange activity may provide a means ofaddressing some of the neurological complications of HIV infection.

     

HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs

There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection “Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers” highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.

Summary Points

• HIV prevention programs for sex workers, especially female sex workers, are cost-effective.
• There are opportunities to further increase the impact of HIV prevention programs for sex workers and to adapt interventions to a changing context.
• Many sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; receive limited domestic financing in many countries; are inadequately codified to ensure consistency and quality; and have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.
• We recommend increasing our understanding of HIV epidemic transmission dynamics, improving situation analyses and programmatic mapping, increasing domestic financing for sex worker HIV prevention programs where feasible, delivering well-codified, comprehensive programs using “Science of Delivery” principles and developing more effective models to reach informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers.
• Given their marginalization, concerted efforts must be made to ensure sex workers have equitable access to HIV prevention, care, and treatment services, as well as wider health services, particularly for STIs, mental health, and addictions.

     

Modelling HIV/AIDS in the presence of an HIV testing and screening campaign

Preventing and managing the HIV/AIDS epidemic in South Africa will dominate the next decade and beyond. Reduction of new HIV infections by implementing a comprehensive national HIV prevention programme at a sufficient scale to have real impact remains a priority. In this paper, a deterministic HIV/AIDS model that incorporates condom use, screening through HIV counseling and testing (HCT), regular testing and treatment as control strategies is proposed with the objective of quantifying the effectiveness of HCT in preventing new infections and predicting the long-term dynamics of the epidemic. It is found that a backward bifurcation occurs if the rate of screening is below a certain threshold, suggesting that the classical requirement for the basic reproduction number to be below unity though necessary, is not sufficient for disease control in this case. The global stabilities of the equilibria under certain conditions are determined in terms of the model reproduction number R₀. Numerical simulations are performed and the model is fitted to data on HIV prevalence in South Africa. The effects of changes in some key epidemiological parameters are investigated. Projections are made to predict the long-term dynamics of the disease. The epidemiological implications of such projections on public health planning and management are discussed.     

Human Papillomavirus Infection and Fertility Alteration: A Systematic Review

BackgroundHPV is the most prevalent sexually transmitted infection and its effect in cancer induction is well documented. HPV infections are mostly asymptomatic, but it is unclear whether HPV infections can result in alterations of reproductive health.ObjectiveTo determine the relationship between human papillomavirus infections and reproductive health in both men and women.MethodsA systematic literature review was performed in PubMed and ScienceDirect data bases from January 1994 through August 2014.ResultsHPV infections are shown to be significantly associated to many adverse effects in the reproductive function. These adverse effects were reported in different levels from cells production to pregnancy and may be related to the infecting genotype.ConclusionsIt appears from this study that HPV detection and genotyping could be of great value in infertility diagnosis at least in idiopathic infertility cases. Like for the risk of carcinogenesis, another classification of HPV regarding the risk of fertility alteration may be considered after deep investigations.     

Projecting HIV Transmission in Japan

Background

Little is known about the epidemiology of HIV in Japan, though newly-identified cases amongst men who have sex with men (MSM) show an increasing trend. Predictions of future trends in the HIV epidemic are essential to identify suitable interventions.

Methods

A deterministic, compartmental model was developed that incorporated risk groups, disease stages, and treatment and testing parameters. This model was calibrated against current figures on new infections and run over 30 years to identify trends in prevalence amongst MSM, low-risk men and low-risk women. Multivariate sensitivity analysis was used to estimate sensitivity ranges for all outcomes.

Results

Without new interventions amongst MSM in Japan, HIV prevalence will climb from its current rate of 2.1% to 10.4% (sensitivity range 7.4% to 18.7%), while HIV prevalence among low-risk men and women will likely decline. With small changes in safer sex behavior and testing rates, HIV prevalence can remain stable or even decline amongst MSM.

Conclusions

Japan is at risk of an epidemic of HIV amongst MSM unless significant changes are made to its current public health intervention framework. More research is necessary to understand the key drivers of the epidemic in Japan.     

Effects of public health educational campaigns and the role of sex workers on the spread of HIV/AIDS among heterosexuals

This paper presents a sex-structured model for heterosexual transmission of HIV/AIDS in which the population is divided into three subgroups: susceptibles, infectives and AIDS cases. The subgroups are further divided into two classes, consisting of individuals involved in high-risk sexual activities and individuals involved in low-risk sexual activities. The model considers the movement of individuals from high to low sexual activity groups as a result of public health educational campaigns. Thus, in this case public health educational campaigns are resulting in the split of the population into risk groups. The equilibrium and epidemic threshold, which is known as the basic reproductive number (R0), are obtained, and stability (local and global) of the disease-free equilibrium is investigated. The model is extended to incorporate sex workers, and their role in the spread of HIV/AIDS in settings with heterosexual transmission is explored. Comprehensive analytic and numerical techniques are employed in assessing the possible community benefits of public health educational campaigns in controlling HIV/AIDS. From the study, we conclude that the presence of sex workers enlarges the epidemic threshold R0, thus fuels the epidemic among the heterosexuals, and that public health educational campaigns among the high-risk heterosexual population reduces R0, thus can help slow or eradicate the epidemic.     

