Expert Notes 'Alarming Data' Connecting Hormonal Contraception and HIV Transmission

An interview with Dr. Timothy Flanigan, an authority on HIV/AIDS prevention and treatment.

The Bill and Melinda Gates Foundation held a July 11 summit designed to raise an estimated $4 billion to promote contraception in the developing world.

The Gates campaign comes amid new research suggesting that use of hormonal contraception doubles the risk of both transmission and acquisition of HIV in regions like sub-Saharan Africa. Register senior editor Joan Frawley Desmond turned to HIV/AIDS expert Dr. Timothy Flanigan to explain how this research is likely to transform family-planning campaigns.

Flanigan offers insight into how big global health organizations and foundations approach these issues and how they perceive natural family planning. He also answers a few burning questions: Why is pregnancy presented as a dangerous medical condition? Are there new opportunities to promote natural family planning?

Flanigan is a professor of medicine and infectious diseases at Brown University Medical School and practices at Miriam and Rhode Island Hospitals in Providence, R.I. He has been caring for patients with HIV/AIDS for 25 years, and his research on HIV prevention and treatment has been funded by the National Institutes of Health and the Centers for Disease Control and Prevention. He is the father of five and is enrolled in the deacon program for the Providence Diocese.


You’re an authority on HIV/AIDS who has published hundreds of peer-reviewed studies on HIV/AIDS transmission, participated in global conferences and cared for patients with HIV/AIDS near your home in Rhode Island. What are your concerns about the promotion of contraception in Africa and other parts of the developing world?

New research raises serious concerns about whether hormonal contraception — Depo-Provera and oral contraception pills (OCT) — actually doubles the risk of a woman acquiring HIV if she is exposed. And if an HIV positive woman is on oral contraception, it may double the risk that she can transmit it to her partner.


How was the study conducted?

It was a very large study that involved seven African countries. The researchers looked at couples with one HIV-positive spouse and one HIV-negative spouse.

The study was designed to look at whether suppressing the herpes virus would decrease HIV transmission. They enrolled well over 3,000 couples, mostly from sub-Saharan Africa.

Since hormonal contraceptives, especially Depo-Provera, are widely promoted in sub-Saharan Africa, the study provided an opportunity to see whether oral or injectable contraception would increase or decrease the risk of HIV transmission. What they found was very concerning: The hormonal contraception widely touted and promoted doubles the risk of acquisition and transmission of HIV.

The study was very well done, coordinated by the University of Washington in Seattle. The results are alarming and have significant implications for programs that actively promote the use of hormonal contraception.

The study was presented at the International AIDS Society in Rome last summer and was then published in the October issue of Lancet Infectious Diseases, a premier medical journal.

Since the study was published, the National Institutes of Health (NIH), UNAIDS and the World Health Organization (WHO) have convened panels to review the research about how hormonal contraception increases the risk of heterosexual transmission of HIV.


How will the study’s conclusion likely affect large-scale contraception promotion campaigns like the Gates Foundation’s global program?

There is great concern, because hormonal contraception has been seen as the solution for reproductive-health challenges. This alarming data must lead to a reconsideration of the whole reproductive-health agenda, which has relied on the promotion of hormonal contraception.


How long will it take for this research to result in a broader reassessment of the present strategy?

The data have been rapidly disseminated, but the change in practice takes a long time. The field is confused, in disarray and uncertain about how to proceed.


In the broader family-planning field, there has been an attempt to assert that post-conception drugs designed to prevent pregnancy do not work as abortifacients.

There is a whole separate issue going on in this field: An effort is being made to say that post-conception contraception does not work as an abortifacient. The reason for this aggressive effort is to normalize it.

This is on the cutting edge of the HHS [Health and Human Services] mandate controversy. People are sympathetic to the Catholic Church’s position that it should be able to deny coverage for abortifacients in its employee health plan. When you poll Americans on this issue, you get very different responses if you explain that abortifacients are covered.


