Nearly 700 million women worldwide, and over 58 million women in Africa alone, use modern birth control methods like oral pills, injectables, implants and intrauterine devices.
Among these different choices, contraception by intramuscular injection is popular in developing countries. These hormone shots last several months and can also be used more discreetly than daily pills, especially if the women don’t want their partners to know. (Several women are reportedly abandoned, humiliated or even beaten up if they are found avoiding pregnancy.)
“In southern and east Africa, many women face the double jeopardy of high HIV prevalence and high maternal and infant mortality from unintended pregnancy,” said Nelly Mugo, head of the sexual, reproductive, adolescent and child health research programme at the Kenya Medical Research Institute in Nairobi, Kenya.
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Recently, however, women have become more sceptical of injectable contraceptives after studies suggested their use could increase the odds of an HIV infection. One report even suggested that the risk doubled. While the reason behind these findings remains unclear, they seeded enough doubt about this otherwise-safe method of birth control to precipitate their disuse. Eventually, two years ago, the WHO the lowered its safety rating for injectable contraceptives.
Against this background, a study published last week found that women using Depo-Provera, an injectable contraceptive, were as prone to HIV as those using either of the two alternative contraceptives tested: Jadelle and Injeflex. Depo-Provera contains the hormone depot medroxyprogesterone acetate. Jadelle is a silicon tube inserted under the skin that releases very small amounts of progestin continuously into the bloodstream. Injeflex is a copper-infused intra-uterine device.
“After decades of uncertainty, we finally have high-quality scientific evidence about the potential relationship between three different types of contraceptives and the risk of HIV from a rigorous randomised clinical trial,” Helen Rees, a professor in the Department of Obstetrics and Gynaecology at the University of Witwatersrand, Johannesburg, and a member of the five-person committee that led this study.
Rees and others obtained their results based on a clinical trial called ‘Evidence for Contraceptive Options and HIV Outcomes’, or ECHO, conducted by the ECHO trial consortium in four African countries: South Africa, Kenya, Zambia and Eswatini. Between December 2015 and September 017, it monitored nearly 8,000 women who had been randomly assigned one of the three birth control methods for signs of HIV infection.
At the end, the authors found that the risk of an HIV infection from each of the three methods was comparable.
The results “will be a relief to both women and health care providers in southern Africa, where Depo-Provera is the most commonly used contraceptive,” Salim Abdool Karim, an HIV expert at the University of KwaZulu-Natal and Columbia University, New York, told the New York Times. He was not involved in the trial.
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Researchers are developing birth-control shots that women can safely give themselves as well as injectables that last six months. If the trial had found hormonal methods dangerous, “a whole avenue of advances would have been shut off,” according to Timothy Mastro, chief science officer at FHI360, a consultancy in North Carolina and one of the organisations behind the trial, told the same publication.
While these results are a relief, the HIV incidence itself was a shocking 3.8%: nearly 4 in every 100 women seeking to prevent pregnancies in Africa are getting infected with HIV.
So on the one hand, the results support the decision to make a broader variety of contraceptive methods available to women, without any significant difference in the risk of an HIV infection. On the other hand, the trial emphasises the need to integrate HIV prevention strategies within birth control services for African women.
In light of the new results, WHO is set to review its safety recommendations next month.
Priyamvada Chugh is a cancer biophysics researcher turned freelance public health journalist, currently working as a communications consultant in Geneva.