What has HIV got to do with contraception?

Although the claim that hormonal contraceptives might increase the risk of acquiring HIV is yet to be proven, experts, in this report by SADE OGUNTOLA, say that women need to also consider combining them with condoms to reduce the risk of HIV infection or STIs. Many of today’s couples carefully plan the number of children they will raise, often with the help of modern contraceptive choices available from their physicians or family planning clinics. But if you are one of the millions of women who take hormonal contraception, your risk for HIV infection could probably be slightly higher.

In a study conducted in Africa, women who used hormonal contraception, in injection form, had double the risk of acquiring HIV or transmitting it to their male partners as those who did not use hormonal contraception.

Hormonal conception such as the oral contraceptive pill or contraceptive injections are effective forms of contraception. But, the study said the risk of acquiring HIV or transmitting it to their male partners was most pronounced for women using injectables like Depo-Provera.

In fact, for groups of women such as sex workers who have a high risk of HIV infection, the implications may be more alarming.

 

Criteria for choice of contraception

Different criteria are used in determining the type of contraceptive a couple is counselled to take to plan their families. There is always a type that is suitable for every woman.

There are medical eligibilities, which is a set of guidelines by the World Health Organisation to determine an individual’s credibility for any particular contraceptive.

For instance, “There are some contraceptives that a hypertensive patient cannot use but others can. We weigh the risk of getting pregnant against what the contraception can do,” said Dr Tosin Awolude, a consultant obstetric and gynaecologist, University College Hospital (UCH), Ibadan, Oyo State.

Even women that are HIV-positive, too, can use contraceptives to plan their families. But “it is important that people with HIV disclose their HIV status since family planning contraceptives are individualistic,” he stated.

However, he declared that some contraceptive methods like female and male condoms confer double protection against pregnancy and sexually transmitted infections, including the virus that causes Acquired Immune Deficiency Syndrome (AIDS), unlike others such as hormonal contraceptives that only protect against pregnancy.

 

Every sexual intercourse is a risk factor for HIV

According to him, “every sexual intercourse is a risk factor for HIV transmission.  But a contraception that has dual advantage has been associated with lower risk of transmission of sexually transmitted infections, including the virus that causes AIDS.”

Nonetheless, he added that some studies had indicated that some hormonal contraceptives might increase a woman’s risk of HIV infection.

“At the early stage of HIV, some studies show that hormonal contraceptive is associated with increased risk of HIV infection. That is why we do not recommend some contraceptive methods for HIV-positive patients.

“This is because the content of these contraceptives is associated with some inflammatory process which can promote HIV transmission.

 

Contraceptives for HIV-positive women

“But the commonly available contraceptives such as oral pills, implants, intrauterine copper device (IUCD) and injectables are allowed generally for HIV-positive women.”

Nonetheless, he said that the risk of hormonal contraceptive increasing a woman’s risk of HIV infection is little, adding “this is all about risk balancing; the advantages of using these methods to prevent unwanted pregnancies generally against the possible increase risk of HIV acquisition. Even family planning is not 100 per cent effective.

“That is why we encourage our HIV-positive population, irrespective of other family planning method they may be using, to also combine it with other barrier contraceptives which could either be a female or male condom.”

Dr Morenike Ukpong is an Associate Professor of Paediatric Dentistry and Consultant at the Obafemi Awolowo University, Ile-Ife, Osun State.

 

Women more are at risk of HIV

According to her, although women are more at increased risk for HIV infection and efforts are ongoing to also ensure that unwanted pregnancies are prevented irrespective of HIV status, advantages of using these methods to prevent unwanted pregnancies generally outweigh the possible increased risk of HIV acquisition.

Dr Ukpong declared: “There is currently no clinical trial-derived evidence to show that any contraception, including progestogen-only injectables, increase the risk of acquiring HIV infections.

“However, multiple low to moderate evidence generated through secondary analysis of data collected for other research purposes but analysed to test possible associations between risk of HIV infection and use of contraception suggest that this association is plausible.

“The ongoing ECHOO study being implemented in South Africa will provide some evidence by 2019 on whether the use of depot medroxyprogesterone acetate [DMPA), more commonly called Depo-Provera, increases a woman’s HIV risk or not. Women need to be educated about the choices they make about use of contraception.

“For women living with HIV, it is important to discuss contraceptive options also. Most anti-retroviral treatments do not interact with family planning drugs.”

The study included 3,790 heterosexual couples in which one partner was HIV-positive and the other was not. The couples were from seven African countries (Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zimbabwe).

Women using hormonal contraceptives were twice as likely to become infected with HIV. The risk was increased among those using injectables and oral contraceptives, although the increase seen in those using oral contraceptives was smaller and may have been due to chance.

Additionally, women who were HIV-positive at the beginning of the study and using injectable contraception were twice as likely to transmit the virus to their male partners as women who did not use hormonal contraception.

The results held even after researchers took into account factors that could affect the HIV transmission rate, such as the whether the woman was pregnant, and whether condoms were used.

It’s possible that hormonal contraception causes biological changes, such as changes to the cells that line the vagina or cervix, that influence susceptibility to HIV, the researchers said.

 

WHO’s stand

In 2017, the World Health Organisation, in a public statement, recognised the possibility of acquiring HIV infection through the use of some hormonal contraceptives.

WHO said it was a critical one, particularly for sub-Saharan Africa where women have a high lifetime risk of acquiring HIV, and hormonal contraceptives constitute a significant component of the contraceptive method mix.

UNAIDS in a statement said that due to the inconsistency of the body of evidence, available data do not establish a clear causal association with HIV acquisition, nor is the possibility of an association definitively ruled out.

It added, “Hormonal contraceptives do not protect against HIV. This is why using dual protection is recommended for preventing both HIV infection and unintended pregnancies.”

The possible rise in HIV infection among women using the contraceptive injection was first noted in 1991. The debate over it has become “increasingly narrow and fierce”.