For as long as I have been living with HIV — I was diagnosed 19 years ago at the age of 25 — I have been following the science related to HIV and the three-month contraceptive injection, DMPA, also known as Depo Provera.
You’ll hear a lot of people say Depo is Africa’s most popular family planning method. But that’s not actually true. “Popular” implies people choose Depo over other contraceptive options because they like it more.
And, while DMPA is the most widely used long-acting method in many countries, including South Africa, the reality is women are, every day, dependent on clinics where it is the only contraceptive choice on offer. Because women then use Depo, the people who pay for contraception argue that users want it.
But that’s far from the truth.
Instead, the situation exposes another problem: the limited contraceptive choices that are offered to women in Africa.
There are reasons why choice matter.
One is equity: For years, questions have been asked about why DMPA is given to predominantly black and brown women and why other modern methods — whether long-acting and discrete, or short-acting and effective — are not available to everyone who needs them.
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But an even more pressing question — whether Depo Provera increases a woman’s risk of contracting HIV — have been asked for more than two decades.
We now finally have an answer. The Evidence for Contraceptive Options and HIV Outcomes (Echo) study results, which were released on Thursday afternoon, found no substantial difference in HIV risk among women using the three different contraceptive methods — DMPA, the Jadelle Implant and the Copper IUD — that were evaluated.
The trial was conducted in South Africa, Swaziland, Kenya and Zambia over three years.
But the research results scare me — and I worked on the study as an external civil society advisor. I also, independently, and as part of a group of African women leading activism and advocacy on this issue, have spent the past years traveling around South Africa talking to women and girls about contraception and HIV.
My greatest fear is that the results are taken as a sign that nothing needs to change for the women and girls that I spoke and worked with while I was on the road. The Echo results don’t mean that Africa’s limited contraceptive choices are okay, just because the most widely used method doesn’t make it easier to contract HIV.
The rate of new infections among trial participants averaged at close to 4%. The World Health Organisation (WHO) considers a 3% incidence — the rate of new infections per year — as “substantial”. An even higher rate — in this case 3.8% — is therefore an indication of just how vulnerable women of childbearing age are to HIV in the countries where the study took place.
I have always known that Echo needed to prompt action, no matter the results. That’s why I got involved with the trial. When there was a question about whether the study should be done — because some women, some of my comrades, thought we already knew the answer — I stood up for it. I told them we as women deserve high quality evidence so that we can make the best choices for ourselves. That’s why I took to the road to hold dialogues with young women about what their contraceptive needs and HIV prevention concerns looked like.
In one of my road meetings, a young girl spoke about being raped at eight and having her family hide that fact. A young woman talked about how the nurses turned her away when she asked for contraception. You apparently don’t get to have the shot until you’ve had a baby.
In rural areas, young women talked about showing up at clinics and being told that they were getting the shot — meaning Depo Provera — no matter what method they’d come for, or wanted. There were also women who turned up at the clinics and found no contraception at all because of stock outs that derived from government corruption and mismanagement.
We of course didn’t need a trial to expose this dire situation and to tell us that new HIV diagnoses in young women are unacceptably high.
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But, what study results can do — and this I’ve learned from my work as an advocate and activist — is to spur action in powerful ways. The Echo results should be used to mobilise action that directly, systematically and generously addresses the issues that women face every day: programmes that don’t offer choice, but instead reinforce shame; shelves that are empty when they should be stocked with options, with some of the stock outs tied back to corruption and mismanagement of funds at the highest levels; clinics that treat one part of a woman but not her whole self — so that contraception is offered but not HIV prevention, or treatment, or vice versa.
Every east and southern African country should design and implement a plan, with milestones, for expanding contraceptive method mix and uptake and integrating HIV prevention into contraceptive service points.
The upcoming WHO meeting in Zambia prompted by the Echo results should generate a declaration of commitment to this, along with a commitment from funders to put money into this work and revisit the key milestones across the regions and in countries in one year’s time.
But this work must be validated by “ground forces” — women who live and work and love in the places I have visited over the last year. There is nothing for us without us, nothing that can call itself a “woman-centered approach” with a straight face if it does not have women, especially young women, in the lead.
The world has been waiting for the Echo study’s results. Now that they’re out, the women are waiting for a wider range of contraceptive options, and the integration of HIV and sexual and reproductive health programmes for Africa’s women also needs to end.
Yvette Raphael is the program for Advocates for the Prevention of HIV in Africa. She was a member of the global community advisory group for the Echo trial.