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, Stephen Lewis.
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 injection.
"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."