Many who oppose artificial contraception on moral or health grounds wonder why global public-health organizations and foundations focus so heavily on contraception promotion and provide fewer resources for other health needs. Is this a fair assessment?

There is an underlying philosophy that the root of almost all problems is too many people and that the way to solve these problems is through population control. That philosophy promotes contraception as the centerpiece of its effort.

Authentic development should not rely on contraception, but on economic, social and community development. When that takes place, families plan their children, and population decreases at a level consistent with improved development.

The other problem with this approach is that women and families want children. Recently, I read an article that reported that women on contraception were still getting pregnant, and they needed to be taught to take their birth-control pills. But one reason they don’t take their birth-control pills is because they desire children.


Why are experts in the field so unwilling to consider natural family planning?

Natural family planning (NFP) is wrongly associated with the “rhythm method” promoted many decades ago, an approach that is not effective. NFP has evolved, and today it relies on excellent science and is used by couples to space children and to enhance fertility when a woman wants to be pregnant.

Second, many in the field assume that it can only be used or understood by individuals who have advanced education.

That is not the case. But NFP does require that a woman develops an understanding of her cycle and that a couple together make decisions regarding their sexual relations during the appropriate time in the cycle, as interpreted by the NFP program they use. If the couple is not committed, it doesn’t work.

NFP is relatively complicated and isn’t easy to “dispense.” It’s easier to give a shot once a month than to take the time to educate and then discuss a woman’s questions about her cycle.

Finally, public-health organizations want a family-planning approach that can be adopted by women in vulnerable, abusive circumstances, where sexual relationships are harmful or exploitative, such as commercial sex workers and prostitutes. In that context, the spousal consultation that makes NFP a gift for married couples isn’t possible.


So because NFP is more of a challenge in non-marital relationships, it is ignored by global health programs. Sounds like they have adopted a one-size-fits-all approach.

Yes, that is true.

But there are programs being tested in resource-limited areas. For example, the World Youth Alliance is working throughout the island of St. Lucia to develop a knowledge-based reproductive-health program.  There, FEMM or “Fertility, Education and Medical Management” is doing very promising work. It’s an example of the promotion of new forms of reproductive health in an atypical setting. It is getting a lot of positive response from the women and teenagers of St. Lucia, along with the Ministry of Health.


Are you suggesting that educating people about NFP, along with other promising reproductive-health programs, is still a work in progress?

It’s always a work in progress, because it’s an intimate, complex issue; and that’s true whenever you are doing work that involves human relationships. No reproductive-health program can be applied in all circumstances, but natural family planning is a beautiful gift that should be promoted. And now that we know hormonal contraceptives carry serious risks, a more holistic approach that includes natural family planning may get consideration.


Many pro-life activists view the term “reproductive rights” with suspicion because it is often linked to an abortion-rights agenda.

Reproductive health should be a top priority. And “reproductive rights” should mean that a woman deserves the best health care possible for her, her family and her children.

But reproductive rights have been hijacked. The term now emphasizes the need for “safe abortion.” An “unsafe” abortion takes the life of a child and risks the life of the mother as well. But the answer is not to promote safe abortion, but to understand and support women so that abortion is unthinkable.


A new study funded by the Gates Foundation concluded that effective contraception could save the lives of the “358,000 women  ... [who] die each year because of complications related to pregnancy and childbirth.” Clearly, the Gates Foundation is basing its campaign goals on this study. If you had a chance to advise Melinda Gates, what would you tell her?

Pregnancy can be an enormous challenge to women’s health, and they can develop life-threatening problems. In the developing world, you address the risks associated with pregnancy by providing trained health-care providers such as midwives and providing access to Caesarean section for extended labor.

It’s important to understand that the risk of pregnancy doesn’t mean that women don’t want children. Look at China: Look at what challenges women will overcome to have their children.

The Gates Foundation has been extraordinarily generous, but the idea that the promotion of oral contraception is the No. 1 answer to maternal health needs is misplaced.