Contraception is integral to HIV treatment, say US aid agency directors

In an implied rebuke to their own government’s policy on restricting funding to family planning organisations because they might provide abortion, two Directors of the Bureau for Global Health in the US Agency for International Development (USAID) write in The Lancet journal that “ensuring that contraception is available to women on antiretrovirals is crucial, not only to the well-being of women and children, but also as a potent instrument to combat AIDS.”

The editorial by James Shelton and Anne Peterson accompanies one signed by over 140 AIDS prevention experts calling for an end to ideological divisions in HIV prevention policy and calling for an integrated approach.

Shelton and Peterson, pointing out that women form 53% of the HIV infected population in Africa, argue that effective contraception provides “major benefits for women by preventing pregnancy-related morbidity…and for children by allowing their parents to space births.

“Women with advanced HIV disease have extraordinary life stresses that can make the additional burden of an unwanted pregnancy even more onerous,” they add.

While acknowledging that some women on HAART may wish to get pregnant because a child symbolises hope for long-term survival, Shelton and Peterson say: “limited evidence suggests that desire for contraception in HIV positive women is high.”

They reference a poster from this year’s World AIDS Conference in Bangkok from a provider of family planning services to women with HIV in Haiti. This programme saw an increase in the use of family planning measures in all women from 6% to 20%, but in HIV positive women to 75% (Deschamps 2004).

Shelton and Peterson cite four other reasons to provide HIV positive women with contraception:

• One of the antiretrovirals on the WHO list of four recommended first-line HAART regimes – efavirenz – has been implicated in birth defects and cannot be used during pregnancy.
• HAART may cause other adverse events such as mitochondrial damage in the infant, low birth weight, and premature birth.
• Combining family planning and HIV treatment services maximises the number of entry points available to women with HIV. The authors say: “An entry point that provides a robust range of services (such as family planning or other maternal and child health services)…can help overcome the stigma related to AIDS…providing more than one service can also support drug adherence and follow-up.”

While stressing that their views do not necessarily reflect those of USAID, Shelton and Peterson’s comments will inevitably be viewed as a rebuke to what has been called the ‘Mexico City’ or ‘Global Gag’ Rule whereby US federal funding is withdrawn from organisations that might provide abortion.

In a recent interview Valeri de Filippo of the Planned Parenthood Federation (PPF) said the effects of the Bush government policy “have been even worse than were expected.”

Five family planning clinics in Kenya had been forced to close and a network of 35 USAID-funded HIV care centres was endangered, and in Zambia an integrated HIV treatment and family planning partnership between the PPF and pro-life groups had had 24% of its funding withdrawn.