Early this month The Lancet medical journal published a study that should have stopped birth control missionaries in Africa dead in their tracks. An international research team reported finding a strong link between HIV transmission and the use of hormonal contraceptives, particularly injectable hormones such as Depo-Provera, which may double the risk both of acquiring and passing on the AIDS virus among users, compared to non-users of contraception.
This is very big, very alarming news. About 12 million women in sub-Saharan Africa receive contraceptive shots every three months because injectables are regarded as the most efficient method for women who are often poor and without easy access to transport. A nurse or other health worker can give the injection so there is no need for a doctor. The wife need not bother her husband for any special consideration; the teenage girl need not remember to take a pill (and she is certain to forget the condom).
It is the dream method in the eyes of “reproductive health” promoters who believe that the greatest favour they can do Third World women — and the underclass in developed countries — is prevent babies arriving.
Now they are faced with robust evidence that DMPA (depot medroxyprogesterone acetate) is probably helping to drive the HIV-AIDS epidemic in the worst affected region of the world. Oral contraceptives are implicated too, and the role of other hormonal devices is not known. This much we do know, however: the international population control establishment has a major crisis on its hands.
But don’t imagine that health authorities have called for an immediate suspension of the very convenient contraceptive jab. For one thing, it is not news to them. The study was reported at an AIDS conference in Rome back in July, but it is only since the Lancet published the research that the mainstream media have picked up the story.
The World Health Organisation is still working out what to say. It has scientists reviewing the evidence and will hold an experts meeting in January. Then it might issue formal advice about the use of DMPA at least. Then it will certainly call for more research on the subject. Meanwhile, nothing must be allowed to halt the birth control programme in Africa — or anywhere else. As a WHO spokeswoman told the New York Times: “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 judgement that would have far-reaching severe consequences for the sexual and reproductive health of women,” she said. “This is a very difficult dilemma.”
An old concern
As a matter of fact it would not be hasty to issue a red alert right now. According to WHO itself, the interaction between hormonal contraception and HIV infection has been a concern since the early days of the AIDS epidemic — that is, the early 1980s. Thirty-odd years. Given the high stakes in human life and suffering, one would think that it would have been a priority for rigorous research. But after all that time no randomised control trial has been set up to thoroughly test the link.
There have, however, been a number (at leat 20 by my count) of studies that have addressed the question — usually by a secondary analysis of data that was collected for another purpose. The new study, “Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study”, is one of those. Renee Heffron and others involved in the Partners in Prevention HSV/HIV Transmission Study re-analysed data originally gathered to investigate whether treatment of genital herpes would reduce transmission of HIV.
While some previous studies had looked at high risk groups, such as prostitutes (“sex workers”), this one involved 3790 couples in which one partner was infected with HIV — in most cases, the woman. They were from seven countries in East and Southern Africa and most were married with children. A little more than one third (1321) of the women used hormonal contraception at some point during the study — the preferred method among couples with young uninfected partners — although some changed methods, some stopped and some became pregnant.
If previous research showing a significant increased risk of HIV transmission where hormonal contraceptives were in the picture (there are at least four, plus monkey studies supporting them) could be filed under “maybe” because of one flaw or another, the new study is generally considered strong. The evidence that risk at least doubles for women on injectable progesterone — and, what has been largely unobserved until now, for their male partners — is something that a leading researcher in the field, also involved in this study, takes seriously.
“We were frankly quite disappointed to see that we had a doubling of HIV risk,” said Professor Jared Baeton of the University of Washington. “We analysed the data several ways, to be sure we had confidence in the results.” “This is a good study, and I think it does add some important evidence,” said Charles Morrison, another expert on the subject working out of FHI 360 (Family Health International), a family planning organisation doing HIV prevention work as well.
The vulnerability of young women
A disappointment it may be, but the new evidence will not be a surprise to anyone working at the interface of contraception and disease. Hormonal contraception has long been linked with bone density loss (especially Depo Provera), cervical cancer and Chlamydia — the last two being diseases now at epidemic levels. Cervical ectopy in young women makes them vulnerable to infection, and it appears also that progesterone thins vaginal tissue and has an effect on the immunology of the vagina and the cervix.
