Birth (out of) control: Is SA’s top contraceptive putting women at risk?
Policymakers are worried as evidence mounts that the three-monthly jab leads to increased HIV and TB risk
Is it better to have an unwanted pregnancy, complications in pregnancy or an increased risk of contracting HIV and tuberculosis?
This is the question South African policymakers and birth control experts around the world are asking as evidence mounts against the most popular contraceptive in sub-Saharan Africa.
The Depo Provera, a three-monthly contraceptive injection with the synthetic hormone Depo-Medroxyprogesterone (DMPA), has long been suspected as increasing the risk of HIV.
One major study suggests the risk could increase by 40%, but other studies suggest there is no risk.
UCT researchers have now shown the active ingredients in the Depo injection stops the immune system from fighting TB, the country’s biggest killer.
However, scientists have cautioned that this was a study of cells in a laboratory and not in people.
The Depo Provera DPMA injection is popular because it is taken every three months, can be used secretly and requires fewer visits to a clinic to access contraception than other options. As a result, 16.5 million women in sub-Saharan Africa use it.
In their study, UCT researchers recruited HIV-negative women, took their blood and extracted the cells that TB infects. They then put the DMPA hormone in some of the cells and analysed what happened.
UCT Lung Institute head Prof Keertan Dheda explained they learned the synthetic hormone used in the three-month injection was “subverting the body’s resistance to TB”.
Essentially, it stops the body fighting TB.
Lead researcher in the study, UCT’s Michele Tomasicchio, called on the government to switch from Depo Provera to NET EN, a contraceptive injection given every two months, which does not appear to increase HIV and TB risk in lab studies.
He said the government needed to change the contraceptives offered.
“My ultimate aim is to make sure that women are aware of the dangers of using [Depo-Provera],” Tomasicchio said.
“On average, injectables are the contraceptive of choice in 25% of cases. However, in rural KwaZulu-Natal, it is used in up to 85% of clinics.”
But it’s not that simple.
The NET EN injection is a lot more expensive, and is frequently out of stock.
University of KwaZulu-Natal pharmacologist Andy Gray said there was only one global supplier of the NET EN injection, leaving the government with no alternatives when stock is low.
Gray said: “Government has managed to get hold of NET EN lately, but the problems are the [low] quantities they can get.”
The great conundrum about how risky the injection is will partly be answered in July when the ECHO trial releases results on the link between the DPMA injection and HIV.
The trial recruited 7,800 women in SA, Kenya and Zimbabwe to use the DPMA injection or the three-year-long acting implant or the non-hormonal intrauterine device.
It will see if more of the women on the DPMA injection get HIV.
SA’s Prof Helen Rees, the head of the Wits Reproductive Health and HIV Institute, is leading the study, and says it will only give answers about HIV risk, not TB risk.
She also cautioned the TB study was a lab study, not a “slamdunk answer”.
She said fundraising for the $50m ECHO study had been a “labour of love” and took her and others years.
“It was extremely difficult to get fundraising. But Bill and Melinda Gates and SA government and Medical Research Council made it available.”
It hopes to answer the HIV risk question “once and for all”.
The World Health Organisation is planning to give guidance on family planning based on the ECHO results.
Rees said: “Big family planning agencies are concerned that in the event the ECHO trial does show something [a significant risk] then they need to decide what to do on a country by country basis.
“For the past year, there have been intensive meetings with global agencies involved in family planning doing scenario planning,” she said.
The experts will weigh up an increase in maternal mortality from no contraceptives, an increase in illegal abortions and also the possible deaths from HIV.
One study in the journal Global Health: Science and Practice indicated more women in Africa “would die without the three-month injection than from HIV – even if using it increased risk of HIV by 40%”.
It found the “loss of life due to pregnancy complications and unsafe abortions would far outweigh the number of HIV infections prevented”.
“The bottom line is we need to have more contraceptives more widely available to give women wider choices,” said Rees.
Gray added: “It is a complicated message. If it is a small increase in HIV will it lead to a change in practice?
“Not everyone is at risk of HIV. Also, some people have HIV.”
The department of health did not respond to questions.