The recent observational study by Heffron et al. published in The Lancet Infectious Diseases reports a doubling of risk of HIV acquisition among HIV-negative women using hormonal contraceptioni, as well as significantly increased transmission to uninfected male sexual partners among HIV-positive women using hormonal methods, particularly injectables. These findings were not the result of a randomized clinical trial but rather incidental to research on oral pre-exposure prophylaxis for the prevention of HIV within discordant couples.
While the study is a valuable addition to our body of knowledge regarding the intersection of two major health challenges, HIV and unintended pregnancy, major changes in public health policy and programs must be informed by a detailed analysis of all well-conducted studies rather than any one study. Jhpiego joins the World Health Organization (WHO) and the U.S. Agency for International Development (USAID) in pointing out that previous studies on oral and injectable contraceptives and the risk of acquiring HIV infections have shown conflicting results, but overall 14 out of 16 prospective studies show no additional risk of HIV acquisition with oral contraceptive use, and 9 out of 14 studies show no additional risk with injectable contraceptive use. It is important to note that this and the previously published studies are not randomized trials but rather observational studies that are prone to selection bias. Although all participants in this study were extensively counseled to use condoms, couples using condoms for contraception may be more likely to use them consistently and correctly than women who are also protected from pregnancy by hormonal contraception. In addition, users of hormonal contraception may have different sexual behavior, such as higher coital frequency, than women who use condoms for contraception or who use no method.
One important tenet of good medical care is to balance the benefits of medication with the potential risks of medication. Sub-Saharan Africa is home to 10% of the world’s women but responsible for 40% of all pregnancy-related deaths globally (WHO/AFRO, 2010). It is a region of high fertility, where unmet need for family planning exceeds 20% in 29 of its 31 countries. Hormonal contraception, particularly pills and injectables, are used by one of every three women in the region who use modern methods of contraception (Rich and Lande, 2006). The risk of unwanted and unplanned pregnancy in women is devastating to both mothers and their offspring and is well proven in numerous studies to increase maternal and neonatal mortality and morbidity. In addition, pregnancy itself may increase both the risk of HIV acquisition among women and transmission to men. Restricting access to contraceptive choice, in particular hormonal contraception, would dramatically increase the levels of unwanted and unplanned pregnancy, and consequent complications.
Jhpiego therefore agrees with WHO and USAID that it would be inappropriate to limit or curtail access to effective hormonal contraceptive methods as the high mortality and morbidity risks of unplanned and unwanted pregnancy are well known and researched, whereas the risk of HIV acquisition from use of hormonal contraceptives is still equivocal.
Jhpiego will continue to watch the developments, additional research and analysis and maintain close contact with WHO, USAID and other global HIV and family planning groups, and is well positioned to support changes in global guidelines and national needs should they be indicated.
Jhpiego takes this opportunity to emphasize the following effective and low-cost means of preventing HIV transmissionas well as expanding contraceptive choice:
- Knowing your HIV status and that of your partner is critical. Couples counseling and testing has been proven to reduce transmission within discordant couples. Testing is also an important linkage to care and treatment. Recent evidence from the HIV Prevention Trials Network (HPTN) study 052 shows that early treatment of HIV infection can reduce HIV transmission within discordant couples by 96%.
- Voluntary medical male circumcision reduces female-to-male HIV transmission by at least 60%. As fewer men acquire HIV, fewer women will be exposed to the virus. Use of condoms (male/female) together with other modern methods of contraception can prevent both HIV infection and unintended pregnancy.
- The IUD has been an underutilized method in Africa, but this highly effective and reversible method may provide an important alternative for women who are interested in spacing or limiting. The 2009 WHO Medical Eligibility Criteria recommends the use of the Copper-T IUD in the presence of high-risk HIV (with the caveat that IUDs do not protect against sexually transmitted infections/HIV and thus correct and consistent use of condoms is recommended), in women with HIV infection and in women who have AIDS but are well and on antiretroviral therapy (MEC for Contraceptive Use, 4th ed., WHO, 2009).
- Testing for HIV in pregnancy and provision of antiretroviral drugs to HIV-positive mothers and their HIV-exposed babies is an effective means of preventing HIV transmission to babies. HIV-positive women who meet clinical criteria for antiretroviral therapy should receive treatment, not prophylaxis.
Following are the full USAID and WHO statements on this important matter: