How many factual errors can you make in a single press statement? Yesterday on the Huffington Post, the Planned Parenthood Federation of America (PPFA) heralded "another victory for women's health" following recent meetings at the World Health Organization (WHO). The world health body convened experts to discuss concerns about hormonal contraceptives and HIV, and to answer to the question: Do women who use hormonal contraceptives face higher risks of HIV acquisition and transmission? PPFA claims that the answer was "a resounding no." That's not true.
The real answer from WHO's experts was: WE DON'T KNOW. They could not draw conclusions from the available research: some studies found higher rates of HIV among women who use hormonal contraceptives, and others did not. Because the findings are inconclusive, and because global experts remain concerned - especially about injectable contraceptives, the most popular method used in sub-Saharan Africa - WHO strongly advises that women who use injectable contraceptives such as Depo Provera (the best-selling injectable by far) should also use condoms. (See the WHO Technical Statement.)
PPFA claims that the experts reviewed one study. Wrong. The experts reviewed all the best scientific research available. They found the data difficult to interpret, and declared that more research is essential.
PPFA claims that the WHO meeting focused on HIV-positive women's risks of transmitting the virus to their sex partners. Wrong again. Most of the data available, and most of the data reviewed at WHO's expert meeting, focused on women who are not HIV-positive, and on the question of whether injectable contraceptives put them at increased risk of acquiring HIV.
PPFA calls it a victory for women that WHO did not have enough data to change its rating of 1 on a scale that weighs data from 1 to 4, with 4 meaning "do not use this method." That simply means that at this point, WHO is equally uncertain about whether injectable hormonal contraceptives are entirely safe, or shouldn't be used. They issued a recommendation that stresses their uncertainty: "A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also use condoms and other preventive measures."
PPFA's statement refers repeatedly to one study, but does not cite it or explain its findings. The Partners in Prevention study was conducted in Africa, and enrolled 3790 heterosexual HIV-discordant couples (meaning just one person in each couple was HIV-positive). At the end of the study, researchers found that there had been twice as many new HIV infections among women who had used injectable hormonal contraceptives as among those who hadn't, as well as twice as many new HIV infections among the male partners of injectable contraceptive users (Heffron R, et al, for the Partners in Prevention HSV/HIV Transmission Study Team. Lancet Infect Dis. 2012; 12: 19-26).
PPFA says that the study appeared in the Lancet this past November. In fact, it was October. PPFA says that "the findings contradicted the majority of previous research on the same topic," and PPFA refers to it as "this flawed study." Wrong again -- very wrong. The findings added more data to the available body of evidence. These findings -- and all findings on this topic to date -- are derived from 'observational data:' that is, while investigating other HIV-related issues, researchers observed that the hormonal contraceptive users in their study had higher rates of HIV acquisition and transmission. The researchers themselves note that such observational data has 'limitations:' their study wasn't designed to answer questions about whether or not there is a causal link between using injectable hormonal contraceptives and higher risks of acquiring or transmitting HIV. Limitations are not flaws. The Partners in Prevention study's authors, as well as all the experts convened by WHO, agree that this data raises serious concerns, and that it is essential to carry out further research designed specifically to answer these questions.
AIDS-Free World understands the anxiety felt in the U.S. today, as the hard-won rights of women to choose and use safe, effective, affordable contraceptives are under attack by retrograde male political candidates. We share PPFA's fear. But sexual and reproductive rights are not advanced when the facts women need are withheld or misrepresented. Voluntary contraception is only voluntary when women understand the choices they have, and the risks as well as the benefits. Women's rights to informed consent are sacrosanct.
WHO made its own grave error by issuing a misleading press release after its expert meeting. The headlines declared that hormonal contraceptives can "safely" be used by women living with and at risk of HIV, but omitted the critical clarification -- IF they also use a condom each and every time they have sex. When WHO was questioned about why their press release conflicted with the "Technical Statement" issued by their expert group (and only available on WHO's website), a spokesperson explained: "The press release was truly meant to be a very short statement that would lead people to read the Technical Statement. The Technical Statement received much more scrutiny from all those who participated. So really we should go with the Technical Statement."
AIDS-Free World is calling on WHO to retract the misleading press release it issued worldwide, and to replace it with the facts. We are also calling on WHO to make a recommendation that may actually save lives: When a woman receives a hormonal contraceptive injection to protect against pregnancy for three months, she must also be given a three-month supply of condoms. She must be clearly informed that unless she uses the condoms, she may be at increased risk of HIV.
We understand WHO's anxiety: 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? What if, as a result of that choice, many more women in countries with high rates of maternal mortality become pregnant? That may nor may not happen, but it is not WHO's choice to make. Both WHO and PPFA have an obligation to improve women's choices, and to inform women about their options. No global experts or family planning organizations have the right to censor the life-and-death information women need in order to weigh their own risks. Neither WHO nor PPFA has a right to make sexual and reproductive health decisions for women.
PPFA states that women need research, not restrictions. That much is true. But it, too, is only part of the story, and not the most important part. Women need information: complete, uncensored, and factually correct.
We can all agree that we need to be honest with women, AND provide them access to a range of birth control options, AND male and female condoms for HIV prevention. These are things we should have been doing before any of these studies, and they need to continue now.
Since the possibility that injectable hormonal contraceptives may significantly increase a woman's risk of HIV acquisition cannot be ruled out at this point, every woman taking these contraceptives must be informed of the potential risk. She is the only one who knows her particular set risks. What if she has a male partner who refuses to wear condoms and she has few to no options to leave him? If she knows she is at high risk for HIV, then she needs to have the option to decide to switch to a non-injectable form of contraception. Yet, the WHO guidance and the ill-conceived position expressed by PPFA would not provide this information to her.
I really appreciate your response, Paula.