Population Council Research that makes a difference

What Have We Really Learned About
HIV and Hormonal Contraception This Week?

The study published online in The Lancet, 4 October 2011, by Renee Heffron and colleagues  from the University of Washington and described in Pam Belluck's 3 October article in The New York Times describes an important study that provides information about HIV acquisition and transmission and hormonal contraceptive use. While the results are suggestive, what is missing from Belluck's piece is a holistic analysis of the evidence on this subject. Over the past two decades 12 published studies have also contributed to the body of research. Five found similar associations; seven did not.  The contributing causes and biological mechanisms underlying this association are still far from clear.

Further, while there are many strengths to the Heffron et al. paper published in The Lancet Infectious Diseases, the project was not set up to answer the question, "Does hormonal contraceptive use impact HIV?" The authors reached this conclusion in a secondary review of the data. Because they were focused on a different query, the investigators relied on self-reporting of contraceptive and condom use, the accuracy of which is unknown and likely incomplete at the individual or couple level. Moreover, we really don't know what products were actually used in terms of brands, doses, and presentations. Their analysis also did not take into account the fact that almost half of the women who used hormonal contraceptives were not using these methods at some point in the period during which they were observed. Also, a range of family planning methods and counseling was not provided at all of the research sites, and few female participants (about 4–15% at enrollment in the study and 15–21% at the follow-up) used hormonal contraception at all. 

While the relative risks are certainly a concern, in absolute terms, 10 seroconversions occurred among women and 19 among men potentially associated with reported hormonal use among nearly 2,800 couples. However, the results appear to be statistically robust, and some study features, including the utilization of sophisticated analytic techniques, are notable. We believe that this study helps to strengthen the case for additional research and analysis in this area to better understand the potential association and its implications for clients, families, and health systems.

Even if a causal relationship between hormonal contraceptive use and HIV is established, the policy implications are complex—especially in Africa where maternal mortality and morbidity are tragically high. That increased risk of HIV would have to be weighed against factors such as the documented social, economic, and health benefits of family planning; the abilities of the existing service-delivery systems to manage changes in the availability of hormonal contraceptives, including injectables; and the likely increased risk of unplanned pregnancies and unsafe abortions.

The confusion among the public and providers caused by this and other research efforts underscores the urgent need for the Population Council to continue to develop a safe, effective product to prevent the acquisition or transmission of HIV and unintended pregnancy. It also speaks to the need for consultation with public health experts and other stakeholders who can skillfully assess the merits and limits of scientific endeavors, and the potential implications for policies, programs, and guidance for women and their families.

Offsite links

• "Use of hormonal contraceptives and risk of HIV-1 transmission: A prospective cohort study," The Lancet Infectious Diseases, 4 October 2011.
• "Contraceptive used in Africa may double risk of H.I.V.," The New York Times, 3 October 2011.
  

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The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science, and public health research in 50 countries, we work with our partners to deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world. Established in 1952 and headquartered in New York, the Council is a nongovernmental, nonprofit organization governed by an international board of trustees.

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