Research Linking Contraceptives to HIV Raises Policy Questions

BY Talea Miller  October 4, 2011 at 4:08 PM EDT

Photo by World Health Oranization
A study showing injected hormonal birth control could make women more vulnerable to HIV is raising big questions about medical guidance in regions with high HIV rates.

Research conducted by the University of Washington in seven African countries found use of injected hormonal contraceptives doubled women’s risk of contracting HIV and the chances of passing HIV to a partner.

Policymakers are moving cautiously in response to the findings, which were first released this summer at an HIV conference and published again this week by the Lancet. The World Health Organization has scheduled a January 2012 review of the research, but for now the organization and the U.S. Agency for International Development are making no new contraceptive recommendations and the two groups have emphasized the study’s limitations.

In a statement released in August when the study first surfaced, USAID noted flaws in the study’s design and called for a randomized, controlled version to flesh out the results. The agency also noted that while a few previous studies show a connection between hormonal contraception and HIV transmission, the majority of previous research found no association.

“USAID does not believe that a change in contraceptive policy or programming is appropriate or necessary at this time,” the statement said, and a USAID spokesperson said Tuesday that finding still stands.

The WHO also took issue with the study’s reliance on data based off observations in a written response to the Lancet publication.

“Users of hormonal contraception may differ in important ways from non-users (for example, with regards to sexual behaviour and condom use),” the organization said. “[E]ven with statistical adjustment, investigators may not be able to account fully for such differences.”

WHO concluded that for now, the weight of available evidence does not show hormonal contraceptives create an increased risk of HIV transmission in the general population.

In a comment in the Lancet accompanying the study, Charles Morrison, head of clinical sciences at the global health and development firm FHI 360, acknowledged some of the research’s weaknesses but said the study “adds to the growing body of observational evidence” that this form of contraceptive might increase HIV risk and warrants further investigation.

The hormone shots used by many of the women included in the study are especially popular in the developing world because they protect over long periods of time and are renewed every three months. Researchers did look at oral contraceptives and found the increase of HIV among these women was not statistically significant, but said more investigation is needed.

The study authors also said more data is urgently needed on other hormonal contraceptives like patches and implants, as well as non-hormonal devices such as intrauterine devices.

Alexandra Garita, international policy officer at the International Women’s Health Coalition said the Lancet study is too limited to draw new policy conclusions, but it makes a case for reinvigorating campaigns to use condoms for both contraceptive and HIV protection needs.

Garita said many HIV-positive women the organization works with already choose not to use hormonal contraceptives for their own health reasons.

“Hormonal contraceptives have had many different reactions among women living with HIV,” Garita said. “So they have known that higher doses of hormones do impact their health and quality of life. There is actually very little research that has been done on this so the more we can encourage the scientific community to develop this research the better.”

Heather Boonstra, senior public policy associate at the Guttmacher Institute, said the results of the study are alarming on first read, but that the study alone does not warrant changes to current programs because of its scientific limitations. The Institute is joining other researchers in calling for another study that randomizes the women involved.

In the meantime, “contraceptive providers and HIV providers should continue to counsel women on the importance of condoms in conjunction with hormonal methods,” she said, adding that access to a range of contraceptive methods should remain.

The health risks associated with unintended pregnancies in poor settings will also have to be taken into account with any final recommendations by the WHO, Boonstra said, including the fact that pregnant women are at an increased risk of HIV infection.

“I am concerned that women will take away that these [contraceptive] methods are not safe,” Boonstra said. “The consequences if we were to pull hormonal contraceptives from the shelves in Africa or high HIV prevalence settings — the consequences for women’s health — could be quite serious.”

Morrision laid out the policy conundrum health experts face in the Lancet: active promotion of the contraceptive “could be contributing to the HIV epidemic in sub-Saharan Africa, which would be tragic,” but limiting a highly used form of contraceptive could increase maternal mortality, “an equally tragic result,” he said.

Photo by the World Health Organization.