Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

27 October 2011

Hormonal Contraceptives and HIV Prevention: The grey area

 * Original content from our Mapping Pathways blog team

“The policy implications are very complicated, and we certainly don’t want to undermine the family planning programs merely because of results like this.”

Big news in the HIV prevention world is the possibility that women using injectible hormonal contraceptives might double their chances of acquiring and transmitting HIV infection. Read more about this preliminary finding, which was first presented at an HIV conference held in Rome this July, in a recent article published in the Lancet. While this issue is a current hot topic, it’s not a new one in the prevention community. In fact, Dr. Tim Farley remembers this issue being raised back in the 1980’s when AIDS had just been identified. Dr. Farley, a former scientist with WHO's Department of Reproductive Health and Research in Geneva, who has been specializing in the area of HIV prevention and the interaction between HIV and sexual and reproductive health for the past 20 years, helped us better understand what this finding could mean in the context of HIV prevention and health policy.

MP: How did you become involved in this area? Was there a particular project you worked on that lead you to this field?

TF: Well, soon after the HIV epidemic was identified, all the different departments at WHO were tasked by Jonathan Mann, who headed up the global program on AIDS, to consider what impact this newly identified viral infection would have on our work. And so we scratched our heads and thought about all the issues that could potentially impact our work, not only our work on maternal health and sexual health but also, more technically, our work on prevention. At that time, all we knew about prevention was that condoms worked, and so the idea of promoting condoms not only for pregnancy prevention but also for the prevention of this new sexually transmitted infection was a new one. So we convened in the late 1980’s to discuss all these issues and map out what was going to be important for our work over the next 10 to 20 years, and in fact, some of those issues that we listed then are still very hot and remain unanswered. For example, the interaction between hormonal contraception and HIV infection -- does it increase women’s susceptibility to infection, does it increase women’s infectiousness, does it modify the course of HIV disease in a beneficial or adverse way? These were questions that were listed in that first consultation, and just recently we had some new data presented in Rome related very much to this issue of increased susceptibility to HIV infection and increased risk of transmission from women to men.

MP: What was this data exactly?

TF: This was data presented by Renee Heffron from the University of Washington. It was actually a secondary re-analysis of data from an earlier HIV prevention randomized control trial that was published a few years ago called the Partners in Prevention. That trial, conducted in seven Sub-Saharan African countries, had been looking at acyclovir to see whether the drug reduces the risk of transmitting or acquiring HIV infection associated with herpes simplex infection. The new data presented by Heffron was a reanalysis of this data, but concentrating on the issue of whether users of hormonal contraception were more likely to acquire infection than women using other contraceptive methods, and also whether women using hormonal contraception who were HIV positive were more likely to transmit to their HIV negative partner.

MP: Why is this an important issue to explore?

TF: Well, hormonal contraception is one of the most widely used reversible methods of contraception worldwide. And in the African region, injectible contraceptives and/or combined oral contraceptives are the backbone of the modern family planning programs. The data from this study, though very limited, do suggest a doubling of the risk of acquiring HIV infection for women users of an injectible hormonal contraceptive. Now whether this is a disaster or not, that needs to be considered very carefully in context. There are huge benefits, particularly in the African region, of avoiding an unwanted pregnancy, not only for the morbidity issues but also for mortality reasons. So one has to weigh very carefully any excess risk. Firstly, we need to work out whether this result is true or not. But even if it is true, it’s quite possible that we need to balance the benefits of avoiding an unwanted pregnancy against the small increased risk of acquiring HIV infection. A doubling of risk sounds quite dramatic, but in fact it’s the attributable risk, that is the difference in risk, which is really critical. And any women living in these generalized epidemic areas in Southern and Eastern Africa has to be taking very good care to reduce her risk of HIV infection—for example, by using condoms or by making sure her partner is regularly tested for HIV. So in the context of a good HIV prevention strategy for an individual woman, a small increased risk of HIV infection with DMPA (a popular hormonal contraceptive) may well be a risk worth taking when you consider the benefits of using a reliable hormonal contraceptive method. We desperately need more data to confirm whether this finding is true. But as I mentioned, even if it is true, the balancing of the risks and benefits of different contraceptive methods in the presence of the HIV epidemic is extremely complex. So the policy implications are very complicated, and we certainly don’t want to undermine the family planning programs merely because of results like this.

Dr. Tim Farley is an independent consultant in HIV and sexual and reproductive health and a former scientist with WHO's Department of Reproductive Health and Research in Geneva. WHO is convening a consultation in early February 2012 to review all the data and to try and understand the policy implications. But for now, WHO and the U.S. Agency for International Development are making no new contraceptive recommendations and the two groups have emphasized the study's limitations. To read more about the reactions to this data, click on the links below:

Research Linking Contraceptives to HIV Raises Policy Questions

Hormonal Contraceptives and HIV Risk—Emerging Evidence in Context

Hormonal Contraceptives May Raise HIV Risk For Men And Women

Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

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