Diet-induced obesity in rats leads to a decrease in sperm motility

Background  

Obesity is rapidly becoming a worldwide epidemic that affects children and adults. Some studies have shown a relationship between obesity and infertility, but until now it remains controversial. Thus, the aim of the present study was to investigate the effect of high-fat diet-induced obesity on male reproductive parameters.     

Epidemiology of HIV Infection in Large Urban Areas in the United States

Background

While the U.S. HIV epidemic continues to be primarily concentrated in urban area, local epidemiologic profiles may differ and require different approaches in prevention and treatment efforts. We describe the epidemiology of HIV in large urban areas with the highest HIV burden.

Methods/Principal Findings

We used data from national HIV surveillance for 12 metropolitan statistical areas (MSAs) to determine disparities in HIV diagnoses and prevalence and changes over time. Overall, 0.3% to 1% of the MSA populations were living with HIV at the end of 2007. In each MSA, prevalence was >1% among blacks; prevalence was >2% in Miami, New York, and Baltimore. Among Hispanics, prevalence was >1% in New York and Philadelphia. The relative percentage differences in 2007 HIV diagnosis rates, compared to whites, ranged from 239 (San Francisco) to 1239 (Baltimore) for blacks and from 15 (Miami) to 413 (Philadelphia) for Hispanics. The epidemic remains concentrated, with more than 50% of HIV diagnoses in 2007 attributed to male-to-male sexual contact in 7 of the 12 MSAs; heterosexual transmission surpassed or equaled male-to-male sexual transmission in Baltimore, Philadelphia, and Washington, DC. Yet in several MSAs, including Baltimore and Washington, DC, AIDS diagnoses increased among men-who-have sex with men in recent years.

Conclusions/Significance

These data are useful to identify local drivers of the epidemic and to tailor public health efforts for treatment and prevention services for people living with HIV.     

Differential COX localization and PG release in Thy-1(+) and Thy-1(-) human female reproductive tract fibroblasts

Akey role exists for prostaglandins (PGs) in reproductive health,including fertility and parturition. However, the cellular sources andregulation of PG production by cyclooxygenase (COX) in the human femalereproductive tract remain poorly understood. We recently reported thathuman female reproductive tract fibroblasts are divisible into distinctsubsets based on their Thy-1 surface expression. Herein, we demonstratethat the expression, induction, and subcellular localization of COX-1and COX-2 and the downstream PG biosynthesis are markedly differentbetween these subsets. Specifically, Thy-1⁺ fibroblastshighly express COX-1, which is responsible for high-level PGE₂ production, a feature usually attributed to the COX-2isoenzyme. In contrast, COX-2, generally considered an inducibleisoform, is constitutively expressed in the Thy-1 subset,which only minimally produces PGE₂. The intracellular signaling pathways for COX regulation also differ between the subsets.Determination of differences in signal transduction, COX expression andlocalization, and PG production by human reproductive fibroblastsubtypes supports the concept of fibroblast heterogeneity and thepossibility that these subsets may play unique roles in tissuehomeostasis and in inflammation.

     

HIV and Latino migrant workers in the USA

Abstract

Migrant workers from Latin America are an essential source of economic development in the US agricultural industry. A majority of migrants are from Mexico and are undocumented and they represent a vulnerable and marginalized group in American society. There is a growing concern for HIV disease in the migrant community. The HIV prevalence rate among migrants is higher than the average rates in USA and in countries of Latin America. There are many behavioural, social, cultural, and health care risk factors and barriers that place migrants at increased risk for HIV infection. Many migrant workers contract HIV while working and living in the USA, which has contributed to rising HIV infection rates in Mexico. In order to prevent an increasing epidemic of HIV disease in Latino migrant workers, there is an urgent call for new and improved health care policies at the international, federal, state, and local levels.     

Future directions for HIV service delivery research: Research gaps identified through WHO guideline development

Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.

Summary points

• Improvements in HIV service delivery are key to bringing countries closer to achieving the target of ending AIDS as a public health threat and situating HIV treatment and care as part of universal healthcare coverage.
• The World Health Organization (WHO) guideline development process is recognized as one approach to identifying research gaps. Systematic reviews form the basis of recommendations formulated by an expert guideline development group, which is also tasked to identify research gaps.
• The 2021 WHO HIV Service Delivery Guideline process identified 27 research gaps grouped into 8 areas where more research is needed to support enhancement and implementation of the new recommendations across the cascade of care.
• Areas covered by the WHO Service Delivery Guideline include antiretroviral therapy (ART) initiation outside the health facility, frequency of visits/refills, tracing and reengagement in care, assessing adherence, integration of HIV and sexual and reproductive health services, integration of HIV and diabetes and hypertension care, psychosocial interventions for adolescents, and task sharing of specimen collection and point-of-care testing.
• Key areas identified by the guideline process that could benefit from future research include tools to support ART initiation outside the health facility, outcomes of spacing of clinical visits/drug refills beyond 6 months, tailored support to minimize disengagement and support reengagement along the continuum of care, and accurate, feasible measures of adherence.
• Strategies of integration of HIV and sexual and reproductive health services and hypertension and diabetes care, costs and cost-effectiveness of psychological support interventions, the performance of newer point-of-care technologies by nonlaboratory personnel, and the impact of diagnostic integration across disease types were also identified as key areas that would benefit from future research.

