Earlier this month, a study published in The Lancet discussed findings that hormonal contraceptives doubled the risk of HIV infection and transmission. The study examined 3,790 sero-discordant heterosexual couples (meaning that one of the two has HIV) in seven African countries. Some of the women were using hormonal contraceptives, mostly injectable (such as Depo-Provera) but also oral (the pill). The study’s authors found these women were at double the risk for contracting HIV from their positive partners or to transmit the virus to their negative partners than if they had not used contraception at all.
Injectable birth control is an important contraceptive method for many women, especially those in places where women are not treated equally, maternal morbidity and mortality are high, and health systems are strained: it is only administered every three months, does not require a doctor to provide the dose, and is discreet. Unfortunately, there is overlap between places with gender inequality and overburdened health care and places with higher HIV rates. The New York Times reports that 12 million women in sub-Saharan Africa use injectable contraceptives (the sample size for women using the pill was too small to draw clear conclusions). The World Health Organization is examining the findings and discussing whether to alter its guidelines on contraceptive use. MedPage Today has a slightly more in-depth discussion of the implications of the study.
To put it simply, this is not good news. Millions of women rely on hormonal contraceptives around the world. Some of these women will be exposed to HIV or will expose their partners to HIV. In cultures, communities, and countries where women have little control over when they have sex, whether they use condoms, or how many children they bear, hormonal contraceptives have been a blessing. In many settings, uptake of any kind contraception has been limited. This finding throws another wrench in the works. Unfortunately, there is little to be done other than further study on the issue. One day, perhaps, we can get everyone to use condoms, have gender equality, and build strong health systems. Unfortunately, we’re a long way away.
In more uplifting news, The New York Times recently reported on a successful Doctors Without Borders (MSF) intervention that has helped people living with HIV who are taking anti-retroviral drugs (ARVs) in a Mozambican province. Patients are put into six-person groups, and every month, one of the group members travels to an HIV clinic to collect the group’s ARVs. The patients pool money for transportation, and each person goes twice a year to get the drugs. Everyone saves on transportation costs and the time it takes to reach and wait at the clinic. For people with very low incomes who live in remote areas, this is a wonderful solution. MSF reports that 97.5% of patients in the groups were still in care, 92% were adhering to their ATV regimen, 2% had died, and 2% were lost to follow-up after two years. These are very good numbers. For example, almost one-third of ARV patients in sub-Saharan Africa are lost to follow-up within two years (that means they can’t be found because they’ve moved, died, or don’t want to be found). This patient collective model also decreases the burden on health care facilities and workers, since only one patient waits for drugs and each patient goes in for a regular consultation (while getting the ARVs) every six months. MSF reports that there was a four-fold reduction in consultations. Even better, the model was designed in consultation with the patients. Although this is not explicitly mentioned in the study, I’d guess that the collectives also serve as informal support groups. Having five other people living with HIV to lean on could increase mental (as well as physical) well-being and decrease feelings of stigma and isolation. This is an easy, low-cost solution to a host of common problems associated with HIV/AIDS, ARV adherence, hard-to-reach locations, and overburdened systems. I hope to see it implemented more broadly, from Boston to Kampala to Bangkok, and everywhere in between.
Header photo, of Kenyans waiting to board a matatu, can be found here. It was taken by luigig, CC BY.
