Which should be the priority for a health organisation: preventing an incurable disease, or preventing a natural function that might have adverse physical consequences?
Preventing the disease, you would think. But the World Health Organisation would rather expose African women to HIV-AIDS than withdraw its support from a suspect method of birth control, arguing that childbirth is also risky in Africa. Riskier, apparently, than the said contraceptive. And at least one of WHO’s major partners agrees.
This is one of the stories you will not have read in coverage of the International AIDS Conference held in Melbourne last week, despite the fact that WHO made an announcement about it during the conference and the findings of a highly relevant study were presented there.
The story is this: there is increasing evidence that the method of contraception preferred by family planning organisations working in Africa (and elsewhere) facilitates the transmission of HIV. The method is the progesterone injection in the form of either DMPA (Depo Provera, the most common) or NET-En (Noristerat).
Millions of women in sub-Saharan Africa receive the injection every three months. The method overcomes problems of access. It can be given by nurses or health workers. A wife need not bother her husband for any special consideration; the teenage girl need not remember to take a pill.
But for 30 years evidence has been accumulating that, for all its “effectiveness” in controlling the number of births, the jab may also be very effective in increasing the number of people with HIV.
Three years ago at another AIDS conference in Rome, researchers who had analysed data from a number of previous studies delivered the disturbing news that injectables at least doubled the risk of infection with HIV for women and their male partners.
That study had its weaknesses but one of the experts present in Rome, Charles Morrison of FHI 360 (formerly Family Health International, a family planning organisation that also works in AIDS prevention), considered it a “good study” and subsequently led another meta-analysis that addressed some of the issues with previous research.
Last week at the Melbourne conference he presented the results. His team had re-analysed raw data on the contraceptive use of more than 37,000 women in 18 prospective observational studies. Of these women, 28 percent reported using DMPA, 8 percent NET-En, 19 percent a combined oral contraceptive pill, and 43 percent no form of hormonal contraception. A total of 1830 women had acquired HIV while in a study.
The analysis showed that both injectables raised the risk of infection by 50 percent:
Compared to non-users [of any hormonal contraceptive], women using DMPA had an elevated risk of infection (hazard ratio 1.56, 95% CI 1.31-1.86), as did women using NET-En (1.51, 95% CI 1.21-1.90). There was no increased risk for women using oral contraceptives.
Similarly, comparing women using injections with those using oral contraceptives, there was an elevated risk associated with DMPA (1.43, 95% CI 1.23-1.67) and NET-En (1.30, 95% CI 0.99-1.71).
Morrison also noted:
The results were consistent in several subgroup and sensitivity analyses. However, when only studies which were judged to be methodologically more reliable were included, the increased risk appeared smaller.
Morrison acknowledged that observational studies such as the FHI analysis depended on have their limitations. He is looking for funding to conduct a randomised controlled study – something that, after 30 years of suspicions and evidence, still has not been done.
So what is his advice to the birth control industry? Stop using this stuff in regions with a high prevalence of HIV until we are sure that we are not feeding an epidemic?
One reason is that FHI is at least as interested in contraception as it is in HIV prevention. Though its website reflects a broad range of development activities, its core business is integrating birth control programmes with HIV prevention. The WHO – one of its partners — describes the US based, 83 percent US government funded non-profit as “a global health and development organization working on family planning, reproductive health and HIV/AIDS.”
Another reason is that FHI 360 has a vital stake in precisely the kind of contraceptives that are under suspicion. Its annual report refers to:
Our trailblazing work in contraceptive research and development continues, as we develop and introduce high-quality and affordable long-acting contraceptives for women in low-income countries. Research is under way to develop a new biodegradable contraceptive implant that would eliminate the need for removal services. We are also working with partners to develop an injectable contraceptive that would last for up to six months. Currently available injectables require reinjections monthly or quarterly, which can be challenging where health services are limited.
That project is funded by the Bill and Melinda Gates Foundation and USAID.
So Morrison did not argue in Melbourne for restrictions on the use of injectables, and neither did the WHO, whose representative at the conference outlined the UN body’s new guidelines on contraception and HIV. Mary Lyn Gaffield said a review of studies up to – but not including Morrison’s – did not warrant a change to WHO’s policy that DMPA and NET-En should be available, without restriction, in areas of high HIV prevalence.
The most WHO will advise is that women should be informed of the risk:
“Women at high risk of HIV infection should be informed that progestogen-only injectables may or may not increase their risk of HIV acquisition. Women and couples at high risk of HIV acquisition considering progestogen-only injectables should also be informed about and have access to HIV preventive measures, including male and female condoms.”
Condoms? How do they defend such cynicism? By equating the risk of HIV with the risks of motherhood – complications of pregnancy or childbirth, maternal death and the effect on infants… And yet motherhood remains risky precisely because 90 percent of the world’s effort is going into contraception!
Seven years ago a meeting of technical experts convened by WHO to study the injectables-HIV link showed the reproductive health establishment worried about that issue, to be sure, but also concerned that funding was flowing disproportionately to HIV-AIDS programmes, setting back the cause of birth control. The integration of family planning and HIV prevention spearheaded by FHI 360 looks like they have found an answer to that problem.
Whether African women are any better off is very doubtful. They remain pawns in a game that is, above all, about controlling their fertility. They and their partners are encouraged to take risks with their health, if not their lives, while researchers scout for funds to do the definitive study.
FHI had an income of $674 million last year, most of it from the US government. Couldn’t it give Charles Morrison the money to do his research today?
Carolyn Moynihan is deputy editor of MercatorNet.