Prepare for possible increase in the risk of contracting HIV, says WHO

The World Health Organisation wants governments to educate health workers so that counselling services for women who go to facilities for contraceptives are told of the possibility that some of the hormonal methods may increase the risk of contracting HIV.

Dr James Kiare, the co-ordinator for the human reproduction team in the World Health Organisation, says this will prepare the providers of health services to start implementation of the results of a study titled Evidence for Contraceptive Options and HIV Outcomes (Echo).

The Echo study results, scheduled for release in mid-2019 will provide conclusive information on whether some contraceptives increase the risk of contracting HIV.

In a random clinical trial, a total of 7,830 women from Kenya, South Africa, eSwatini and Zambia were assigned to use three different methods, to find out whether the risk of contracting HIV changes based on the contraceptive used.

The methods tested include the injectable Depo-Provera, progesterone implant and intrauterine devices.

Although the team did not have a placebo contraceptive, Timothy Mastro the chief officer at FHI 360 says the study will still be able to tell whether some contraceptives increase the risk of contracting HIV, given that different methods are being researched.

FHI 360 is one of the institutions co-ordinating the study, alongside the University of Washington, Wits Reproductive Health and HIV Institute, WHO and research institutions in the participating countries.

Dr Mastro says that the team conducting the study could not include a control group that did not have a contraceptive method, since they were dealing with women who did not want to conceive.

He says that giving women a placebo under such circumstances would have been unethical.

Methods

To make up for lack of a control group, Dr Mastro says their teams collected comprehensive medical data on the women in the study. As a result, the doctors will determine how the different methods relate with the risk of contracting HIV.

Determining the risk of contracting HIV is the primary objective, but because the information collected is comprehensive, it will help to ascertain the likelihood of getting pregnant while using a particular method.

The study will also givee an indication of the seriousness of side effects attributed to each method and how often women discontinue their contraceptive method.

Although the use of Depo-Provera has previously been associated with the increased risk of HIV/Aids infections, the study co-ordinators say no one knows whether this contraceptive is the cause.

The Echo team argues that studies that linked Depo-Provera to increased risk of acquiring HIV infection could have been biased since their designs were intended to answer different questions.

An observational study published in the Lancet in 2011, showed that the use of Depo-Provera doubled the risk of contracting HIV/Aids.

The study also noted that HIV positive women were more likely to infect their partners when compared with those not using the contraceptive.

Injectables vs oral

The observational results were not conclusive enough, but WHO was prompted into offering guidelines stating that women at high risk of contracting HIV be told that the progestin-only injectables may or may not increase risk of HIV acquisition.

Dr Mastro says that information that progestin-only injectables may or may not increase the risk of contracting HIV did not prove to be of much use in decision making, yet women need to know whether Depo-Provera or other contraceptives affect their risk of contracting HIV.

“That way women are able to make informed choices about contraception and HIV prevention,” he added.

Information provided by the partners at Echo shows that sub-Saharan Africa is the only region in the world where injectables are the most popular contraceptive method.

“Women like injectables because they can use them without their partners knowing,” says Dr Mastro.

In Europe, injectables are barely used as women prefer oral contraception and IUDs while a few opt for sterilisation. In Asia, it is female sterilisation, IUDs, oral contraception and injectables.

As a result of these statistics, East and Southern Africa also happen to be the regions with the highest HIV incidence rate in the world, were chosen for the Echo study.

With the results from the randomised study, which cost $50 million, Dr Kiare says that WHO will now be able to form conclusive guidelines, on who can or cannot use certain contraceptive methods.

He says that in cases they find that certain contraceptive increase the risk of contracting HIV, WHO will recommend that high-risk populations do not use the method.

In the context of Uganda, high risk populations include sex workers, women under 30 and women who live in fishing communities.

Dr Kiare says that they would not want to abruptly discontinue available methods, as it is important that countries are able to achieve a health method mix for all women.

Dr Kirsten Vogelsong, the senior programme officer in the family planning team at the Bill and Melinda Gates Foundation, says that achieving a healthy mix is now possible, because there are options for protecting women against contracting HIV, while also maintaining a healthy contraceptive mix.