Quandary for women: Contraceptive use vs HIV risk in Africa

Mother and child, Ethiopia
Mother and child, Ethiopia
Flickr, subcomandanta

Researchers at the University of Washington have reported some highly problematic findings regarding a common method of birth control in eastern and southern Africa.

They are problematic in that they indicate a popular injectable hormone, Depo-Provera, used by perhaps 140 million women worldwide (and often in poor settings) signficantly raises a woman’s risk of HIV infection.

But they were also problematic in that the evidence for this alarming claim is somewhat weak and inconclusive, meaning it could be wrong.

That’s science. But the net effect right now could be that women will choose to give up one form of known health protection — contraception — to protect against a still hypothetical threat.

The New York Times said Contraceptive Used in Africa May Double Risk of H.I.V.:

The most popular contraceptive for women in eastern and southern Africa, a hormone shot given every three months, appears to double the risk the women will become infected with H.I.V., according to a large study published Monday.

(Does anyone know why the News York Times spells it H.I.V. rather than just HIV?. Odd)

The Guardian reported HIV could spread if birth control injections increase, scientists warn:

“These findings have important implications for family planning and HIV-1 prevention programmes, especially in settings with high HIV-1 prevalence”, said Jared Baeten from the University of Washington, Seattle, one of the study’s authors.

“Recommendations regarding contraceptive use, particularly emphasising the importance of dual protection with condoms and the use of non-hormonal and low-dose hormonal methods for women with or at risk for HIV-1, are urgently needed,” said lead study author Renee Heffron, also from the University of Washington.

More than 140 million women worldwide use some form of hormonal contraception.

The Los Angeles Times headline was a bit more muted, stating Africa study suggests hormonal contraceptive tie to HIV infection. The story began much the same way as the NYTimes or Guardian story (minus the weird spelling) but quickly emphasized:

The finding, published online in the journal Lancet Infectious Diseases, isn’t definitive and … was not ideal for a variety of reasons. For one, it relied a lot on self-reporting — participants told the researchers whether they were using hormonal contraceptives and how often they used condoms.

The caveats are bit wonky, I know. But they are important limitations. These results were not obtained from the gold standard approach of medical research — a randomized clinical trial. They were based on observations and follow-up interviews with couples.

It’s possible couples’ statements were not accurate. It’s possible that couples who use injectable contraceptives also have sex more often, which would increase the risk of HIV transmission. The study also found that the men in these couples had slightly higher rates of HIV. How is it that the men are put at increased risk if the woman gets the injectable hormone?

These research findings had been presented earlier, at an international AIDS research meeting, but this time gained more media attention this week due to its publication in the Lancet.

Many questions remain so what should women, or women’s health advocates do?

As the NYTimes said:

The findings potentially present an alarming quandary for women in Africa. Hundreds of thousands of them suffer injuries, bleeding, infections and even death in childbirth from unintended pregnancies. Finding affordable and convenient contraceptives is a pressing goal for international health authorities.

Many experts are urging that more studies get done to determine if this is a real risk or a misguided association. The U.S. Agency for International Development put out this statement:

Previous studies have examined these issues. Some found similar associations (including one of the largest studies on this topic); most have not found HC to be associated with HIV acquisition or transmission in a general population. The new findings raise concerns, particularly since the analysis involved a large sample size of serodiscordant couples, used sophisticated statistical techniques, and may provide biological support by measuring viral shedding.

As two experts quoted in the LA Times article noted:

“A separate analysis by the same study team suggests that pregnancy itself might increase the rate of HIV transmission,” write Drs. Charles S. Morrison and Kavita Nanda of the global development organization FHI 360, based in Durham, N.C., in the accompanying commentary. “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.”

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Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at]humanosphere.org or follow him on Twitter @tompaulson.