HIV risk higher with birth control, less with circumcision
Female hormonal contraceptive doubles the risk of both acquiring HIV and passing the virus on to male partners, according to a new study in The Lancet Infectious Disease. The risk was increased for both injectable birth control — such as the “depot shot,” formally known as depot medroxprogeterone acetate or DMPA — and oral contraceptives, but the data was not as strong against oral contraceptives.
“Active promotion of DMPA in areas with high HIV incidence could be contributing to the HIV epidemic in sub-Saharan Africa, which would be tragic,” comments Charles S. Morrison from the clinical sciences department of Family Health International in Durham, NC.
“Conversely, limiting one of the most highly-used and effective methods of contraception in sub-Saharan Africa would probably contribute to increased maternal mortality and morbidity [from pregnancy] and more low birthweight babies and orphans — an equally tragic result,” he adds.
The study, conducted in seven African countries — Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda, and Zimbabwe— recruited 3,800 heterosexual couples where one partner was HIV-positive and the other was not. The results highlight new challenges in providing contraception and family planning options for women at highest risk.
The researchers call urgently for more data to understand whether other hormonal and non-hormonal contraception has less HIV risk. News that a reliable and widely-used hormonal contraception leaves both men and women at greater risk of HIV is devastating.
In the same countries where these trials were conducted — some of which have HIV prevalence rates of up to 26 percent — male circumcision for adults and infants is promoted by the World Health Organization scaled up for HIV-prevention.
The case for male circumcision as a prevention tool against HIV infection, particularly in sub-Saharan Africa, is backed by compelling evidence. Initial studies highlighted how high male circumcision rates in West Africa were associated independently with low HIV infection rates, and vice versa in East Africa.
“The results were so strong and so consistent. That it was just — wow,” reflects Helen Weiss of the London School of Hygiene and Tropical Medicine. “When you find something that seems to be so strongly associated with HIV, you can’t ignore it — it’s unethical.”
Male circumcision is now promoted by the World Health Organization for HIV prevention in 14 African countries.
Circumcising men is considered playing catch-up with respect to HIV prevention. However, compelling studies show a 60 percent reduced risk of becoming HIV-positive. Weiss adds that that reduction exists whether circumcision is performed on an infant, child or adult male.
Adult male circumcision can provide additional health benefits to healthy young men — including reducing the risk of HPV and other sexually transmitted infections as well as reducing the risk of urinary tract infections.
Yet, while men continue to choose elective circumcision globally for a variety of reasons — preventing sexually transmitted infections is not often the foremost reason.
One European man from Malta tells theGrio that he chose circumcision for “mechanical,” rather than health-related reasons.
“I chose to get circumcised because me and my wife decided to try for a baby. Unprotected sex was impossible due to the extreme pain in my foreskin when it was being retracted back,” he explains.An American man, however, currently planning to be circumcised, said that he chose circumcision for health reasons.
“I have been suffering from recurring yeast infections in the past and now I am ready to get rid of them for good,” he says.
Moreover, as it is notoriously difficult to attract healthy young men into healthcare clinics, Weiss has noticed that with men being interested in elective circumcision, it gets them into the clinic, so you also see big increases in HIV testing.
“That’s a fantastic thing,” Weiss says.
However, male circumcision campaigns targeting groups at high-risk of HIV, including African-American men who have sex with men, could increase stigma, considers Weiss. In addition, any tangible benefits of male circumcision for HIV risk reduction in men who have sex with men are, as yet, unproven.
The CDC is reviewing evidence and considering recommendations specifically on male circumcision for HIV prevention in the United States. Understanding whether proven reductions in HIV acquisition that result from male circumcision remain robust, when use of hormonal contraceptives double HIV risk of HIV, will be important.
Sexual health messages that physicians give to their patients about HIV and hormonal contraceptives may also become complicated by these new findings.
Already, for reasons of stigma, or passing judgement on their patients, physicians serving African-American communities are unprepared to talk about sexual behavior with their patients, reflects A. Cornelius Baker, Senior Communications Advisor and Project Director for the National Institute of Allergy and Infectious Disease.
“If you’re a black physician, you need to talk to every one of your patients about HIV testing without even discussing — irrespective of what you believe their sexuality is,” Baker says.
Social and political stigma around sexuality and HIV remains an important U.S. problem, which exacerbates the challenges of targeting existing HIV prevention tools to high risk groups, like men who have sex with men and young Americans under 18.
Baker states that the problem is exacerbated by “public health code 2500 — the ‘no promo homo’ code [which means] you you cannot engage in education that appears to promote homosexuality.”
However, as written, the CDC states states: “None of the funds appropriated to carry out this title may be used to provide education or information designed to promote or encourage, directly, homosexual or heterosexual sexual activity or intravenous substance abuse.”
This refers to specific CDC-funded programs, and homosexuality is not singled out.
As new HIV interventions, including vaccines and microbicides, are successfully trialled, the arsenal for combination preventative tools against HIV will grow in coming years, but so too will the challenges associated with HIV prevention. Aside from early treatment for HIV-positive individuals and male circumcision, no new HIV interventions are ready to roll out.
Even the eagerly awaited and promising RV144 HIV vaccine which could change the game for HIV won’t be 100 percent effective alone. These vaccines will likely require lots of back-up protection.
With the controversy surrounding the vaccine for HPV — the virus causing cervical cancer, that kills over 4,000 women each year — there will likely be pushback and skepticism surrounding the HIV vaccine.
For now, there is no getting away from the same clear messages about using condoms, getting tested, and knowing your status, a recent drop in AIDS cases in New York City showed this simple model works.
Following this model, including early treatment, is responsible for a significant “drop in AIDS cases”: in New York City.