The issues discussed include social and behavioral, programme and implementation, and biological and clinical.
From the behavioral standpoint, planned pregnancy requires unprotected sex, which brings a risk of transmission of heterosexual HIV/sexually transmitted infections (STI), both from man to woman and from woman to man. Pregnancy in an HIV-infected woman may result in an infected newborn (or an orphan). Barrier methods, specifically condoms (predominantly male condoms in most of the world) protect against HIV/STI, but are sub-optimal contraceptives since they are not consistently or correctly used.
The worst-case scenario is in urban Africa, where over 20% of urban childbearing women are HIV-infected, total fertility rates range from 4 to over 8, and family planning programmes are struggling to meet the demand for modern contraception. Barrier methods were virtually unknown as contraceptives in the pre-HIV era. The most common contraceptives have been the oral contraceptive pill (OC) and injectables; more user-independent methods [BTL, intrauterine devices (IUD), Norplant] remain rare.
AIDS was first described in the United States 1981, and the first reported cases in Africans were in 1983. The serological test for antibodies to HIV were developed in 1985, and were rapidly added to screening protocols in blood transfusion services all over the world. The Global AIDS programme (later changed to UNAIDS) was established at the World Health Organization in 1986, and country programmes were developed in Africa beginning in 1986–1987. Despite the existence of serological tests since early in the epidemic, voluntary HIV counseling and testing (VCT) did not gain support as an important public health programme until 2000.
In the 1980s–1990s, family planning programmes in Africa were reluctant to be associated with HIV programmes and vice versa. Fmily planning and HIV programmes were vertical structures that were difficult to integrate and sometimes had competing messages (longer acting contraception versus barrier), with a shared a perception that their target audiences were distinct.
A more enlightened approach has evolved over the years, with the consensus that HIV/STI prevention goals can be mutually reinforcing. In sub-Saharan Africa (and increasingly elsewhere), married couples are the largest group at risk for both HIV and unintended pregnancy. Programmes are now striving to provide a continuum of reproductive health services, from ante to postpartum and including family planning as well as HIV/STI prevention.
As we work to achieve this goal, lessons from the past should guide us. If married couples are the largest target group, it is clear that appropriate advice will differ based on the combination of HIV test results in the two spouses. A basic premise is that most sexual contacts occur within the couple, with fewer than 10% of sexual exposures occurring with non-primary partners. In this case, if both spouses are HIV negative, remaining so and preventing unplanned pregnancy are the top priorities. The use of long-acting methods within the couple and barrier method use with other partners is the appropriate advice. If both partners are HIV positive (which is the case for more than 20% of married couples in many African cities), preventing unplanned pregnancies and planning for the family's future should be the main focus of counseling messages. Finally, for HIV-discordant couples (one partner HIV positive and the other HIV negative), dual method use is the key, with condoms to prevent the transmission of HIV between spouses and an additional more effective long-acting contraceptive for added protection against pregnancy. This ‘dual method use’ message is also appropriate for single, sexually active women.
As a practical matter, the implementation of joint HIV/STI/family planning services will require the integration of services. Examples include the provision of VCT and condoms in family planning clinics, and a supply of condoms AND long-acting contraceptives in HIV testing and care facilities (including prevention of mother-to-child transmission programmes). Targeted, client-centered messages are critical, and attention must be paid to the appropriate crafting of messages that result in the mutual reinforcement of barrier method and long-acting method use.
All this assumes that there is no negative interaction between long-acting contraception and HIV transmission or disease. In theory, pregnancy and/or long-acting contraceptives may affect vulnerability to HIV; pregnancy and/or long-acting contraceptives may affect transmissability of HIV and the progression of disease in HIV-positive women; and hormonal methods may increase vulnerability to HIV.
These concerns are not supported by data from long-term studies in Rwanda and Zambia. In two cohorts from Rwanda, oral and injectable contraceptive use was not associated with HIV seroconversion in 998 HIV-negative women recruited from antenatal clinics, nor in HIV-negative women with HIV-infected spouses. In both cohorts, the average hormonal contraceptive prevalence was of the order of 20%. In Zambian discordant couples with HIV-infected men and HIV-negative women, the seroconversion rate was approximately nine per 100 person-years (PY) after counseling. Proportional hazards modeling showed no relationship between past or current OC or injectable use and male-to-female transmission of HIV. There was no decrease in condom use among hormonal method users in that study.
A concern has also been expressed that hormonal contraceptive use might make HIV-infected women more infectious. Among Zambian discordant couples with HIV-negative men with HIV-infected wives with a linked transmission rate of seven per 100 PY linked transmissions, proportional hazards modeling showed no relationship between hormonal contraceptive use and female-to-male transmission of HIV.
In a Rwandan cohort of mostly married HIV-infected women with low STI rates, five out of 20 cervicovaginal fluid samples (20%) taken during hormonal contraceptive use versus 85 out of 146 (42%) taken during non-use were HIV-DNA polymerase chain reaction (PCR) positive (P = 0.046). In a Zambian cohort of HIV-infected women, OC and injectable use were not associated with detectable HIV DNA in 276 samples from 118 HIV-infected women (Nancy Kiviat, Jane Kuypers, Ulgen Fideli, unpublished data).
More than 90% of deaths in urban African women of childbearing age are now caused by HIV infection. The relationship between hormonal influences including pregnancy or hormonal contraceptives and the progression of HIV disease has been questioned. In a Rwandan cohort of 460 HIV-infected women followed at 6-month intervals from 1988 to 1994, the use of OC or injectable contraception was associated with lower mortality rate, although the statistical significance was borderline (P = 0.07–0.08). In a Zambian cohort of 487 HIV-infected women followed at 3-month intervals for a mean of 22 months, neither pregnancy nor hormonal contraceptive use were associated with mortality from HIV disease. Observational cohorts such as these are susceptible to bias. If sicker women have lower fertility rates, it will confound the analysis of the effect of pregnancy on HIV-related mortality. This should not, however, affect an analysis of the effect of hormonal contraception on mortality.
In conclusion, hormonal contraceptive use was not associated with reduced condom use or increased HIV seroconversion in two large cohort studies of (mostly) married women from Rwanda and Zambia. Hormonal contraception was also not associated with increased transmission from wife to husband in Zambia. Hormonal contraception and pregnancy were not associated with increased mortality in HIV-infected women in Zambia. In Rwanda, both OC and injectable hormonal contraception were associated with reduced mortality.
The relationship of hormonal contraceptive use with transmission and the natural history of HIV disease may be different in women with high STI rates or exposure to multiple partners (e.g. sex workers), and/or in women receiving antiretroviral therapy. The majority of Africans at risk of HIV infection and AIDS are married and of reproductive age. For them, the alternative to contraceptive use is pregnancy. Most women will have no choice but to breastfeed. Few will have access to therapeutic antiretroviral therapy.
The prevention of unplanned pregnancy and HIV/STI through the use of long-acting contraceptives and barrier methods should be viewed in a broad context of women's own health, the well-being of their families, and the realities of their social and economic circumstances. In this context, women's fertility control options should not be needlessly constrained. Pending consistent and reproducible evidence (including epidemiological as well as laboratory-based data) to the contrary, family planning and HIV prevention programmes should not alter their client counseling with respect to hormonal or dual method use. More attention should be given to research (behavioral, programmatic, and biological) on the longest-acting methods (BTL, IUD, Norplant/implant) in the context of HIV infection.
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