     

Tracking Official Development Assistance for Reproductive Health in Conflict-Affected Countries

Background

Reproductive health needs are particularly acute in countries affected by armed conflict. Reliable information on aid investment for reproductive health in these countries is essential for improving the efficiency and effectiveness of aid. The purpose of this study was to analyse official development assistance (ODA) for reproductive health activities in conflict-affected countries from 2003 to 2006.

Methods and Findings

The Creditor Reporting System and the Financial Tracking System databases were the chosen data sources for the study. ODA disbursement for reproductive health activities to 18 conflict-affected countries was analysed for 2003, 2004, 2005, and 2006. An average of US$20.8 billion in total ODA was disbursed annually to the 18 conflict-affected countries between 2003 and 2006, of which US$509.3 million (2.4%) was allocated to reproductive health. This represents an annual average of US$1.30 disbursed per capita in the 18 sampled countries for reproductive health activities. Non-conflict-affected least-developed countries received 53.3% more ODA for reproductive health activities than conflict-affected least-developed countries, despite the latter generally having greater reproductive health needs. ODA disbursed for HIV/AIDS prevention and treatment increased by 119.4% from 2003 to 2006. The ODA disbursed for other direct reproductive health activities declined by 35.9% over the same period.

Conclusions

This study provides evidence of inequity in disbursement of reproductive health ODA between conflict-affected countries and non-conflict-affected countries, and between different reproductive health activities. These findings and the study''s recommendations seek to support initiatives to make aid financing more responsive to need in the context of armed conflict.     

Differences in the Access to Sterilization between Women Living and Not Living with HIV: Results from the GENIH Study,Brazil

BackgroundIn many countries, young women of reproductive age have been especially affected by the HIV epidemic, which have fostered research to better understand how HIV infection influences and shapes women´s fertility and reproductive and sexual decisions. In Brazil, few studies have focused on the impact of the HIV epidemic on contraceptive choices among women living with HIV (WLHIV).ObjectiveThis study evaluates the impact HIV infection may have in the access to female sterilization in Brazil, using a time-to-event analysis.MethodsA cross-sectional quantitative study (GENIH study) was conducted between February 2013 and April 2014 in the city of São Paulo, comparing two probabilistic samples of 975 WLHIV and 1,003 women not living with HIV (WNLHIV) aged 18 to 49. Sexual and reproductive data was collected retrospectively in order to reconstruct women''s reproductive trajectories. Given the objectives of this study, the analysis was restricted to women with parity one or more and, in case of WLHIV, to those sterilized after HIV diagnosis and not infected through vertical transmission. The final sample analysis included 683 WNLHIV and 690 WLHIV. A series of multivariable-adjusted Cox models estimated the probability of being sterilized after HIV diagnosis, compared with WNLHIV. Models were adjusted for schooling, race/color, and stratified by parity at last delivery (1–2, 3+). Hazard ratios were calculated for female sterilization, and separately for interval and postpartum procedures (performed in conjunction with caesarean section or immediately after vaginal delivery). Additionally, information regarding unmet demand for female sterilization was also explored.FindingsNo statistical difference in the overall risk of sterilization between WLHIV and WNLHIV in the two parity-related groups is observed: HR = 0.88 (0.54–1.43) and 0.94 (0.69–1.29), respectively, among women with 1–2 children and those with three and more. However, significant differences regarding the impact of HIV infection at sterilization are observed depending on the timing and the type of sterilization procedure. The probability of obtaining an interval sterilization is significantly lower for WLHIV compared to those not living with HIV. The reverse occurs regarding postpartum sterilization. Although sterilization is mainly performed in conjunction with caesarean section in Brazil, it is evident that caesarean sections are not the sole factor increasing the risk of sterilization among WLHIV.ConclusionThe results indicate barriers in the access to services offering interval sterilization for WLHIV and certain facilitation in obtaining the procedure in conjunction with caesarean section. Health policy makers at local and national levels should promote institutional changes in order to facilitate access to interval sterilization and to confront the sensitive discussion of WLHIV’s eligibility for postpartum sterilization. It is also urgent to increase access to a wider range of contraceptive methods for WLHIV and promote dual method protection strategies. Moreover, since condom use may decrease in the future in the context of the preventive effect of antiretroviral therapy, promoting dual methods will expand the choices regarding the reproductive rights of women living with HIV.