WHO on Depo Provera: Deny, Delay, Deflect, Defer, Duh!

Around a month ago, the New York Times ran an article about research suggesting that injectable forms of popular hormonal contraceptives, such as Depo Provera, may increase the risk of HIV transmission to women, and from HIV positive women to men. Faced with the opportunity to give clear advice to women who receive these injections, WHO, UNAIDS, CDC and others have chosen to dither.

Almost all users of injectable Depo Provera and similar products are Africans in low resource countries. This means that they may also face the added risk of unsafe healthcare, reuse of injecting equipment, failure to follow (or even have) procedures to minimize risk of transmitting diseases, especially blood borne diseases such as hepatitis and HIV.

This is not even the first or most egregious instance of these institutions procrastinating over the same issue. WHO published a document in 2007, which was a response to a consultation that took place in 2005. In fact, serious concerns about the use of hormonal contraceptives in general have been raised for over thirty years, and the 2007 document says "The interaction between hormonal contraception and human immunodeficiency virus (HIV) infection has been a concern since the early days of the AIDS epidemic". So the wait until WHO's 'high-level meeting' in January seems minor in comparison to what seems like institutionalized delaying tactics.

Generally, the evidence available has not been very clear and is sometimes contradictory. However, in 2007 they noted that "The available data have been from observational studies conducted among women at high risk of HIV infection." By this, they mean sex workers and clients of STI (sexually transmitted infection) clinics. But the big question about HIV is why prevalence is so high in some African countries, even among sex workers and people with STIs, when this is not the case outside of some African countries?

In other words, being a sex worker, or even being a highly promiscuous person (and therefore at risk of infection with STIs), are not very closely associated with HIV infection among heterosexuals who don't have other risks, such as intravenous drug use, in non-African countries. Whereas, it is mainly heterosexuals with low levels of 'risky' sexual behaior in high prevalence African countries who are HIV positive. How are they becoming infected?

Unsurprisingly, in all the literature I have seen, there is no mention of the possible role of unsafe healthcare in HIV transmission. This is despite the fact that it is the injectable versions of hormonal contraceptives that are associated with higher HIV prevalence. Also, in recent discussions, there has been no mention of a paper published in 2008 which finds that women using injectable hormonal contraception are more than 10 times more likely to be infected with HIV. That's a lot more than the 2 times more likely mentioned in the New York Times article.

WHO and others are worried that people using injectable hormonal contraceptives will stop using them and may not use any alternative form of contraceptive. That is a legitimate worry. But is it preferable to tell people to continue taking these injections when such a high risk of HIV transmission has not been ruled out? What if their 'high level' meeting in January finds that it is better for people to stop using Depo Provera and similar products? Will they apologize to all the people who have been infected in the previous few months, or even years or decades?

We seem to be following the West's agenda, to promote birth control, to espouse the 'population control' theory of development and poverty reduction. But what about the risk of allowing thousands, perhaps tens of thousands of women, to continue using a dangerous product? And what about the future of reproductive health, even general health programs, if the putative beneficiaries find that we have been lying to them?