The power to protect and to plan

Wednesday November 30 2011

Kenyans light candles on a symbolic grave, in remembrance of those who have died from Aids-related complications, during last year’s World Aids Day at the Eldoret Town Hall grounds. Photo/JARED NYATAYA

Kenyans light candles on a symbolic grave, in remembrance of those who have died from Aids-related complications, during last year’s World Aids Day at the Eldoret Town Hall grounds. Photo/JARED NYATAYA 

By MILLICENT MWOLOLO and RACHEL JONES [email protected] [email protected]

When it comes to reproductive health issues, Mercy Kagiri’s life could mirror those of millions of women on the African continent.

The 27-year-old mother of two children, aged four years and seven months, lives in Nairobi’s Kibera slum settlement.

She runs a food kiosk near her home, while her husband, Peter Mwangi, 32, is a driver.

After the birth of her first child, Ms Kagiri began using a three-month injectable contraceptive until she was ready to conceive again.

She realises that it can only protect her against unwanted pregnancies.

“But I cannot ask my husband to use a condom, since it would raise issues of distrust in our marriage,” she explains, and adds that her husband knows she uses this contraceptive.

Demographic Health Survey data collected in countries in Africa and Southeast Asia reveal that injectable contraceptives are the most popular option for women like Mercy Kagiri, who face daunting cultural and social pressure to produce many children.

Often, women conceive and deliver those children knowing they cannot afford to raise them, or when the pregnancy is a threat to their own health.

But although Ms Kagiri lauds her contraceptive method for its convenience, she is troubled by a missing link. “I am less worried about a pregnancy, but what if I contracted HIV?”

Indeed, although a recently-published research suggested a tentative link between use of injectable contraceptives and contracting HIV, so far, women like Kagiri have not been deterred.

The good news is that researchers have been trying to link the two realms of family planning and HIV prevention for years.

This week, many of those researchers, public health officials, and advocates for family planning and reproductive health issues are meeting in Dakar, Senegal, for the International Conference on Family Planning.

It is the largest ever meeting of its kind, bringing together more than 2,000 experts to discuss progress and challenges in the fields of family planning and reproductive health.

It is no coincidence that during the four-day gathering, the World Aids Day will be observed on 1 December.

HIV/Aids is one of the biggest challenges in the areas of reproductive health and family planning.

But while that historic event is occurring in Senegal, Kenya, will mark an important anniversary that has equal resonance.

This year marks the 20th anniversary of the Programme for Appropriate Technologies in Health (PATH) operations in Kenya.

PATH’s work in issues like diarrhoeal disease and vaccine development is only surpassed by its ground-breaking research in Multipurpose Prevention Technologies (MPTs).

MPTs are prevention tools that women can use to protect themselves from a range of health issues that affect them, says Ms Pauline Irungu, a programme officer with Global Microbicide Campaign (GCM), a network of advocates and non-governmental organisations working to expand HIV prevention options through research.

Two innovative MPT strategies currently under development are using a diaphragm (contraceptive barrier) to deliver microbicides and combining microbicidal and contraceptive drugs into one product for on-demand or sustained use.

The diaphragm is combined with a microbicide, Tenofovir (TFV) gel, that has proven effective against the transmission of the HIV.

Also in the offing is a three-month intra-vaginal ring that releases both the contraceptive hormone levonorgestrel and TFV.

TFV prevents HIV replication in susceptible cells. It is the first microbicide proven to be efficacious in humans, having a proven 39 per cent protection rate against HIV infection and 51 per cent effective in reducing the transmission of the herpes simplex virus.

This makes the combination ring potentially triple protective, since it guards against HIV, unwanted pregnancies, and sexually transmitted infections.

Ms Irungu notes that microbicides can be used vaginally or rectally to prevent HIV and possibly other sexually transmitted infections.

Microbicides could be produced in a number of forms, including gels, creams, suppositories, films, lubricants, or delivered through a sponge or a vaginal ring that slowly releases the active ingredient.

“The development of MPTs is a highly anticipated move since women have expressed the need for research to find tools that can address HIV as well as other sexual and reproductive needs, especially contraception and other sexually transmitted infections,” she adds.

The key to further unlocking the effectiveness of this medical research lies in one simple but evocative word: “empowerment”.

MPTs have the potential to give women the means to protect themselves from acquiring HIV with or without their partners’ knowledge or consent, especially when they may otherwise feel helpless to discuss these issues with their partners.

“Women need these tools to address their sexual and reproductive health needs, such as preventing HIV, sexually transmitted infections and pregnancy, among other concerns,” Ms Irungu says.

