African Journal of Reproductive Health Women's Health and Action Research Centre ISSN: 1118-4841 Vol. 8, Num. 2, 2004, pp. 7-9

African Journal of Reproductive Health, Vol. 8, No. 2, Aug, 2004 pp. 7-9

Editorial

Rethinking Contraception in Africa in the Era of HIV/AIDS

Friday E Okonofua¹

¹ Editor, African Journal of Reproductive Health and Provost, College of Medical Sciences, University of Benin, Benin City, Nigeria.

Code Number: rh04021

Since the onset of the HIV/AIDS pandemic, a relevant question has been whether contraception can influence or be influenced by the disease, and how HIV prevention can be integrated into HIV prevention and care programmes. On face value, it would appear that the promotion of all types of contraceptives would complement and synergize HIV/AIDS prevention efforts. However, there is now sufficient evidence indicating that this may not necessarily be so. There is a growing body of evidence suggesting that of all known contraceptives, only the male latex condom and perhaps the female condom can protect against HIV/STIs as well as unplanned pregnancy. By contrast, other contraceptives, including oral contraceptive pills, injectable contraceptives, intrauterine contraceptive device and spermicidal agents, have little dual protective effects. While contraceptives may be effective against unplanned pregnancy, many do not prevent HIV and other STIs. Indeed, there is some evidence that many of them may increase the risk of HIV in susceptible individuals.

A recent meta-analysis of 28 studies found a significant association between HIV-1 and oral contraceptive use, with the strongest effect found in studies conducted in Africa.¹ Two prospective studies among sex workers in Kenya and Thailand have reported elevated risks of HIV-1 among women using injectable contraceptive depot medroxyprogesterone acetate (DMPA).^2,3 A study from Mombassa, Kenya, has also reported that women using implantable contraceptive norplant were at an increased risk of HIV-1, although the results were not significant.⁴ The findings are inconsistent, since some studies also found no relationship between oral or injectable contraceptive use and the incidence of HIV-1.⁵ However, a theoretical concern exists that hormonal contraceptives might increase the shedding of HIV and increase the transmission of the virus to unintended partners. Thus, the general recommendation at the present time is for programmers to be cautious in using hormonal contraceptives in HIV infected women or those at risk of infection.

Similarly, although there has been enthusiasm regarding the use of nonoxynol-9 (N-9) as a means of preventing HIV infection and STIs, it would appear that N-9 does not prevent HIV to any significant extent. Indeed, a technical experts committee convened by the World Health Organization and the US-based CONRAD Program in 2002 concluded that N-9 spermicides increase the risk of HIV infection when used frequently by women at high risk of infection.⁶

Also, the addition of N-9 to barrier methods of contraception including cervical caps, diaphragm and the male latex condoms have not proven to increase the protective effects of these methods against HIV and STIs. By contrast, N-9 may reduce the effectiveness of these barrier methods in preventing HIV and STIs.

Insertion of the intrauterine contraceptive device in an HIV-infected woman or one at risk of infection is not usually recommended, according to the World Health Organization's medical facility criteria for safe use of contraceptives. Thus, we are left with the male latex condoms and female condoms as the only contraceptive agents that can protect against HIV. When used consistently and correctly, male latex condoms provide protection against HIV, gonorrhoea and unplanned pregnancy. Depending on the model used to assess effectiveness, consistent condom use has been shown to reduce HIV by at least 80%, and perhaps by as much as 97%.⁶ Similarly, the female condom has been shown to be impermeable to various STIs including HIV in the laboratory. In theory, therefore, the female condom device should protect against STIs and HIV in susceptible persons as well, but more studies of its clinical effectiveness especially in Africa are needed.

Given the widespread promotion of several methods of contraception in African countries with high prevalence of HIV, health workers ought to emphasise that condoms are the only methods proved to prevent HIV-1 transmission. Thus, as part of efforts to integrate family planning and HIV prevention, women who use hormonal contraception especially those at risk of HIV-1 should be encouraged to use condoms consistently. Unfortunately, condom promotion efforts are currently mired by controversies throughout much of sub-Saharan Africa, which have tended to reduce the intensity of HIV prevention efforts in the continent.

