The Kenyan government and rights groups have expressed outrage at a project in western Kenya that is paying HIV-positive women to undergo long-term contraception.
Project Prevention, a US-based NGO, offers cash to drug addicts in the US and the UK to undergo long-term contraception or permanent sterilization. In 2010, the project started offering HIV-positive women in western Kenya US$40 to be fitted with intrauterine devices (IUDs), which can prevent pregnancy for over a decade.
The project uses a medical practitioner in the western Kenyan town of Kakamega to insert the IUDs for $7 per woman; so far, 22 women have undergone the procedure.
"There are two issues here; one is using incentives to push women into taking up birth control, and the second is pushing women with HIV to take up long-term birth control irrespective of their reproductive needs," said Agnes Odhiambo of New York-based Human Rights Watch. "All women, including women with HIV, have the right to make informed choices about their reproductive health and that effectively means to use a contraceptive method of their choice, whether long or short term - the key word here is informed choice.
"Giving economic incentives to women with HIV, or any woman for that matter, to undertake long-term contraception is a form of coercion and violates women's reproductive rights and choices," she added.
According to James Kamau, coordinator of the Kenya Treatment Access Movement, the project was "wrong, immoral and unethical".
He noted that it contradicted provisions against discrimination in the country's HIV and AIDS Prevention and Control Act of 2006. Ministry of Health officials say Project Prevention did not seek the government's authority before beginning its operations, making its activities illegal.
"Someone, somewhere, is sleeping on the job because a project like this cannot and should not be allowed to practise in Kenya," Kamau said.
South African media reports in May said Project Prevention planned to start similar operations in South Africa.
Willice Okoth, coordinator of the Kenyan operation, argued that the project's aim was to fill family planning gaps, prevent HIV-related infant deaths and lower the number of orphans in the country.
"HIV has been the longest disaster and only birth control amongst HIV-positive women provides an opportunity to end it," he said. "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," Okoth told IRIN/PlusNews.
According to the US Health Policy Initiative, there is an unmet family planning need of almost 20 percent among married Kenyan women. The government is working to reduce this gap, and the prevalence of contraceptive use has increased from 39 percent in 1998 to 46 percent a decade later.
The country is also increasing access to services for prevention of mother-to-child HIV transmission (PMTCT); an estimated 72 percent of HIV-positive pregnant women receive antiretroviral prophylaxis to reduce the risk of HIV transmission to their babies, while more than 3,300 health facilities around the country offer PMTCT services.
"Fine, one would argue that PMTCT has reduced cases of HIV-positive babies but statistics from government show that just 44 percent of deliveries occur in health facilities," said Okoth. "It means many more HIV-positive mothers who do not deliver at the hospital stand the risk of infecting their unborn children. When you look at the intentions of PMTCT, prevention of unintended pregnancies is one of the key pillars."
Yunia*, a 31-year-old mother of six, says she would have chosen to stop having children as soon as she was diagnosed with HIV four years ago, but had no access to contraceptives. "I didn't want to have a child, but here in the rural area, people cannot advise you because they also don't know. I have had two children since, and one of them died," she told IRIN/PlusNews.
Yunia was happy to take the one-off payment of $40, which she says will help her family income. "I have six children and I could still give birth to more because I am fertile but have nothing to buy food or clothes for them; now if you can get some small money to start a business plus you are helped also to stop giving birth - why not take it?"
Project Prevention gives the money to groups of 10 women for income-generating projects; Yunia and her group have not yet decided on a business venture.
“Wrong way to go”
Senior government officials say, however, that cash incentives targeting a particular group of women is the wrong way address family planning gaps.
"We can't say as a government we have been good at providing family planning needs of women or even men but we are putting measures in place. But it is important to stress that even HIV-positive women have the right to have children if and when they desire. HIV doesn't take that right way, not at all," said Peter Anyang' Nyong'o, Minister for Medical Services.
"Women need reproductive health services - including family planning - but before you give those services, you must educate them and give them a range of choices and then they voluntarily agree to take the one they feel best suited for their case, but to flash money and say take this - no, that is not how to do it," he added.
*Not her real name