Family planning method that ‘raises risk of HIV’

What you need to know:

  • The eye of the storm: The World Health Organisation has convened a meeting to discuss the findings of a research that links popular hormonal contraceptive Depo-Provera to a higher risk of HIV transmission between couples. Health experts, however, say there is no proven scientific connection in the claims, and that somebody is taking the condom business a bit too far. Will pharmaceutical giant Pfizer survive this onslaught? What about the millions of women on the drug?

A recent report that linked injectable family planning methods to increased HIV infection “was nothing but a ploy by condom manufacturers to sell more of their products”, health experts have said.

The report, published in the health journal Lancet Infectious Disease, indicates that continued use of Depo-Provera exposes women to a higher risk of HIV infection, and that the best way to shut out the virus is to go the dual protection way — that is, to use Depo-Provera, a hormonal contraceptive, and condoms at the same time.

Health experts, however, have dismissed the recommendations of the report, saying there is no proved scientific link between HIV and Depo-Provera.

Prof Joseph Karanja, chairperson of Kenya Obstetrician Gynaecologist Society (KOGS), told DN2 last week that hormonal contraceptives are still safer than condoms, and that “unless there is a scientific link (to the claims advanced in the report), I do not see any cause for worry”.

“When you are prone to HIV,” Prof Karanja added, “you definitely will have to use condoms and hormonal contraceptives at the same time. This is what we call ‘dual protection’ because condoms alone are not enough surety against unwanted pregnancies, even though they are highly effective in the prevention of transmission of diseases.”

Countries where pregnancy rates are highest are also ravaged by HIV, the virus that causes AIDS. So the evidence suggesting that the injectable contraceptive has biological properties that may make women and men more vulnerable to HIV infection is particularly troubling.
Injectable hormones are very popular

About 12 million women between the ages of 15 and 49 in sub-Saharan Africa, roughly 6 per cent of all women in that age group, use them.

While the study involved only African women, the New York Times reported, scientists said biological effects would probably be the same for all women.

But they emphasized that concern was greatest in Africa because the risk of HIV transmission from heterosexual sex was so much higher there than elsewhere.

“The best contraception today is injectable hormonal contraception because you don’t need a doctor, it’s long-lasting, it enables women to control timing and spacing of birth without a lot of fuss and travel,” said Isobel Coleman, director of the women and foreign policy programme at the Council on Foreign Relations in the US.

“If it is now proven that these contraceptions are helping spread the AIDS epidemic, we have a major health crisis on our hands.”

The study, which several experts said added significant heft to previous research while still having some limitations, has prompted the World Health Organization to convene a meeting in January to consider if evidence is now strong enough to advise women that the method may increase their risk of getting or transmitting HIV.

“We are going to re-evaluate WHO’s clinical recommendations on contraceptive use,” said Mary Lyn Gaffield, an epidemiologist in the World Health Organization’s department of reproductive health and research.

Before the meeting, scientists will review research concerning hormonal contraceptives and women’s risk of acquiring HIV, transmitting it to men, and the possibility that hormonal contraceptives accelerate HIV’s severity in infected women, The New York Times reported.

“We want to make sure that we warn when there is a real need to warn, but at the same time we don’t want to come up with a hasty judgment that would have far-reaching severe consequences for the sexual and reproductive health of women,” she said. “This is a very difficult dilemma.”

The study involved 3,800 couples in Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia. In each couple, either the man or the woman was already infected with HIV.

Researchers followed most couples for two years, had them report their contraception methods, and tracked whether the uninfected partner contracted HIV from the infected partner.

Pfizer, the manufacturer of the branded version of the injectable, Depo-Provera, declined to comment on the study, saying officials had not yet read it.

According to the Kenya Demographic Health Survey (2008-2009), the current contraceptive prevalence rate for married women aged between 15 and 49 is slightly less than half (46 per cent).

Modern methods of contraception are more commonly used (39 per cent) than traditional methods (6 per cent). Of the modern methods, injectables are the most widely used, while the rhythm method is the most popular traditional method.

In a paid-for advert in the papers last week, Dr Shariff Shahnaz, the Director of Public Health, said his department was already advising dual protection methods to couples at a higher risk of HIV infection.

“It is important to note that other than the male and female condom,” Dr Shariff said, “none of other contraceptive methods provide any protection against HIV or STIs. This requires that we provide condoms to couples who are at a risk of HIV infection in addition to another contraceptive method.”

On whether it is true that injectable methods heighten the risk of infection, Dr Shariff said his department was closely monitoring incoming scientific evidence to confirm the association of hormonal contraception and the increased danger.

Dr Nelly Mugo, a research scientist who was part of the team that produced the report, told a gathering at the Kenyatta National Hospital, Nairobi that they had identified a potential risk of the transmission of the HIV virus through hormonal contraception, especially injectables.

Non-hormonal or low-dose hormonal contraceptive methods should be considered for women with — or at risk of — HIV, she added.

Dr Mugo’s choice of venue for the delivery of the message couldn’t have been better. The injectable method is available in most government and private hospitals at the affordable fee of Sh100, and Kenyatta National Hospital happens to be the biggest referral hospital in this part of the world.

Such alarming news is likely to dent Kenya’s family planning efforts, especially because many men do not consider family planning to be their responsibility and, as such, will scarcely use the condom should their wives decide to discontinue hormonal therapy methods.

“Most men, especially the semi-literate and illiterate, advise their wives against using family planning methods,” says Ann Njoki, a mother of four. “They are totally against the idea of contraception and some even get violent when the issue is brought up for discussion. The injectables save us a lot of hustle since they are discreet.”

Prof Japheth Mati, formerly of University of Nairobi’s Department of Obstetrics and Gynaecology, says there is no such thing as a contraceptive that is 100 per cent safe, and that every method has its own perils.

“Contraceptive practice is associated with a variety of risks, depending on the method used. Family planning service providers must assess the risk of complications and side effects to clients, and this assessment must be based on the health history and nature of the method chosen.

“It is important that all clients seeking family planning services are assessed with regard to their risk of STIs, including HIV/Aids, remembering that all persons at risk of getting infected with an STI are also at risk of getting infected with HIV. It must be realised that HIV/Aids is largely a sexually transmitted disease,” says Prof Mati.

If there is no scientific link between HIV and injectable methods of contraception, could this report have been a ploy to sell more condoms?

No, not at all, according to researchers: “The male or female condom is among contraceptives that prevent consumers from HIV and STIs, but it is not as effective as hormonal contraceptives, which provide a higher level of prevention from unwanted pregnancies. That is why we emphasize on dual protection,” says Prof Karanja.

Whatever the case, there is likely to be a huge shift towards the prophylactic sheaths in the coming months. Already, Kenya has made a mark as a ravenous consumer of condoms. A consignment of 19 million condoms lasted only six weeks at the start of this year, for instance.

“The demand was eight million per month, then it went to 12 million and currently stands at around 20 million. That gives you the number of encounters people have in this country,” said Dr Shariff in an interview at a time when the country was experiencing a shortage of the prophylactics.

As debate rages on whether the injectables are safe, the government has assured all that it is reviewing the situation and will advise accordingly.

“After a planned review by the World Health Organisation in January 2012, the Ministry (of Health) will update, if necessary, our guidelines and update our clients, providers and programmes to reflect the new scientific evidence,” says Dr Shariff.

As you wait for January, you will have to live with one headache, and that is whether the use of hormonal contraceptives has inadvertently fuelled the HIV/Aids pandemic — a “tragic” situation, if true, according to Charles Morrison, PhD, and Kavita Nanda, MD, both of Family Health International in Durham.