Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization
20/02/2012 Comments Off on Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization
Many feminists, including me, actively opposed the hormonal injectable contraceptive Depo Provera (DMPA) three decades ago ̶ it was at a time when certain women weren’t being given a choice of method or any information about possible side effects, and before long-term post-marketing studies began to be done to monitor long-term safety. Here in the UK, we demanded that all women be given information about side effects and a choice of methods, and we called for long-term safety studies. The research was duly done, and it found that the side effects were within the range of what experts consider to be safe and acceptable. Once these were known and women began to be given a choice of method, there was nothing more to oppose.
Injectable contraception has distinct advantages ̶ it is highly effective, the woman and her partner need do nothing more in between injections to gain protection from unwanted pregnancy, and women can use it without partner consent or knowledge if they need to. However, like all hormonal methods, female sterilisation and IUDs, injectables do not provide protection against sexually transmitted infections, including HIV. For that, people need to use condoms or other forms of safe sex, or always have sex with only one partner (who is negative) who also always has sex only with them (also negative).
Many studies have been done on whether hormonal contraceptives increase HIV risk or not, and the findings have sometimes shown an increased risk and sometimes not. This variation is because there are a lot of confounding factors and risks involved that are extremely difficult to control for. On PubMed, for example, a study on this subject at the very top of the page using the keywords “Depo Provera and HIV risk” today reached the following conclusion: “In this study conducted among [5,567] South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.”[i]
Several other recent studies, however, have found an increased risk of HIV acquisition among Depo Provera users. As a result the Department of Reproductive Health and Research/Human Reproduction Programme at the World Health Organization held an expert consultation several weeks ago to consider the latest evidence and decide whether it warranted a change in their current guidance, dating from 2009, on this subject. They decided not to change their current advice. Below is the press release they sent out a few days ago, explaining this. The fact remains, it’s the lack of safe sex/condom use and sex with more than one partner, or with a partner who has more than one partner, that really puts women and men at risk of HIV. That hasn’t changed since the HIV epidemic began.
WHO Press Release (a different version of this release is available on the WHO site):
WHO upholds guidance on hormonal contraceptive use and HIV
Geneva, 16 February 2012. Following new findings from recently published epidemiological studies, HRP convened a technical consultation (from 31 January to 1 February 2012) regarding hormonal contraception and HIV acquisition, progression and transmission. It was recognized that this issue was likely to be of particular concern in countries where women have a high lifetime risk of acquiring HIV, where hormonal contraceptives (especially progestogen-only injectable methods) constitute a large proportion of all modern methods used and where maternal mortality rates remain high. The meeting was held in Geneva between 31 January and 1 February 2012, and involved 75 individuals representing a wide range of stakeholders. Specifically, the group considered whether the guideline Medical eligibility criteria for contraceptive use, Fourth edition 2009 (MEC) should be changed in light of the accumulating evidence.
After detailed, prolonged deliberation, informed by systematic reviews of the available evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiological evidence, and analysis of risks and benefits to country programmes, the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, the group recommended that a new clarification (under category 1) be added to the MEC for women using progestogen-only injectable contraception at high risk of HIV as follows:
Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not demonstrate this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male and female, and other preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in the light of new evidence.
The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits. The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male and female, as hormonal contraceptives are not protective against HIV transmission or acquisition.[ii]
[i] Morrison CS et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS 2012;26(4):497-504.
[ii] Technical statement: Hormonal contraception and HIV and background documentation.