To the Editor: We write in response to J V Larsen's letter on the psychological effects of termination of pregnancy among women living with HIV, which appeared in the February 2008 edition of the SAMJ. (1) Dr Larsen stated that '... there is strong evidence that a decision for termination of pregnancy

may precipitate a severe grief reaction which is associated with increased rates of suicide and homicide ...' as well as an increase in the occurrence of psychiatric illness. Dr Larsen used this statement to support his conclusion that because people with HIV already experience high levels of grief, they may be particularly badly affected by termination of pregnancy and therefore require very skilled counselling when deciding whether to terminate a pregnancy.

We wish to take issue with some of the conclusions reached by Dr Larsen. The authors of the one of the key articles that he cites (2) stated, in response to the anti-abortion discussion that their article generated, that their results '... do not support the hypothesis that abortion itself causes suicide'. (3) Furthermore, a high-quality study of the psychiatric effects of abortion, in which 13 261 women were prospectively followed up after unplanned pregnancies, found that rates of total reported psychiatric disorders were no higher after termination of pregnancy than after childbirth. ()

While we fully agree with Dr Larsen that skilled counselling is advisable for all women seeking termination, we believe that the evidence regarding increased occurrence of psychiatric illness following abortion is at best inconclusive. Most of the evidence shows no causal association. It is therefore unwise for health care providers to draw conclusions regarding practice on the basis of Dr Larsen's interpretation of the evidence.

Like all women, those who are living with HIV, and who may constitute a particularly vulnerable group, deserve choices in deciding whether to continue with a pregnancy or not.

(1.) Larsen JV. Of HIV, grief and TOP. S Afr Med J 2008; 98(2): 69.

(2.) Gissler M, Kauppila R, Merilainen, J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland in 1987-1994--definition problems and benefits of record linkeage. Acta Obstet Gynecol Scand 1997; 76: 651-657.

(3.) Gissler M, Hemminki E. Pregnancy-related violent deaths. Scand J Public Health 1999; 27: 55.

(4.) Gilchrist AC, Hannaford PC, Frank P, Kay CR. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry 1995; 167: 243-248.

Chelsea Morroni

Margaret Hoffman

Di Cooper

Women's Health Research Unit

School of Public Health and Family Medicine

University of Cape Town

Chelsea.Morroni@uct.ac.za

Dr Larsen replies: My concern in writing my letter came from the fact that in practice in the public sector, TOP is often offered to women with HIV with little or no counselling, almost as if it were just another part of a patient management package. I worked in O&G services in the public sector for 32 years and as a pastoral counsellor for 22 years, and now work in a communicable diseases clinic, so I have seen the emotional reactions of people to HIV and to TOP from a number of perspectives. A grief reaction to both life experiences is normal and more or less universal.

My plea was not that women with HIV should be denied TOP, but that they be recognised as a group needing special care in counselling before that procedure is done. I make that plea because grief upon grief makes people very vulnerable.