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Emily Bass is AVAC's Director of Strategy & Content.
The incomparable activist and writer Kenyon Farrow used to write a blog called Non-Shock of the Week, and it came to mind when I read yet another analysis of the interplay between hormonal contraception (HC), HIV, and the long-term impact on women's health in Africa.
This paper, published by the journal Global Health: Science and Practice, uses models to explore what would happen if the injectable contraceptive DMPA, or Depo-Provera, was withdrawn from the parts of the world where it is most widely used.
Why ask this question? Because there is a possibility that DMPA (and other injectable contraceptives that contain the same synthetic hormone) could increase women's risk of HIV. The World Health Organization (WHO) identifies this "theoretical or possible risk" in its current classification of three products: DMPA, NET-EN (another injectable that uses a different hormone from DMPA) and DMPA-SC, also known as Sayana Press, which is the same hormone as Depo but uses a different, simpler delivery method. (More background information is available here.)
DMPA is the mostly widely used contraceptive in East and Southern Africa, so my non-shock of the week was its key finding: Taking away DMPA without offering a comparable method would increase women's risk of dying from pregnancy-related outcomes (e.g., unsafe abortions, complications from pregnancy), and that more women would die than would be protected from HIV.
Well, yes. That's not news. Various models have drawn the same conclusion, and an updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition was published in 2016. At least one of the authors of the recent analysis knows this, having participated in forums where civil society have implored "experts" to stop promoting these false choices. No responsible funder, government, activist or advocate would ever suggest that DMPA should be pulled off the shelf without a replacement. Maternal mortality claims too many lives; contraceptives are essential; and DMPA is the right one for many women.
So why do we keep on being told how bad it would be if DMPA were to vanish, in the event it turns out to increase women's risk of HIV? A cynical analysis is that these publications are preparing the ground in advance of data due in 2019 from the ECHO trial, which is expected to yield an answer to these questions. (ECHO is measuring whether DMPA administered through an intramuscular injection (IM) and two other HC methods-the Jadelle implant and the non-hormonal copper intrauterine device (IUD)-impact women's risk of HIV.)
The ECHO trial is designed to provide clarity where there hasn't been any-by using a randomized clinical trial design that aims to eliminate the potential for bias, which could be influencing observational data available thus far. If DMPA does increase women's risk of HIV, there will be an imperative to change the status quo and do things that are costly, hard and largely avoided by many countries for many years. Things like: increasing the number of choices that women have for contraception; integrating HIV prevention and contraceptive provision services into one clinic; and providing oral PrEP as part of comprehensive HIV prevention options.
Does this sound far-fetched? Consider this:
The article concludes, "In countries with the highest maternal mortality rates, an unrealistically large proportion of the women would need to transition from progestin-only injectables to another effective method in order to reach net neutral mortality thresholds." (Emphasis added)
In fact, the authors found (except in South Africa) 80 to 90 percent of women now using DMPA would need to switch to something just as effective to net more lives saved than lost. This calculation seems to be borne out by the available facts, but it also puts the problem in a vacuum. If a contraceptive method impacts a woman's HIV risk she should be given the option to switch methods; she should be provided the means to make different choices about HIV prevention.
The modeling paper could have suggested that now is a moment to intensify efforts to give African women access to oral PrEP along with other methods of HIV prevention-at the same places where they choose their contraceptives. This has been the refrain of advocates working on this issue all along: Women must be able to protect themselves from HIV and access safe and effective contraception. There is no time for programs or modeling papers that, however inadvertently, put forward a false dichotomy between women's HIV prevention needs and their contraceptive needs.
Instead of issuing papers and arguments about how hard and risky it will be to change anything if ECHO does indeed find that a given method impacts risk, global and national decision makers need to send the message: This is an opportunity to advance women's health via integration of HIV prevention and contraceptive programs and expanding the method mix of both. There's consistent evidence that women want this and that it's good for individual and community health. So why not do it at scale now, irrespective of the ECHO trial? Send money with the message. Fill the shelves with options for women to choose from and provide counselors skilled in explaining the risks and benefits of different methods. This is not impossible.
Another article published recently, which sits behind a paywall, looked at possible explanations for why DMPA might increase women's risk of HIV. It's dense, but the bottom line is that the specific progestin in DMPA acts differently than other progestins. Some of those differences could increase women's risk of HIV. It's all inference-there's no direct measurements of DMPA use and HIV risk. The authors looked at the available data: different kinds of cells, immune substances, other markers that the body produces and how DMPA affects them. The authors say that there could be a rational explanation for why DMPA may increase women's risk and other methods don't. But their research doesn't supply an answer, just more information in a murky space that might-or might not-be cleared up by the ECHO result.
In the meantime:
- WHO should clarify their course of action if the ECHO study shows that DMPA does impact HIV risk, including how they will engage stakeholders and convene a guidelines review. WHO should contribute further models, other literature and resources that will lead to clear communication and policy guidance.
- All stakeholders working in both HIV and reproductive health need to plan, ideally together and not in silos, now for the range of potential results from the ECHO trial.
- Programs, policies and messages need to be developed and evaluated to understand how best to honor and uphold women's right to know all available information on the contraceptive method(s) they are being offered.
- Investment is needed now in programs that provide women with broader choices in contraception and HIV prevention.
- Ongoing engagement with women affected by these issues is essential. Their perspectives and experiences must guide policy, programs and messaging.