The New York Times had an interesting article about HIV and artificial birth control.

There seems to be a statistical increase in the risk of getting HIV with the shot:

The most popular contraceptive for women in eastern and southern Africa, a hormone shot given every three months, appears to double the risk the women will become infected with H.I.V., according to a large study published Monday. And when it is used by H.I.V.-positive women, their male partners are twice as likely to become infected than if the women had used no contraception.

This is worrisome, because when I worked in Africa, we provided the shot in our baby clinics as part of our malnutrition prevention program. We had a large number of children who suffered from protein malnutrition, and the way to prevent this was for women to breast feed for two to three years.

The pill used back then was thought to cut down the amount of breast milk, but the “shot” did not, and may have even increased breast milk production. And unlike the pill, the shot was easy to use, and preferred by busy mothers even though at the time we had “pill ladies” in most of the larger villages.

Since usually when moms are breast feeding they don’t get periods, the main side effect of the shot, no bleeding, was not a problem. And the weight gain associated with the shot in some women was an advantage, not a problem.

There is another little factoid that few mention. We worked in rural areas, where tribal customs were still strong. That meant no intercourse during pregnancy and breast feeding, because when mom got pregnant she stopped breast feeding or lost her breast milk and the weaned baby often died of malnutrition.

However, many of the husbands worked away from home, and no longer were satisfied to go along with the old fashioned customs of abstinence/other forms of sexual expression, nor were they rich enough for the third alternative, polygamy.

Hence we had a lot of malnourished children, and using the shot to space pregnancies was a blessing for our women.

The question is why does the shot increase the rate of HIV transmission in both the women and the men? Is it because condoms are not used?

Well, the dirty little secret is that condoms don’t work well in South Africa: they are of poor quality and often break, the man objects to using them, and they are expensive.  One study showed encouraging condoms didn’t cut the rate of new HIV cases very much. That doesn’t mean that condoms for HIV positive folks should be banned, just from a public health standpoint condoms doesn’t work as well as other prevention methods, such as male circumcision.

But the reason male circumcision works comes down to cleanliness and fewer minor irritations that let the HIV virus enter.

This suggests a possible explanation for the HIV enigma.

It is well known that vaginal drying agents used in some cultures increase the rate of HIV transmission. This makes some of us think that the vaginal dryness from the high progesterone shots might increase these minor irritations and be one reason behind the increased transmission rate.

This all leads to a dilemma. Stop the shot, and a lot of women will have unwanted pregnancies (and some will die from legal or illegal abortions) and a lot of babies will die of malnutrition related disease because mom will stop breast feeding too early. And pregnancy, with it’s increase in irritations and wetness, also has an associated increased risk of HIV transmission.

So what does one do?

Dr. Ludo Lavreys, an epidemiologist who led one of the first studies to link injectable contraceptives to increased H.I.V. risk, said intrauterine devices, implants and other methods should be explored and expanded. “Before you stop” recommending injectables, he said, “you have to offer them something else.”

So, does this mean a switch to the pill? Maybe or maybe not. There is no good data on the pill’s effect on HIV because it’s not used as often. Since the more modern pills also have a high progesterone profile, one suspects it too may increase the risk. A similar problem can be found in the very long lasting “implants”.

So what about the IUD? One insertion, and voila, no babies for five years.

Except that you might bleed heavily (a problem with women who are not well nourished to begin with) and frequent spotting. This last is only an annoyance in the West, but one has to remember the tribal and religious taboos against intercourse with menstruating women could be a real problem. True, the more expensive hormone type IUD’s are better for this, but they are also much more expensive. You also have the risk of a minor STD turning into full blown Pelvic Inflammatory disease, resulting in hospitalization and infertility. Finally, there is the problem of training personnel to place them properly. Put them in carelessly, and you could end up with a uterine perforation needing emergency surgery.

No, I don’t have an answer.

Yet one might try to work with tribal customs to encourage the “old fashioned” ways of behavior.  Marital Faithfulness, encouraging women to live with their husbands instead of staying home while he works in the cities or mines, polygamy or mistresses, and non genital sexual expression were common in the past, and have worked in some countries to lower the rate of new infections.

The real question that was not brought up in the article is: Does the problem of the birth control shot and HIV mean we doctors should avoid the birth control shot in the US?

The dirty little secret is that the real reason for the drop in the rate of teenaged pregnancies is not just more abstinence but because we docs tend to give the shot to our high risk teenagers. (If I had a “mature” teen with a steady boyfriend, she could get the pill. The others got the birth control shot, because the pregnancy rate on the pill is high due to forgetfulness).

Since the HIV rate is low in the US, I don’t think this would change my mind, but it makes me wonder if we should be using it in areas with high rates of HIV in women due to bisexual men and IV drug abuse in their partners.

Alas, like most of life, there are no easy answers to any of this.

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Nancy Reyes is a retired physician living in the rural Philippines. She has worked in Africa and in the rural USA.

A version of the above was cross posted at her HeyDoc Xanga blog.

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