Cross-posted with permission from K4Health.
A new study published this week in The Lancet Infectious Diseases suggests that use of hormonal contraceptives, particularly injectables, may double the risk of uninfected women acquiring HIV. The study also suggests that use of injectables may double the risk of HIV-infected women transmitting the virus to their uninfected partners. The large study followed 3,790 HIV-discordant couples, in which only one partner had HIV infection, in seven African countries. (RHRC initially reported on the study here.)
News of the study findings, reported in the New York Times and elsewhere, sent ripples of concern among the international public health community. Family planning programs and service providers want to know what this means for their programs and for the women and couples they serve.
For now, international health organizations and donors, including the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the U.S. Agency for International Development (USAID), caution against making hasty changes to contraceptive policy or practice. WHO is convening a Technical Consultation of a multi-disciplinary group of experts from 31 January to 1 February 2012 to examine all evidence related to the potential effects of hormonal contraception on HIV acquisition, transmission, and disease progression. The experts will decide through consensus whether modifications need to be made to the current WHO guidance for hormonal method use among women with HIV or AIDS, or women at risk of HIV.
Hormonal methods are the most commonly used contraceptives in sub‑Saharan Africa. The Guttmacher Institute reports that 12 million women use injectables and 8 million use oral contraceptive pills, while 11 million women use non-hormonal methods. Over the past 15 years, the number of women choosing to use injectables has grown substantially because the method appeals to many women who want a highly effective method that does not require daily action and that can be used privately.
Several strengths of the new study are making the international public health community pay close attention to the findings. Charles Morrison and Kavita Nanda of FHI 360 note that the main strength of the study is it provided direct data on the risk of hormonal method users acquiring HIV from their infected male partners and, conversely, of hormonal method users with HIV transmitting the virus to their uninfected partners, because only one partner in the couple had HIV infection when they were enrolled. In addition, the study used sophisticated analytical techniques.
However, WHO and USAID stress the importance of reviewing the new study in context of the entire body of published evidence on this issue, especially because the study had several limitations despite its strengths:
- Study participants chose whether they wanted to use contraception and which method they wanted to use. Participants who chose hormonal contraceptive methods may differ in important ways from non-hormonal method users. For example, hormonal method users could potentially have sex more frequently or use condoms less often than non-hormonal method users. Only a randomized controlled trial, in which participants would be randomly assigned to use a particular method, could provide definitive answers. Some experts are calling for such a study.
- The study was not designed specifically to examine HIV risk with hormonal method use. Rather, it was a secondary analysis of data from an HIV prevention trial.
- Few women in the study used hormonal methods: 624 women used hormonal methods at enrollment among the 3,790 total women enrolled (16 percent).
- There were few new HIV infections among hormonal method users (10 new HIV infections among users of injectables and 3 new HIV infections among pill users).
- Contraceptive use was self-reported by study participants and not confirmed by clinical records.
- Contraceptives were not provided at all 14 sites in the seven African countries.
- Study participants commonly switched contraceptive methods: almost half of the participants who used hormonal methods, either at enrollment or at some later point during the study, used a non-hormonal method or no method at some other point during the follow-up period.
While the public health community anxiously waits for definitive answers from the WHO Technical Consultation in January 2012, they emphasize that the study does drive home certain points that they have been advocating for years:
- Health service providers should counsel women and couples to use condoms correctly and consistently with another contraceptive method—whether hormonal or non-hormonal—to prevent both unintended pregnancy and sexually transmitted infections (STIs), including HIV.
- Integrated family planning and HIV programs are crucial to addressing the needs of women and couples holistically and offer opportunities to reach more people with the life-saving services of contraception and HIV prevention and treatment.
- More resources and research are needed to develop new methods of contraception, particularly ones that provide dual protection against both unintended pregnancy and STIs, including HIV.
The public health community will need to consider the evidence published this week carefully, balancing the potential risk of HIV with the real risk of unintended pregnancy, which contributes to maternal disease and death. This is especially true in the context of sub-Saharan Africa, the region that bears the largest share of the global HIV burden, where 60 percent of those living with HIV are women and 39 percent of pregnancies in the region already are unintended.