Integrated Regional Information Networks - October 7, 2011
JOHANNESBURG, 7 October 2011 (PlusNews) - Hormonal birth-control
injections may double a woman's risk of contracting HIV and
passing it on to her partner, according to a new study. The
research comes at a time when many governments are looking to
scale up their family-planning programmes in a bid to reduce
Published in the 4 October 2011 online edition of The Lancet's
Infectious Diseases journal, the study followed about 3,800
heterosexual couples in seven African countries over about two
years. Researchers found that women who relied on hormonal shots
to prevent pregnancy doubled their HIV risk. In women who were
HIV-positive, using "the shot" doubled the chances that they
transmitted HIV to their partners.
Researchers also evaluated the HIV risk associated with
birth-control pills. While findings suggest a similar
relationship between the pill and HIV risk, study author Jared
Baeten of the US University of Washington cautioned that too few
women reported using the pill to draw a definite conclusion.
Although participants were not asked to identify which injectable
birth control they were receiving, it is likely many were on
depot medroxprogeterone acetate (DMPA), according to Baeten. More
commonly known by its brand name, Depo-Provera, this drug
features in most family-planning programmes in Africa.
Research from South Africa, with an HIV prevalence rate of about
18 percent, has indicated it may also be the most prevalent birth
control method aside from condoms.
"Active promotion of DMPA in areas with high HIV incidence could
be contributing to the HIV epidemic in sub-Saharan Africa, which
would be tragic," said Charles Morrison, senior director for
clinical sciences at Family Health International, in a related
commentary published in The Lancet.
"Conversely, limiting one of the most highly used effective
methods of contraception in sub-Saharan Africa would probably
contribute to increased maternal mortality and morbidity and more
low birth-weight babies and orphans - an equally tragic result."
The research could mean changes for high prevalence countries
like South Africa that are hoping to lower maternal mortality by
preventing unplanned pregnancies.
The study is the first to show a relationship between birth
control injections and increased HIV risk, Baeten noted. While it
did not investigate how, biologically, hormonal contraception
increased HIV risk, participants' cervical swabs showed that
HIV-positive women on hormonal contraception had increased HIV
levels in their genital tracts, which may explain why their male
partners were more likely to contract the virus.
"Truthfully, we don't know perfectly how HIV establishes
itself... what happens between exposure and infection," Baeten
"Previous studies have suggested that perhaps contraception can
lead to microscopic thinning of the vaginal mucous membrane [and]
changes to genital tract... that makes it easier for HIV to
Mucous membranes line body parts like the nose, mouth, vagina and
anus. HIV can pass through this type of tissue and into the
bloodstream, leading to infection. Damage to this membrane is
thought to increase this risk.
Morrison urged donors to support a randomized trial to
investigate the link between hormonal contraception and HIV.
"The time to provide a more definitive answer to this critical
public health question is now; the donor community should support
a randomized trial of hormonal contraception and HIV
acquisition," he wrote.
UNAIDS has already called for more research and analysis before a
January 2012 meeting when the World Health Organization (WHO)
will review various studies as it prepares to revise
recommendations on HIV and contraception use.
"If a new study is proposed, it will be years until we have the
results so that's why it's important to have correct messaging,"
said Baeten, adding that women should continue to be offered
hormonal contraception but that they should be counselled about
the possible risks. The importance of condom use alongside other
birth control should be re-enforced.
"This study should not result in women stopping contraception -
it's too important from the individual and pubic health
perspective," he told IRIN/PlusNews. "It should promote a
conversation about how we keep women safe while reducing
unplanned pregnancy and the complications from that."
Adapting family planning in Africa
With the WHO recommending family-planning services as the first
step to reducing maternal mortality and deaths linked to botched
abortion, several countries, including Nigeria, Uganda and South
Africa, have recently rejuvenated such services to bring down
their stubbornly high maternal mortality rates.
In Uganda, USAID recently announced the rollout of the birth
control pill Mycrogynon following a similar 2010 campaign in
South Africa is revising its family-planning guidelines and has
embarked on a national campaign to increase access to
According to Eddie Mhlanga, cluster manager for maternal, child
and woman health and nutrition in South Africa's Department of
Health, the new family-planning guidelines will caution health
workers about the increased risk of HIV associated with hormonal
The guidelines may also demonstrate a shift towards contraception
with lower hormone levels, and the re-introduction of
intrauterine contraceptive devices (IUCDs), Mhlanga told
The last available data from 2003 showed South Africa's
hardest-hit province, KwaZulu-Natal, had the highest uptake of
contraception in the country, predominately hormone injections.
To address the over-reliance on injections, the province plans to
expand access to birth-control pills, including emergency
contraception, as well as condoms and IUCDs, which are inserted
into the uterus in order to prevent pregnancy.
According to Baeten, non-hormonal IUCDs may be a good option for
women in high HIV prevalence settings.
"From the point of a medical intervention, it would be about
provider preferences and patient demand," he told IRIN/PlusNews.
"Whether it's a choice in contraception or a choice of soda, part
of that is about what strategies are put in place to promote it."