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What's the best way to deal with the uncertainty regarding the use of hormonal contraceptives (specifically injectable progestogen-only products like DMPA/Depo Provera) and women's risk of acquiring HIV? As AVAC and our allies have said for years, it's to tell women the truth—what's known and unknown—in the context of programs that offer multiple contraceptive methods and male and female condoms.
More recently, PrEP has entered the equation as another HIV prevention option that should be offered to all people at substantial risk of HIV (per WHO recommendations) and could be piloted in innovative family planning programs. And up until recently, the World Health Organization had supported this approach, with a clear, expert-informed 2014 statement that women should be informed about the uncertainty regarding progestogen-only methods and HIV risk, and that those women choosing DMPA should be urged to use condoms.
Unfortunately, a statement WHO issued in late-October, ostensibly to clarify the 2014 statement, directly contradicts this message. The October statement says, incorrectly, that there is no evidence of a causal association between DMPA and increased risk of HIV acquisition. (There is no definitive evidence, and no concrete proof of causality, but this statement as it stands eliminates all sense of uncertainty for the vast majority of readers.) It rolls back women's right to know and it removes the recommendation that DMPA users get specific counseling about condoms.
Civil society has responded with concern and urgent demands. An array of groups from many countries, led by ICW-Eastern Africa, sent a letter today to the Director General of WHO, Dr. Margaret Chan, and the head of the Human Reproduction Unit, Dr. James Kiarie. In it they demand that the statement be removed from the WHO website until it can be discussed, with substantive civil society input, at a meeting in December that WHO already had planned on this topic.
The text of the statement is below, along with a list of signatories. A link to the PDF is here. If you would like to download and send with your additional signature to the WHO representatives, be in touch and we will provide their email addresses.
A PDF version of this letter is available for download.
To: Dr. Margaret Chan, Director General of the World Health Organization
Dr. James Kiarie, Coordinator, Human Reproduction Team, World Health Organization Re: Women’s Response to new WHO statement on DMPA
Dear Dr. Margaret Chan and Dr. James Kiarie,
We are writing to express grave concern with the WHO’s 21 October “Statement on Depot- medroxyprogesterone acetate (DMPA)1” and, for the reasons described in the letter that follows, to ask with urgency that the statement be removed from the WHO website until it can be discussed with stakeholders, including in-person consultation at your upcoming meeting on HC-HIV in early December, and revised as needed.
Our reasons are as follows.
- Whereas there are a range of studies indicating that DMPA increases women’s risk of HIV and a range of studies that do not find an association, we are gravely concerned that the first sentence of your conclusion, stating “There is no evidence of a causal association between DMPA use and women’s risk of HIV acquisition” is demonstrably false and request that you either furnish the new data upon which your conclusion was based or immediately clarify that statement which, if left standing, will have a detrimental effect on programs and research immediately. This clarification should return to the existing 2014 statement which recognizes the need for further research and the current uncertainty about the existing data in language that is clear and supported by the evidence.
- The new statement notes that, “The purpose of this statement is to reiterate and clarify the existing (current) WHO position based on public guidance that is still valid.” We take this to reference the statement released in 20142 based on input from the WHO Guidelines Development Group. We have come to understand that the new statement issued in October 2015 came as a surprise to several members of the GDG, raising questions about the process by which it was developed and reviewed. These concerns are particularly urgent given that your new statement does not clarify or support the 2014 statement but in fact appears to contradict it. For example, the 2014 statement includes the recommendation:
“Given the importance of this issue, women at high risk of HIV infection should be informed that progestogen-only contraceptives may or may not increase their risk of HIV infection. Women and couples at high risk of HIV acquisition should be informed about and have access to HIV preventive methods including male and female condoms.”
We note that the October 2015 statement directly contradicts this important guidance regarding women’s right to information that allows a full, informed choice about their contraceptive methods. Your representative, Dr. Petrus Steyn, has indicated in a recent public forum that the new language was developed “at the request of member states” who found the previous guidance confusing. Rather than acquiescing to member states’ requests without engaging stakeholders who have contributed hours and days of time and analysis to this issue over the years, it would have been far preferable that you referred to the reports, proceedings and action steps from consultations in 2012 and 2013 where the question of whether a broad dual protection message urging all women to use condoms for HIV prevention was a sufficient response to the current uncertainty regarding a specific hormonal method. The answer, as evidenced in the WHO’s own 2014 statement was: No. There is a specific right to information regarding the uncertainty about DMPA. Your current statement rolls back that right and so harms women everywhere. - We note that the existing statement contains expanded language regarding prevention options that should be made available and recognizes the importance of VMMC and ART for HIV positive partners. The new statement, in its brevity, omits these key elements which should also be addressed in a clarification, with additional recognition of the PrEP as a new tool now recommended by the WHO and the subject of a new target from UNAIDS.
Finally, we reject this statement as final and demand that it be removed from the website and treated as a draft until it is put through a rigorous consultative process that aligns it with your existing guidance as developed by the GDG.
Lillian Mworeko
Executive Director, ICW EA
Mitchell Warren
Executive Director, AVAC
On behalf of
AIDS Information Centre, Uganda
AIDS Legal Network, South Africa
ARASA, South Africa
ATHENA Network, USA
AVAC
CHANGE, USA
European AIDS Treatment Group (EATG)
GS:SG, Germany
HEPS, Uganda
International Planned Parenthood Foundation, UK
International Community of Women Living with HIV/AIDS Eastern Africa
International Community of Women Living with HIV/AIDS Southern Africa
International Community of Women Living with HIV/AIDS
Lux Vitae, Croatia
Nigeria HIV Vaccine & Microbicide Advocacy Group
Mama’s Club, Uganda
Planned Parenthood, France
Salamander Trust, UK
SisterLove
Uganet, Uganda
Uganda Network of AIDS Service Organizations (UNASO)
Young Black Gay Men’s Leadership Initiative, USA
Zambia Network of People Living with HIV
Anna Forbes, MSS, Independent Consultant, USA
Erica Gollub, DrPH, MPH, USA
Angel Luis Hernández, HIV Prevention Advocate, Puerto Rico
Heidi E. Jones, PhD MPH, Epidemiology & Biostatistics Program, CUNY School of Public Health, Hunter College
Maria José Campos, Medical Doctor, Internal Medicine Specialist, Portugal
John Mutsambi, HIV Prevention Advocate, South Africa
Definate Nhamo, HIV and Sexual Rights Advocate, Zimbabwe
Teresia Otieno, Personal Initiative for Positive Empowerment (PIPE)
Julie Patterson, AVAC PxROAR Advocate, USA
Marion Stevens, WISH Associates, South Africa
DaShawn Usher, Community Education and Recruitment Manager, Project ACHIEVE
Jacque Wambui, HIV Prevention Advocate, Kenya
1http://www.who.int/reproductivehealth/topics/family_planning/statements-reversible-hc/en/
2http://apps.who.int/iris/bitstream/10665/128537/1/WHO_RHR_14.24_eng.pdf?ua=1