Integrated Regional Information Networks - February 17, 2012
JOHANNESBURG, 17 February 2012 (PlusNews) - Four months after a
study suggested women on hormonal contraception may be at an
increased HIV risk, the World Health Organization (WHO) has
reaffirmed the birth control method's safety, but strongly
recommends that women on progesterone-only injections, like
Depo-Provera, also use condoms to prevent HIV infection.
In October 2011 the British medical journal, The Lancet,
published the findings of a study showing that women who relied
on hormonal shots to prevent pregnancy doubled their HIV risk.
They also found that women on this type of birth control and
living with HIV doubled the chances that they could transmit HIV
to their partners.
Although the women in the study did not identify their birth
control methods, most were probably using the progesterone-only,
depot medroxprogeterone acetate shot. More commonly known by the
brand name, Depo-Provera, this drug is the backbone of most
African family-planning programmes.
The study prompted WHO meetings in late January and February
2012, during which experts and civil society representatives
reviewed research on hormonal contraception and HIV risk.
However, because no clinical trial has ever looked specifically
at this potential link, including the October 2011 study,
evidence remains largely inconclusive.
In the absence of a proven link between hormonal contraception
and HIV infection, the WHO issued a statement on 16 February
standing by current guidelines that allow women living with or at
high risk of HIV to use hormonal contraception. However, the body
has recommended that current guidelines be amended to advise
women using progesterone-only injections be strongly advised to
use condoms concurrently to prevent HIV infection.
The need for future research into the matter was discussed at
side meetings, said Dr Jared Baeten of the US University of
Washington, one of the authors of the 2011 study. Although no
decision was taken, he added that conducting such a trial would
pose serious challenges. About 12 million women in sub-Saharan
Africa are estimated to be on injectable contraception.
Women need options and integration
"I think the [WHO] statement really reflects what was an
extremely thoughtful deliberation and detailed evaluation of the
evidence," Baeten told IRIN/PlusNews.
"They made a clear statement by issuing a strong clarification
and I think that what's important in the context of delivering
family planning service is that we strongly remind women at high
risk of HIV that contraception does protect against HIV and that
condoms are the HIV preventative measure."
Baeten has worked in high HIV prevalence countries such as South
Africa, Kenya and Uganda - all of which depend on family planning
services to help fight high maternal mortality rates - and said
he was also happy that the need to integrate family planning and
HIV services, voiced by policy-makers and researchers at the
meeting, was recognized.
This would mean that health facilities providing care and
treatment for HIV and other sexually transmitted infections would
offer clients family planning and reproductive health services -
and an extended array of contraceptive choices.
"What this statement should stimulate is making sure that women
have access to a variety of contraceptive choices, and this could
include intrauterine contraceptive devices (IUCD) or lower-dose,
long-acting hormonal contraception," Baeten added. "The point is
that Depro shouldn't be the default."
IUCDs are available in both hormonal and non-hormonal forms. A
device is inserted into a woman's uterus, where it affects the
ability of the sperm to fertilize an egg, and the egg's ability
to implant itself in the uterus. The devices are cost-effective
and work for almost all women, according to research by the
Maternal, Adolescent and Child Health division at the University
of the Witwatersrand in South Africa.
Dissent in the ranks
There has been some criticism of the WHO. Paula Donovan, former
East and southern Africa AIDS advisor for the UN Children's Fund
(UNICEF), now heads the international HIV advocacy organization,
AIDS-Free World, with former UN Special Envoy on AIDS in Africa,
Days before the WHO released its statement, Donovan issued a
statement of her own slamming the body for not moving sooner on
consultations when it had convened emergency meetings on past
issues like swine flu. She faulted the WHO for not involving
more people living with HIV in discussions, and because the body
did not issue clear or cautionary messaging to the public
following the 2011 study.
According to Donovan, only one HIV-positive African woman was
present at the WHO meeting, and confidentiality agreements
prevented her from sharing what was discussed with networks of
activists and people living with HIV.
Donovan has also criticised the WHO statement, saying that it
goes too far by conclusively stating that women living with or at
high risk of HIV can continue to use hormonal contraception when
the evidence is inconclusive.
"WHO and UNAIDS have violated human rights by withholding
information," Donovan said in her statement. "They have failed to
inform women that using hormonal contraception may carry some
risk. Women have the right to make fully informed sexual and
reproductive health decisions."
She added that she would have liked to see the WHO go further in
its recommendations, advising that all hormonal contraceptive
users be given a three-month supply of condoms with every
"No reasonable person can believe that condom use will increase
because the WHO issued a statement declaring that hormonal
contraceptives are safe - but condoms should also be used to
protect against HIV," she told IRIN/PlusNews. "Statements don't
prevent HIV. We would have hoped that [the] announcement would
have been accompanied by a plan of action."