Hormonal Contraceptives And HIV Risk: What Does It Mean For Women Living With HIV?

The study, led by Renee Heffron at University of Washington in Seattle, suggested that, where one partner was infected with HIV, the female partners who used hormone-based contraceptive injections (Depo-provera) were twice as likely to acquire and pass on HIV compared to those who used other contraceptives or none at all.  Yet, the researchers are unsure of why this increased transmission risk occurs. 

It is extremely problematic if injectable hormonal contraceptives are found to help spread HIV.  Lillian Mworeko, Regional Coordinator for the International Community of Women Living with HIV Eastern Africa (ICWEA) stated, "Women have found injectables to be incredibly convenient for
several reasons. Since you don't need to take it daily, it decreases the burden of daily medication. The one-time cost of the contraception shot decreases overall expenses. Additionally, the majority of women, especially in sub-Saharan Africa, have partners who disapprove of family planning altogether, which renders injectables really helpful in this case."  Gcebile Ndlovu, Regional Coordinator for the International Community of Women Living with HIV Southern Africa (ICWSA) added, "The injectables have been favored by many.  It empowers women in the sense that the fear of getting pregnant would be out of mind." Now, the only realistic family planning method for women may actually worsen the risk of HIV transmission. 

However, there is an even more troubling aspect to this news.  A concerned woman living with HIV who has been working as an advocate on Sexual Reproductive & Health Rights (SRHR) in South Africa reported, "We have cases of forced contraception in women living with HIV.  Sometimes, acceptance of Depo-provera is a condition to access treatment (a dark side of integrating HIV services with family planning services disguised as (SRHR services).  I am concerned and angry about this news because scientists knew this a long time ago.  There was always a link between STIs, diabetes, and Depo-provera because it affects the vaginal lining.  Depo-provera's risks have been on the radar since I got involved with AIDS in 2000, but we were always cautioned to speak softly for fear of upsetting the family planning lobby."

Ndlovu added, "In Swaziland Depo Provera was phased out at Public Health Institutions and a shorter acting injectable, Nur-Isterate, is being used. I am concerned and wonder if networks in these countries mentioned in the study (Botswana, South Africa and Zambia for Southern Africa) had knowledge of what was and is going on or if [Heffron, et al] have gone back to the couples that took part in the study to share the results with them."  

"This study begs the questions, what are the HIV transmission risks of other unexamined forms of hormonal contraceptives.  Women have the right to know the potential benefits and risks of all forms of contraception and to make their own informed decisions.  However, more research is needed more quickly.  Furthermore, those responsible for the production and coerced use of these drugs must be held accountable," said Beri Hull, Global Advocacy Officer with International Community of Women Living with HIV (ICW Global).

In the meantime, protections must be put in place so that women have full information about the risks and benefits of current options and can choose between them before the findings are conclusive. 

Beyond Depo-provera, a broader concern is the failure to find biomedical interventions that work for women. Ndlovu stated, "To some extent, such research findings keep pushing the blame to women.  Could researchers, donors, and pharmaceutical companies focus on what women can use with less hassles and dangers?  Where are we with research on microbicides that are safe for women living with HIV?"  Male-oriented interventions have had much greater success.  For example, research has confirmed that male circumcision reduces HIV transmissions to over 60%, while microbicides are effective only up to less than 40%.  Male condoms are cheaply available, yet female condoms are really uncomfortable and frequently unavailable. 

The Heffron study findings underline the urgent need to understand why this discrepancy persists. Moreover, they fuel the push for multi-purpose microbicides and robust investment in other female-controlled methods. Follow up to these findings on all fronts is critical. The South African advocate affirmed, "This is an opportunity to call for research and production of safe contraceptives for all women, including women living with HIV.  I support calls for further investigation as UNAIDS has said, but Depo-provera should go off the shelves now.  There is no need for further research on this aspect. Rather, research should focus on how many women have been potentially infected because of Depo-provera."  

One clear way to work toward safer and more effective female-controlled family planning methods is to meaningfully involve women living with HIV in the UNAIDS and WHO led analysis of this research and upcoming policy development processes.  In particular, ICW urges the World Health Organization to meaningfully involve women living with HIV at their meeting of experts and researchers in January 2012 when they discuss the findings in preparation to update global guidance on HIV and contraception use.

Certainly, we cannot be angry at the numbers, but we can be angry if the scientific community constantly focuses on the wrong thing because they have not asked women living with HIV what they need and what could work. 

The International Community of Women Living with HIV (ICW Global) is the only global network by, for, and of women living with HIV.  Founded in 1992, we work to increase the visibility of women living with HIV within the global response to HIV and AIDS and to ensure that we are equal partners in all decisions, which impact our lives.  ICW Global envisions a world where ll women living with HIV know and exercise their rights to health, including sexual and reproductive health, and dignity. Nothing for us without us!