This special edition of the African Journal of Reproductive Health was commissioned as a collaborative venture between the Reproductive Health Research Unit of South Africa and the Women's Health and Action Research Centre, Nigeria, to document research and service delivery efforts in contraception and HIV/AIDS in Africa. Arising from the unrelenting rates of HIV infection in many parts of Africa, we hypothesised that family planning can in some way be used as an entry point to get people to access qualitative prevention and care services for HIV/AIDS. Several papers in this edition of the journal report various aspects of family planning and HIV/AIDS in Africa, but only the article by Enosolease and Offor⁷ addresses the specific connection between HIV and family planning. The authors report low acceptance rate of voluntary confidential counselling and testing for HIV by women seeking abortion and post-abortion care in urban Nigeria. Studies such as these are highly relevant and important within the context of Africa so that policymakers, advocates and programmers can begin to understand the realities of HIV and family planning prevention and device innovative methods to offer integrated services.

The relevant question now in Africa is: in this era of HIV/AIDS, how can contraceptive services be provided to address the twin problems of unplanned pregnancy and HIV? The answer to this question is not simple but it would appear that it lies in the domain of active integration. We believe that the promotion of family planning should be intensified in all parts of Africa to tackle the currently huge unmet needs for contraception in the continent. Research is needed to understand how family planning and HIV prevention and care services can be integrated in ways to enhance the effectiveness and relative effectiveness of programmes to address both concerns in Africa. Family planning services can uncover previously unknown HIV clientele; it can provide humane counselling and care services to those already infected; it can promote positive prevention among HIV infected individuals; and it can link susceptible communities to effective dual protection services against HIV and unplanned pregnancies. Most importantly, family planning providers can provide continuing evidence-based information on the effectiveness of various contraceptives in preventing HIV/AIDS and STIs. In our current state of knowledge, the male condoms (and possibly female condoms) are the only effective contraceptive methods that prevent against HIV. Clearly, an important challenge of family planning programmes in Africa is to find ways to break current barriers to the promotion of condoms for the prevention of HIV and STIs in the continent. Addressing these challenges will position family planning services in ways to make important significant contributions to reducing the burden of HIV/AIDS in Africa.

References

1. Wang CC, Reilly M and Kreiss JK. Risk of HIV infection in oral contraceptive pill users: a meta-analysis. J Acquir Immune Deficiency Syndrome 1999; 21(5): 428.
2. Sugar M, Lavreys L, Baeten JM, Richardson BA, Mandaliya K, Ndinya-Achola JO and Kreiss JK, Overbaugh J. Identification of modifiable factors that affect the genetic diversity of the transmitted HIV-1 population. AIDS 2004; 18(4): 615-619.
3. Lavreys L, et al. Hormonal contraception and risk of HIV-1 acquisition: results of a 10-year prospective study. AIDS 2004; 18(4): 695-697.
4. Martin HL Jr, Uyange PM, Richardson BA, Lavreys L, Mandaliya K, Jackson DJ, Ndinya-Achola JO and Kreiss J. Hormonal contraception, sexually transmitted diseases, and risk of heterosexual transmission of human immunodeficiency virus type 1. J Infect Dis 1998; 178(4): 1053-59.
5. Kiddugavua M, Makumbi F, Wawer MJ, Serwadda D, Sewankambo NK, Wabwire-Mangen F, Ltulao T, Meehan M, Xianbin, Gray RH and Rakai Study Group. Hormonal contraceptive use and HIV-1 in a population based cohort in Rakai, Uganda. AIDS 2003; 17(2): 233-240.
6. WHO/CONRAD technical consultation on nonoxynol-9, WHO, Geneva, 9-10 October 2001. Summary report. Reprod Health Matters 2001; 10(20): 175-181.
7. Enosolease ME and Offor E. Acceptance rate of HIV testing among women seeking induced abortion in Benin City, Nigeria. Afr J Reprod Health 2004; 8(2):86-90.

© Women's Health and Action Research Centre 2004