Summary

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This paper reviews some of the key studies within the epidemiological literature that examine the relationship between hormonal contraception (HC) use, primarily depot-medroxyprogesterone acetate (DMPA) injectables, and HIV acquisition. The primary objective is to reassess the findings rather than reinterpret them; consequently, it synthesizes the findings and implications published in peer-reviewed scientific journals, and it discusses their translation into preventive actions. Recent publication of findings raises lingering questions about the role of DMPA injectables, administered once in three months, in the transmission of the virus. The vulnerability of young females to infection in the epidemic, a phenomenon as yet not fully understood, and of the women engaged in sex work makes it critical to re-examine and reassess the findings that “overall” there is no association between hormonal contraception (HC) use and HIV disease acquisition.

Emerging and persistent questions about hormonal contraception’s role in disease progression and infectivity (transmission) have also increased the urgency of gaining a fuller and more nuanced understanding of the potential hormonal contraception-HIV relationship, especially because investigators and commentators have noted limitations of their findings. The 2005 WHO Nairobi statement left the Medical Eligibility Criteria for Contraceptive Use (MEC guidelines) unchanged and appears to have sanctioned the continuing use of these contraceptives by all women living in areas where the HIV epidemic is widespread. The WHO statement has been reinforced by reassurance on the website of Family Health International (FHI), a contraceptive research and service agency, that hormonal contraception does not increase the risk of contracting HIV. In scientific publications, FHI researchers acknowledge that age could be a modifier of the association and more research is needed. The researchers’ recommendations for further research and for hormonal contraceptive users to use dual protection, however, are less likely to be mentioned when the principal finding of no “overall” association is cited.

Through synthesis of the findings from two groups of studies that each followed a cohort of women and measured changes in their status over a period of time, the paper highlights important insights and information that have to be disseminated alongside the finding of “no overall association.” It discusses the shortcomings in the HC-HIV study that precipitated the WHO statement, and their implications, and recommends that revised guidelines are instituted to protect, inform and educate all women and particularly the subgroups of women at risk when using hormonal contraception.