Around the world, women, sexual and reproductive health advocates, service providers, researchers and other stakeholders are following the discussion of if and how hormonal contraceptive use affects HIV-negative women’s risk of acquiring or transmitting HIV, and how it might affect HIV-positive women too. In recent months, AVAC has worked with civil society stakeholders to convene various dialogues on this issue.
In depth resources on this subject are available below.
What's New
The World Health Organization (WHO) published a statement on a recent technical consultation on the use of hormonal contraceptives and HIV risk, and WHO recommendations around contraceptive use for women living with HIV/AIDS or at high risk of HIV. (Read the accompanying clarification note.) AVAC held a global teleconference to discuss the recommendations. Listen to a recording of this call.
In the statement, the WHO notes that experts at the consultation concluded that the WHO should continue to recommend that there are no restrictions on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, they recommended that a new clarification be added for women using progestogen-only injectable contraception at high risk of HIV. They emphasized that women should also use condoms to prevent HIV acquisition and transmission. They also stressed the need for further research on the issue and the importance of offering a wider choice of contraceptive options. For a summary of the consultation proceedings, click here.
A global advocates' teleconference to discuss the WHO recommendations recently took place. It featured representatives from the WHO, UNAIDS, program implementers and civil society representatives who participated in the technical consultation. The bulk of the call will be devoted to a facilitated discussion on the WHO recommendations and what they mean for women and the programs that serve them.
Background
In light of recent data suggesting the the use of hormonal contraceptives might double the risk of HIV transmission among women and their partners, the World Health Organization recently convened a stakeholder group to review the existing data and discuss what might go into a new guidance document.
The most recent data comes from two prospective studies of HIV incidence: the Partners in Prevention HSV/HIV Transmission Study and a separate observational study of couples enrolled at Partners' sites. Women using hormonal contraception, primarily injectable hormonal contraception, had a two-fold increase in risk of acquiring HIV. Women who were HIV-infected at the beginning of the study and using injectable contraception were also two times as likely to transmit the infection to their uninfected male partners and had higher genital HIV RNA concentrations.
Mixed Data
However, previous research on hormonal
contraceptive use and risk of HIV transmission
has been mixed. In 1991, Plummer et al. were
the first to report an association between the
risk of HIV-1 infection and oral contraceptive
use. In 2004, Lavreys et al. analyzed data from
a ten year prospective cohort study in Kenya
and found that women using either injectable
hormonal contraceptives or oral contraceptive
pills were at increased risk of HIV-1
acquisition, and in 2009 Watson-Jones et al.
also found some association between HIV
incidence and exposure to hormonal
contraceptives.
Yet, in 2007 Morrison et al. published results from a ten year prospective cohort conducted in the general population finding no association between hormonal contraceptive use and HIV acquisition overall. In 2009, Morrison et al. conducted a peer-reviewed literature review of prospective studies finding that the data they analyzed suggests that neither oral contraceptive pills nor injectable hormonal contraceptives increase the risk of HIV infection among women in the general population.
However, in 2010 Morrison et al. analyzed their 2007 results again using a different analytical method and found an association between injectable hormonal contraceptive use, a large association for young women in particular, and increased risk of HIV acquisition, but found no increased risk for oral hormonal contraceptive users.
All studies called for further research to be conducted to verify their findings.
Further Resources
Civil Society Consultations and Statements
Ugandan
Service Provider Perspectives on the WHO
Recommendations on Hormonal Contraceptives and
HIV Risk
September 2012
AVAC Prevention Research Advocacy Fellow Lydia
Mukombe presents on her advocacy on HCT-HIV
with Ugandan service providers
No
More "Stay the Course": Acting on Risks of DMPA
for Women and Men
July 2012
Excerpted analysis of the data to date and the
imperative to act by Erica Golub, Dr.PH and
Zena Stein, M.A., M.B., B.Ch., Dr. Med. Sc.
(hon)
Video of Helen
Rees on HIV Risk and Contraceptive
Use
April 2012
Dr. Helen Rees, Executive Director of Wits
Reproductive Health and HIV Institute, speaks
on HIV risk and contraceptive use at the
Microbicides 2012 Conference in Sydney,
Australia
Response
to World Health Organization
Guidelines
The International Community of Women Living
with HIV, February 2012
The ICW urgently demands the WHO to correct the
Note for the Media, acknowledges the WHO
Technical Statement on Hormonal Contraceptives
and HIV with concern and caution, and demands
greater communication and further research
now.
The
UN's Gag Order on Reproductive
Health
AIDS-Free World, February 2012
A statement by AIDS-Free World Co-Director,
Paula Donovan, on the confidentiality
agreements prohibiting dicussion on hormonal
contraceptive safety.
African
Women's Civil Society Consultation on HIV Risk
and Hormonal Contraceptive Meeting
Summary
January 2012
On 25th January, more than 40 women
representing HIV prevention advocates,
reproductive health service providers, and
women living with HIV from Kenya, South Africa,
Rwanda, Uganda and Zimbabwe met to review and
discuss the existing data on hormonal
contraceptive use and HIV risk.
Collaborative
Statement from Women's Health
Advocates
ATHENA Network,
January 2012
This is a collaborative statement from women's
health advocates from a WHO and partners
stakeholders' meeting on hormonal contraception
and HIV that took place in Geneva.
Global
Teleconference on Hormonal Contraceptives and
HIV—AVAC, October
2011
A global advocates’ teleconference took place
to provide an opportunity for advocates,
researchers and policy makers to discuss and
ask questions about recently published data on
the relationship between hormonal contraceptive
use and risk of HIV infection.
Introductory Material
Issue
Overview: Hormonal contraceptives and HIV-1
risk
AVAC, UPDATED April 2012
A short primer providing background, help
understanding the issue and what happens
now.
UNAIDS
Q&A on Hormonal Contraceptives and
HIV
UNAIDS, March 2012
UNAIDS released a frequently asked questions
document on hormonal contraceptives and
HIV.
Q&A
- Hormonal Contraception and
HIV
FHI 360, February 2012
FHI 360 assembled a short question and answer
piece to help understand hormonal
contracpetives and a potential increase in HIV
risk acquisition.
Published Research and Editorials
Hormonal
Contraception and HIV: an unanswered
question
Lancet Infectious Diseases, October
2011
Charles Morrison and Kavita Nanda of FHI 360
offer a short overview of some of the relevant
data, note the need for a better understanding
of the relative risks and call for a randomized
trial of hormonal contraception and HIV
acquisition.
Hormonal
Contraception and HIV: Weighing the evidence
and balancing the risk
RH Reality Check, October 2011
This article looks at the limitations of the
most recent study on the topic, discusses
possible ways to conduct research designed to
specifically examine these questions and
considers how to balance the risks women face
both from HIV and unintended pregnancy.
Hormonal
Contraceptives and HIV Risk: Emerging Evidence
in Context
Guttmacher Institute, October
2011
Provides additional commentary and background
on this issue.
WHO and UNAIDS Technical Guidance and Other Documents
Medical
Eligibility Criteria for Contraceptive
Use
World Health Organization, 2009
This document reviews the medical eligibility
criteria for use of contraception, offering
guidance on the safety of use of different
methods for women and men with specific
characteristics or known medical
conditions.
Medical
Eligibility Criteria Wheel for Contraceptive
Use
World Health Organization, 2008
This wheel contains the medical eligibility
criteria for starting use of contraceptive
methods. It is based on the Medical
Eligibility Criteria for Contraceptive
Use, 3rd edition and its 2008 Update, one
of WHO’s evidence-based guidelines.