This is truly an exciting prospect, but she admits it is not yet certain when MPTs would be available in Kenya.

“From scientific proof that a prevention tool works, it takes a long time to get it into the hands of users. There is a need to speed up the process, though,” she says.

Researchers and global health advocates are also working to ensure that these innovative tools will be affordable for most of the women who most need them.

In countries hardest hit by HIV, including Kenya, women desperately need cheap HIV prevention tools.

“Various stakeholders in the field are working on modalities to facilitate access to MPTs when they are proven safe and effective through research,” Ms Irungu states.

A variety of factors will influence the cost. International agencies such the World Health Organisation (WHO) as well as governments are starting to plan early for access and sustainability in countries with high HIV burdens.

Key considerations include funding, access, and planning for introduction of these new technologies.

“The collective efforts of the Global Campaign and collaborators are raising the profile of microbicides and increasing funding for research. The American government and the Bill & Melinda Gates Foundation are the largest donors to microbicides research. Numerous other public funders have supported this work during the past two decades,” Ms Irungu explains.

This is good news for Ms Doreen Achieng Olalo, a 43-year-old woman from Lea Toto in Kibera who has been living positively with HIV for seven years now.

She believes an MPT would reduce the risks of her being re-infected with the virus. “My partner is also positive and chances of us re-infecting each other are high,” she adds.

Ms Olalo currently uses a combination of a three-month injectable contraceptive and condoms, which she gets from an African Medical Research Foundation (Amref) clinic in Katwikira, where Ms Kagiri also lives.

“I get the combined contraception alongside my ARVs,” Ms Olalo says. MPTs would be more convenient for her.

MPTs would enable women to reduce the number of tools that they need to adhere to in their lives while addressing their sexual and reproductive health needs.

Before she contracted the virus, Ms Olalo, a mother of seven, says she was using oral contraceptive pills.

“With this I was able to space my children.”

But it did not protect her from contracting HIV. “If the anticipated MPTs were available then, I would still be healthy and a much happier woman than I am today. I would now be more focused on my personal development and the future of my children, and less worried about HIV and the uncertainty of death,” she says.

Ms Olalo and some of her friends are able to use other contraceptives alongside condoms.

But the anticipated MPTs are likely to change this, since they would combine two preventive products into one tool for usage.

The grim reality of HIV and a fast-rising population, coupled with dwindling resources, highlight the dire need for MPT’s in Kenya.

Data from the 2009 census, released this year, found that Kenya’s population growth rate stands at 2.9 per cent annually, with a population of 38.6 million.

As the average woman gives birth to five children during her reproductive years, this translates to an average population increase of two million people a year.

The National Coordinating Agency for Development (NCAPD) has also reported that one in four married women actively wants to space or limit the number of children they have, but that they are not using any form of contraceptive.

In addition, statistics from EngenderHealth, an international non-governmental organisation that supports the improvement of women’s’ health worldwide, indicate that about 120,000 HIV-infected women in Kenya become pregnant every year.

Results of the Kenya Service Provision Assessment Survey 2010 released in May this year, show that public hospitals charge for condoms, oral pills, and injections.

Half of the clients visiting the health facilities pay at least Sh30 for the family planning services, a cost that could make the services a luxury for many in a country where most of the people cannot afford a decent meal a day.

Cultural and religious barriers for contraceptive use, alongside fear for their side effects, also contribute to low usage rates by Kenyan women.

The government has also focused more on other areas such as malaria and HIV/Aids, which decreases support for family planning both in terms of donor funding and government support, says Ms Joyce Wanderi, the Population Services International (PSI) Kenya deputy director of reproductive health.

“What this has resulted in is a generational gap of close to 20 years in mass communication about family planning,” Ms Wanderi says.

Also, unchecked population growth in Kenya could result in less spending on infrastructure, health, education, environment, and other social and economic sectors.

The minister for Planning, National Development, and Vision 2030, Mr Wycliffe Oparanya, says family planning is the missing link to achieving various national and international development goals, including the Millennium Development Goals (MDGs).

“Our population structure poses a critical challenge of addressing the rising youth unemployment rates and their potential adverse consequences on social stability,” says Mr Oparanya.

This is especially critical when the young population is educated, but the economy does not generate enough jobs or support young people to start their own businesses.

Among other benefits to Kenya, better family planning would reduce the rate of child mortality from HIV, maternal mortality, and poverty.

This would translate into healthier families, improved access to basic services such as education, health, and other social amenities.

It would also mean improved access to food, shelter, and clothing and other basic needs, since families will have fewer children that they can raise.