Saturday, March 10, 2012
Paula Donovan of AIDS-Free World, writing in the Huffington Post, makes some important points about an article by Vanessa Cullins of the Planned Parenthood Federation of America (PPFA), also writing in the Huffington Post. Donovan corrects some of Cullins' errors about the WHO's decision not to change the advice it gives women in African countries about injectable hormonal contraceptives such as Depo Provera. As Donovan says, the WHO's decision for now is that they don't know if use of injectable Depo really increases transmission of HIV from women to men and from men to women. All WHO did was reiterate their advice that condoms be used in conjunction with Depo.
Donovan is a bit hopeful in thinking that WHO reviewed "all the best scientific research available." They reviewed some research, left out some and still found the data difficult to interpret. But not too difficult to decide in favor of advising that people continue using the method, with condoms, until more decisive research can be carried out. That might be understandable if Depo were the only form of birth control available or if injection was the only or best method method of administration; but neither are the case.
In fact, what AIDS-Free World, PPFA and WHO fail to mention is that all the data that was considered was about sexually transmitted HIV. Not all HIV is transmitted sexually, but it is usually assumed that all or most is transmitted through heterosexual sex in African countries. Neither condoms, Depo Provera, however administered, nor probably any other contraceptive method, protects against certain types of HIV transmission, such as through unsafe healthcare or cosmetic services. Indeed, high use of injections in healthcare facilities where safety standards are not very closely adhered to might be part of the problem; or it may have been part of the problem at one time.
Donovan asks "What if women at high risk of HIV hear that experts are concerned about injectable hormones, and choose to stop using them until researchers have come to definitive conclusions?" Well, as long as they use some other form of contraception, what if they do stop using Depo? Donovon goes on: "What if, as a result of that choice, many more women in countries with high rates of maternal mortality become pregnant?" One of the reasons why maternal mortality rates are high is because conditions in health facilities are extremely bad; so bad that many opt not to use them and rely on something that may or may not be a lot worse.
If AIDS-Free World, PPFA and even WHO are worried about maternal, infant or child mortality, choice of contraceptive method is really not the most important issue. Especially if the 'choice' to use injectable Depo could be exposing women to risk of infection with HIV and other diseases (or may have done in the past). The solution to the problem of unsafe healthcare is safe healthcare, not birth control. I suspect PPFA and the like have been imagining that they are 'saving' lots of women by persuading them to use their (the NGO's) favored method of birth control; but if healthcare facilities remain as appalling as they are now, even those follow current advice may still risk being infected with non-sexually transmitted HIV and other healthcare associated infections.
PPFA use the rather emotive term "lifesaving contraceptive methods", as if women's lives depend on Depo, injectables or any single type of contraceptive. But if they are so worried about women's safety, they should take more interest in conditions in healthcare facilities, or they could be exposing them to far higher risks. Cullins even recognizes that condoms on their own give 'dual' protection against unplanned pregnancies and sexually transmitted infections, including HIV; but there are several other methods she doesn't even mention. Injectible Depo Provera has been aggressively marketed in African countries for a long time, so it could be a little tenuous to claim that it is 'popular'.
If women need more options, as Cullins argues, that should include non-hormonal methods, non-injectable methods, etc. Even Michael Sidibe of UNAIDS points out that women need safe contraceptive and HIV prevention options, but he rather piously mentions 'ownership' and 'management'. One of the reasons injectable Depo has been favored by those who promote it is because they themselves can 'own' and 'manage' it. Women just go to the health facility every three months. There may be a sense in which Depo is more 'female controlled' than male condoms, for example. But if women can't control men's use of condoms, injectable Depo Provera may well be the last method they should consider using; after all, you would be failing to follow WHO's advice if you used Depo even though your sexual partner refused to use a condom.
Both AIDS-Free World and PPFA seem to recognize that healthcare conditions are not particularly good in some countries. So why not warn people that they may be exposed to HIV and other diseases through their use of these facilities? If people don't recognize the risks they will not be able to avoid them. Whatever about the dangers of hormonal contraceptives per se, injections and other skin piercing practices are highly efficient modes of HIV infection, far more efficient than heterosexual sex. When healthcare conditions are poor, injections are best avoided. Low levels of maternal health and high maternal mortality are not primarily a matter of birth control method; women need safe healthcare and appropriate birth control methods, not whatever commodity NGOs like PPFA happen to be pushing.