It is also well known among experts that genital tract infections cause increased shedding of HIV cells. Genital herpes (HSV-2) is of particular interest because there is a strong relationship between HSV-2 and HIV transmission, and evidence that hormonal contraceptives reactivate HSV-2, thus increasing HIV-1 shedding.
Furthermore there is evidence that these contraceptives may increase the seriousness of the infection transmitted as well as hasten the progression of HIV. They may also increase the risk of a mother passing HIV to her baby during breastfeeding. How the synthetic hormones interact with anti-retroviral therapy is another question to be answered.
All this and more was discussed at a meeting of technical experts convened by WHO in March 2007 to review priorities for research in this area.
One of the things that hit them forcibly was the evidence — from some new data crunching by Morrison — that young women were most at risk from hormonal, and especially DMPA, contraception. To quote from the report of the meeting:
As one participant noted, what “jumps out” of the data is the issue of age. Of particular concern is that hormonal contraception use in younger women (<25 years) – the same population that is driving the HIV epidemic – may increase the risk of HIV infection.
In Morrison’s study (“Hormonal contraception and the risk of HIV acquisition,” AIDS, 2007) girls aged 15 to 19 had treble the risk of getting HIV if they were on the progesterone injection compared with those not using hormonal contraception, and women aged 20 to 24 had nearly double the risk.
That was four years ago. How many young African women are still getting the jab, one wonders.
The contraceptive empire at risk
The WHO report is a fascinating document, showing the reproductive health establishment wrestling with a problem that threatens a large part of its empire — one already undermined by the massive flow of international funds to HIV/AIDS programmes. It laments:
Services and policies in many settings are overwhelmed and dominated by HIV-prevention and AIDS-treatment programmes. While this is an important achievement for activism and public health, in some settings it constrains the provision of other services, including family planning and contraception. Continued advocacy is needed to strengthen sexual and reproductive health services, including the critical need to provide safe, effective, and appropriate contraception to HIV-infected women.
Note the jibe at AIDS “activism” here and the sense of unfair competition from that quarter, as though the sexual and reproductive health project itself had not been making work for the HIV/AIDS sector. (Just one concrete example is suggestive: within South Africa, where 18 per cent of the population overall is infected with HIV, the hardest-hit province, KwaZulu Natal, also has the highest uptake of contraception in the country — predominantly hormone injections.)
Certainly the participants had a sense of urgency about getting answers to pressing questions about hormonal contraception and HIV and promoting alternative methods if necessary, but their over-riding concern was that there should be no fall-off in contraceptive use. As the report notes:
The consultation and discussions reported here started from the perspective that all women — whether HIV infected or uninfected — need access to effective contraception.
That is where it ended, too, and where the whole army of birth controllers appears to stand united at this moment. They talk about the need to offer women an effective alternative before advising them to give up any method, about weighing the benefits of contraception against the risks, and about condoms, a method of “protection” that has never turned the tide of the HIV/AIDS epidemic anywhere.
None of their desperate rhetoric about the risks of “unintended pregnancies” and “unsafe abortions is convincing, however, when the alternative is the risk of contracting or spreading the disease that has killed or debilitated millions of poor people around the world and orphaned or killed their children. There are other ways of helping the poor than pumping artificial hormones into their women on an act first, ask questions later basis. Apart from anything else it betrays a shocking disregard for their fundamental human rights and dignity.
The late Margaret Ogola, a Kenyan doctor who did as much as anyone to care for the victims of HIV/AIDS, told the 1995 UN conference on women that “there seems to be a conspiracy to keep women in the dark, especially the African woman, regarding the many dangerous side-effects of contraceptives”.
At this point her words seem prophetic. If the World health Organisation and its partners in birth control want to show their sincerity with regard to maternal and infant health in developing countries they should issue a clear warning about the probable risks now. Not in January or some years down the track when a trial is completed. Now.
Carolyn Moynihan is deputy editor of MercatorNet.