It is now 20 years since initial reports in Morbidity and Mortality Weekly Report called the world's attention to a disease that soon became known as AIDS. Over that time, advanced antiretroviral medications have gone a long way toward transforming what was once regarded as a virtual death sentence into a somewhat manageable chronic condition--at least in well-off societies such as ours. Thus, HIV-infected individuals now strive to live as normally as possible. Yet given fears of transmitting the virus to a partner or to a fetus, one normal part of life still may seem unlikely for those living with HIV--having a child.
Does the simple wish to have a child vanish with the news of an HIV infection? In this issue of Family Planning Perspectives, James Chen and colleagues examine the extent to which HIV-infected women and men hope to have children. They find that in 1998, almost 30% of HIV-infected men and women in the United States desired children in the future, and that at least three in five who desired offspring actually expected to have one or more children. Such desires have important implications for societal efforts to prevent vertical and heterosexual transmission of HIV, for the content of counseling for HIV-positive individuals and for the future demand for social services.
Elsewhere in this issue, two articles focusing on Washington State examine issues relating to reproductive health--health insurance coverage and access to emergency contraception. Ann Kurth and coauthors find that in 1998, many of the 91 top-selling health insurance plans in the state covered such reproductive health services as gynecology, maternity, reproductive cancer screening, STDs, and HIV and AIDS. In contrast, half covered no reversible contraceptive methods; moreover, 75% of female enrollees lacked core coverage for reversible contraceptive services, half had no coverage for induced abortion and nearly all lacked coverage for infertility treatment.
Meanwhile, emergency contraception is widely viewed as being safe, effective, uniquely able to reduce unintended pregnancy--and vastly underutilized. One view on why this is so is that even though a dedicated product for emergency use is commercially available, many women lack quick and easy access. A report by Jacqueline Gardner and colleagues describes a special effort initiated in Washington State in 1997 to increase women's access to emergency contraception via community pharmacies. Over the course of the project, Washington State women received nearly 12,000 prescriptions for emergency contraceptive pills at 130 pharmacies. They appear to have found the pharmacy-based emergency contraception services to be convenient, and making such services available in more states and localities that permit such programs should increase the chances that women can use the regimen within the 72-hour window. While tubal sterilization has for years been the leading contraceptive method among U.S. women, surprisingly little is known about how many sterilization procedures are performed, who obtains them and what techniques are most commonly used. Andrea MacKay and coauthors characterize tubal sterilization using data for 1994-1996. In those three years, more than two million tubal sterilizations were performed in the United States, an average annual rate of almost 12 per 1,000 women. About 50% were performed postpartum, all of which were done during inpatient hospital stays and half of which were paid for through private insurance. The other 50% were unrelated to a pregnancy; nearly all of these were outpatient procedures, and two-thirds were paid for through private insurance.
When Congress reworked the welfare system in 1996, one aspect of the overhaul was an initiative to emphasize abstinence from sexual activity outside of marriage. This abstinence education program (Section 510 of Title V of the Social Security Act) provides states with $50 million each year, and requires states to match three in four federal dollars with state or local support. According to an article by Adam Sonfield and Rachel Gold, program coordinators in 43 states, the District of Columbia and Puerto Rico report having spent a total of $69 million as part of the program in FY 1999--$33 million through public organizations, $28 million through private entities and $7 million through faith-based groups. Many states prohibited recipients from providing clients with information about contraception (other than failure rates), even when the client requests such information. Most also left localities free to define "abstinence" and "sexual activity"; this suggests that activities supported through the program may have been inconsistent about what clients were expected to abstain from.
Finally, Peter Donaldson argues that a picture is worth a thousand data points. Observing that photography played a greater role in the early years of social science research than it does now, he proposes reexamining the utility of photos in studying reproductive health issues, especially given the availability of moderately priced digital cameras. So say cheese!