Hormonal Birth Control and HIV Rates in Uganda: Information Required

Kampala, Uganda:

Uganda’s family planning authorities have a clear message for the authors of a study linking hormonal birth control, the country’s most popular contraceptive method, to a doubled risk of contracting HIV: they want more information.

The country is holding out for recommendations from the World Health Organisation, which will come after a meeting of experts scheduled to begin tomorrow - January 31. But the ‘wait and see’ approach worries community-based health-workers looking for guidance on how to communicate the findings to the people with whom they work. The absence of an official policy, they say, invites misinformed decisions.

The debate stems from a report published online in October last year by the medical journal, The Lancet, showing that women who use either oral and injectable hormonal birth control – like Depo-Provera, which is the easiest and most accessible contraceptive for most Ugandan women – had almost twice the rate of infection as other women in the study who did not use that method. Furthermore, HIV-negative males were nearly twice as likely to become infected by positive female partners using the hormonal contraceptive as men whose partners did not use hormonal contraception.

Official line

According to officials at the Ministry of Health, Uganda’s official line on the study is that the country is waiting for WHO guidance before it considers a strategic policy shift. A WHO concept note ahead of the meeting stipulates that the task force will need to review the body of evidence about the link between hormonal birth control and HIV before it considers updating any of its recommendations. In the meantime, Uganda’s policy has not changed: all women on contraceptives should continue to follow standard guidelines – abstain, be faithful or use condoms – to prevent the transmission of HIV/AIDS, while continuing to use the family planning method of their choice.

“We are appealing to people who are on Depo-Provera to continue using it, because the intended goal of Depo-Provera is actually to postpone pregnancy; it has nothing to do with HIV,” the Ministry of Health’s Permanent Secretary Asuman Lukwago said in a press conference shortly after the study was released.

Family planning and public health experts are questioning the merits of the study: they point out that the sample was small, including just 1,314 couples. They wonder why the researchers did not include pertinent details, like whether male partners were circumcised.

“I don’t see anything, yet, which is cause for alarm,” said Jackson Chekweko, the executive director of Reproductive Health Uganda (RHU), the country’s oldest family planning organisation. The international community seems to agree; a companion commentary in The Lancet called on the international donor community to fund a follow-up study before any policy changes are made.

There is also an underlying, and perhaps bigger, concern in Uganda that the premature adoption of the findings could undo the recent efforts of the country’s family planning movement to facilitate better access to, and knowledge about, contraceptives. Officials want to control the messaging around the findings so that it does not lead women to abandon birth control completely. So far that has translated into a decision not to launch an expensive and widespread education effort to get health workers and others up to speed on the findings and the government’s response.

There are two obvious risks to that approach. The first is that the findings might be validated and Ugandan families on Depo-Provera will have been exposed to a heightened risk of contracting HIV. At the moment, however, officials are comfortable with their decision to follow the lead of the international community and wait for more research. The other risk comes from assuming that people will not learn about the study. Community-based health workers say that is not necessarily the case and, in the absence of government training, families will be left to make under-informed choices about whether to change their birth control methods or stop using it completely.

On Message

It is still early to call family planning in Uganda a success story. In a country with the world’s second youngest population, only 38% of women have ever used a modern method of contraception, according to the Uganda Demographic and Health Survey 2006 - the most recent available.

Organisations like RHU have been working for years to tie family planning to a national dialogue about poverty, women’s health and education, both to increase political buy-in and to raise awareness within communities. “They have been able to link family planning with other aspects of development,” Chekweko said. “In so doing, I think the policy environment is increasingly improving.”

Moreover, RHU officials are hopeful that next year’s new Demographic and Health Survey will reflect their efforts by showing a marked upturn in birth control use. This is because women like 21-year-old Moimuna Kyozira, who lives outside Jinja, are starting to feel more comfortable controlling the size of their families. After she had her second daughter two years ago, she told her husband that she was going to start using a contraceptive, and then walked to a local clinic and asked for injectable birth control.

“When I went to the health worker, I told her injectables are the best,” she said. It is what her friends use, it is affordable and, unlike pills, she only has to worry about it once every three months.

But when she learned about The Lancet study and the potential double risk of contracting HIV while on Depo-Provera, Kyozira said she was going to switch methods, whether or not there was an official policy recommendation from the government.

Officials assume that, without a blitz of local radio coverage about the study, it is unlikely that many people in far-flung communities will learn about its content. Yet community-based workers argue that women on Depo-Provera have a right to know both the study’s findings and the government’s response. They will then be able to make a fully informed decision, rather than one based on misinformation or misunderstanding.

“If [health workers] land on the information, there is a risk that they will misinform the communities,” said Betty Walakira, the executive director of Health Child. Her organisation’s work includes maternal health services, like providing family planning consultations and information. “Sometimes the health workers do not know the impact of the information they tell women and their communities. A woman can jump and say this method causes HIV infection.”

There are already a lot of concerns about birth control that her organisation already has to address, she said, such as worries about weight gain, loss of sexual appetite, heavy vaginal bleeding. It will be important for the government to firm up its messaging about The Lancet study and make sure they clearly articulate that message to everyone who provides Depo-Provera – from health workers to drug store employees who illegally offer over-the-counter injections.

“I wish we could know the extent [of the risk],” Walakira said.

Everyone, it seems, is waiting.

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