The Global Implications of Putting Population Control Over HIV Prevention

In 2011, the New York Times published a front-page article on research that claimed the hormonal contraceptive injection Depo Provera doubled the risk of transmission and acquisition of HIV. The largest study of its kind conducted by Renee Heffron in Africa found that HIV-negative women being given the shot every three months had twice the risk of contracting the virus and that HIV-positive women were twice as likely to pass the virus on to their partners.

This year the World Health Organization made a statement that the research was not broad or deep enough to be conclusive and recommended Depo Provera continue to be administered with no restrictions, in addition to encouragement of the use of condoms. In response, the headlines of national newspapers reported falsely that there was no concern of a link between the method and HIV. The research reported on by the New York Times is backed by ten years of prior research that suggests the same conclusion: Depo Provera increases significantly the development of HIV in communities. So why is the desire to exert population control being put before the health of people in developing countries? Malthusian theory -- the idea that mankind is fated for catastrophe due to population overshooting resources -- is used to justify this position.

Currently in Sub-Saharan Africa where HIV is most rampant, the contraceptive injection is the most widely used method of birth control, with 12 million women on Depo, and oral contraceptives used by 11 million. The contraceptive's effectiveness, invisibility, lack of daily routine and its requirement of only four visits to a medical professional per year have made it the most widely distributed birth control method.

This July, the Bill and Melinda Gates Foundation presented its strategy to get the Depo Provera shot to millions more women in Africa and South Asia. In her recent TED talk Melinda Gates discussed how "popular" the injection is with African women. The Gates Foundation is partnered with the pharmaceutical company Pfizer, the maker of Depo Provera, in this mission.

The company has produced Uniject, a shot that can go under the skin instead of intramuscularly and so does not require a doctor for its use and can be administered by the woman herself. Billions of dollars have been poured into increasing uptake of this particular method in developing countries.

Betsy Hartmann, writer of "Reproductive Rights and Wrongs: The Global Politics of Population Control" and director of the Population and Development Program and professor of Development Studies at Hampshire College wrote about her opposition to this Depo Provera strategy in a piece for Truth Out.

"For over a decade now studies have pointed to a possible link between Depo Provera use and increased risk of acquiring HIV. Precaution would dictate that Depo be phased out in populations at high risk of AIDS, but instead the WHO has thrown caution to the wind," wrote Hartmann. "At a time when Depo Provera should be under intense scrutiny, the Gates initiative is vigorously promoting it, along with a Chinese hormonal implant, as the two main contraceptive technical fixes for sub-Saharan Africa and South Asia."

Hartmann has written on the incentives received by clinics in Africa that provide the most women with the recommended forms of birth control. There have been reports of direct coercion of women via bribes and threats. Those women looking for birth control are rarely provided with a range of choices or given all of the information on benefits and side effects. If women are to inject themselves with Depo, they will receive only the information provided by whatever written instructions arrive with the Uniject devices. Pregnancy prevention at any and all cost to women is the driving force behind the plans.

"It's shocking how little critical concern there is, especially amongst women's health activists," said Hartmann. "Unfortunately, the vacuum is being filled by anti-abortion groups who are taking on the role of investigators highlighting the problems with Depo."

Depo Provera’s Host of Side Effects

Aside from the risk of HIV transmission and acquisition, Depo Provera carries a myriad of reported side effects that for women in developed countries are serious enough, but for women in developing countries that are already struggling to maintain good health could hold even worse risks.

Irreversible bone mineral density loss is a serious enough risk to warrant a FDA black box warning on the insert. Laura Wershler and Dr. Susan Rako have written on the impact of suppressing the menstrual cycle via endocrine disrupting drugs such as the injection citing the negative effect on the metabolic system and immune system.

Women using the shot have lowered general health with suppressed immunity and decreased ability to take in nutrients from food. The injection can cause consistent bleeding, which would not only cause ill health in women with already poor nutrition, but can cause social problems too in certain areas of Africa where a bleeding woman would be ostracized.

Depression, anxiety, paranoia and loss of libido are frequently experienced. The Depo shot is used as a form of chemical castration for imprisoned sex offenders in several U.S. states. Wershler has also collated evidence to suggest that after stopping use women experience physical and emotional withdrawal symptoms for extended periods of time.

One of original pioneers of the Depo shot is Elsimar M. Coutinho, former director of the human reproduction council of the WHO. He wrote a book titled "Is Menstruation Obsolete?" The work claims, from a historical and social perspective more so than a scientific one, that there are no health risks to suppressing the menstrual cycle via hormonal contraceptives. This book has become the basis of justification for much of the promotion of reversible long-acting methods like the shot and the implant.

In trials in the U.S., the Depo shot has a discontinuation rate of approximately 50 percent after six months with only 23 percent remaining on the method after one year. These side effects are seen to stop women using the method for birth control. Women in Africa and Asia without access to information or alternatives may endure problems for much longer, but at a risk to their overall health and well-being. They may share their experience with others and as such develop a suspicion of all methods provided by the clinics.

In the U.S., African Americans are 13 percent of the population and yet account for more than 49 percent of the AIDS cases. AIDS is the leading cause of death of African-American women between the ages of 25 and 34 and the second leading cause of death for African-American men between the ages of 35 and 44. Moira Brannan wrote for Ms. Magazine on how African American teens are disproportionately provided Depo Provera. One in five African American teens are on the Depo shot, far more than white teens.

Experts Stress Barrier Protection and Microbicides Over Hormones

Nalini Visvanathan highlights in a paper for the Pop Dev publication that research suggests it is young women who are more disposed to be at higher risk of HIV transmission through hormonal contraceptive use.

"Until scientists fully elucidate the association between hormonal contraception and HIV acquisition, progression and transmission, we need integrated services for family planning counseling and HIV counseling so that clients receive comprehensive information about the potential risks of hormonal contraception and the urgency for adopting a dual protection approach," wrote Visvanathan. "To do this there should be vertical integration of family planning and HIV counseling centers and an expansion of educational e?orts to get communities fully informed about the risks and benefits of hormonal contraception."

Integration of HIV prevention and family planning would necessitate the elevation of non-hormonal and barrier methods of contraception. In development currently is the SILCS one-size-fits-all diaphragm that does not require medical assistance. It has shown to be as effective at preventing pregnancy as previous designs of diaphragms that have required individual fitting, although diaphragms do not prevent HIV transmission.

But there is also research underway into microbicides -- vaginal gels that may prevent or lower the risk of the transmission of HIV in women. Tenofovir gel is leading the way, a gel developed from an antiretroviral drug prescribed orally for the HIV-positive.

The WHO statement on Depo presupposes women in developing countries have the ability to negotiate condom use with their partners, therefore funding and research into the development of suitable barrier methods seems to be the next logical step. Barrier methods, when used correctly and with spermicide, can be as effective as a hormonal method and cause far less side effects. There is a need for the development of spermicides that are not irritating and destructive to the vaginal walls.

The Gates Foundation is supporting research into non-hormonal and barrier contraceptives. But for now, Depo Provera continues to be the frontline, signature method of the campaign.