Anecdotes and local speculations have long hinted on the need to strengthen existing service provision guidelines and to equip service providers with the requisite competencies to interact with HIV-positive clients professionally. In the case of HIV, it is not only the medical facts that are relevant to their health, but also many of the psychosocial issues relevant to their interest in having children . Health workers themselves have sent out several calls for knowledge updates through refresher training. One does not have to carefully peruse the yearly reports churned out by the Ghana Health Services to recognize this. This current study on providers’ awareness and in-depth knowledge on reproductive matters of persons infected with HIV reveal two main perspectives. An overwhelming majority of the providers acknowledge HIV-positive person’s right to reproduction. However, these providers, at the same time, were very ignorant about the various reproductive options available to persons infected with HIV.
First, it was refreshing to note that nine out of every ten providers acknowledge HIV-positive person’s right to reproduction. This is in line with articles 1 and 16 of the Universal Declarations of Human Rights, which state that “All human beings are born free and equal in dignity and rights…”; and that “men and women of full age, without any limitation, have the right to marry and to found a family…”.
However, when the in-depth knowledge of these providers was scrutinized, only 1 in five were aware that measures exist to help HIV-positive women conceive and deliver safely. The measures mentioned were the use of antiretroviral drugs and delivery via elective Caesarean section. de Bruyn  notes of a gathering in 2004, where more than 25 national and international organizations presented a statement to the secretariat of the United Nations Commission on the Status of Women that highlighted relatively neglected areas in the reproductive health of women affected by HIV and AIDS . Ipas in collaboration with the International Community of Women Living with HIV, the Center for Health and Gender Equity and the Pacific Institute for Women’s Health, used that statement and a literature review  to develop a practical tool to help interested organizations address those neglected areas of reproductive health. Delineated in this tool are various reproductive options. These have been described in detail in the introductory section of this paper.
A discussion on the perspectives and in-depth knowledge of the service providers needs to be nuanced. A careful scrutiny of the various guiding instruments used by the providers reveal no such guidelines on reproductive rights or options for HIV-positive clients. Secondly, while the various options described above are available in developed countries, they are usually unavailable in resource-poor settings. In places where these are available, they may not be affordable, or acceptable. For instance, while the various options described above are available in Ghana, their prohibitive costs make them unattractive to the group of clients under discussion as well as the general Ghanaian public (Dr. Maxwell Antwi, La General Hospital; Personal Communications). The costs range from six hundred Ghana cedis (approximately 400 us dollars for elective Caesarean section) to seven thousand Ghana cedis (approximately 4,600 us dollars for IUI).
Even if these procedures/options are affordable, there are other social, religious or moral concerns that preclude their adoption, For example, insemination with a donor sperm though perfectly safe, may not be acceptable due to the removal of possibility of genetic parenthood. This has tremendous moral and ethical implications. Adoption, depending on the setting may not be acceptable due to the presence of HIV infection in one or both partners. As such, these realities, and not only the appreciation of the medical risks involved, influence decision-making by service providers. Finally, given that there are no specific policies with regard to reproductive options for HIV persons accessing services in Ghanaian hospitals, it is not surprising that most of the health workers were ignorant about them.
A fundamental premise for successful counseling is that the counselor has both confidence in his/her own professional knowledge, and the relevant application of this knowledge for the individual client being counseled. About 1 in four of the providers would advise HIV-positive woman to have an unprotected intercourse as an option to conceive. Some of the providers openly expressed during the interactive in-depth interviews their inability to give qualified advice to HIV-positive clients on the various reproductive options. The constraints mentioned both in the structured and in-depth interviews were lack of resources particularly guidelines, and refresher training which are essential for knowledge update. This finding compares favorably with findings of previous investigations [24, 27, 28]. In their study Leshabari et al. explored the experiences and situated concerns of nurses in Tanzania. It revealed a high level of stress, frustration, and acknowledgment of incompetence by the nurse-counselors.
Could these perspectives be influenced by some demographic attributes of the providers? The designs of the studies cited precluded the exploration of this possibility statistically. The current analysis did. At the bivariate level, age, level of education, and site of provider were important. Significantly higher proportion of providers from the Manya study site, and those younger than 30 years, found it inappropriate to provide contraception counseling to HIV-positive clients (Table 3). With regard to age and education, it would seem natural that the younger and less educated/experienced providers would be challenged. Although not significant at the multivariate level, a higher proportion of providers without tertiary level education tended to withhold contraceptive information from their clients.
Taken together, the current findings suggest that HIV-positive clients do not receive comprehensive information about their reproductive options. Even though this may be motivated by legitimate concerns, such practices by the counselors infringe on the reproductive rights of HIV-positive clients. An alternative counseling approach that respects clients’ rights to informed and considered decision-making concerning childbearing should be encouraged. Such an approach would require contextualizing the counseling encounter with candid discussions. Unfortunately, this is not possible without the revising and introducing of reproductive health matters into the current service provision guidelines.
At this point, it is apropos to discuss a number of limitations that this study may suffer from. First, given the design of the study, these findings may not be generalized to the entire population of health workers providing these services in Ghana. It is, however, reasonable that the results, which are based not on one, but on three facilities, and which are collected through a triangulation of two methods, have considerable relevance for HIV-related service provision well beyond the three health facilities. Furthermore, the scope of the study is limited; only service providers are included. A more comprehensive exploration of problems that may compromise counseling on HIV and reproductive options would involve other groups of study participants. Views of HIV-positive women would be particularly relevant in this. To this end, a related study that explored the challenges that health workers face implementing PMTCT counseling, as well as the experiences of HIV-positive clients receiving these services at seven health facilities in the Greater Accra Region of Ghana show that providers face various challenges including lack of counseling acumen, inadequate logistics, inadequate training, and uncertainty about the credibility of counseling information . The challenges presented in this paper may therefore not be unique to only the service providers of the three facilities, but may be experienced by other in various parts of Ghana.