The recent study, reporting that injectable contraceptives lead to an increased risk of HIV acquisition, and thus confirming earlier similar studies, puts women in high HIV areas in a reproductive quandary – how can they get pregnant and space and limit their pregnancies without putting themselves at undue risk for HIV? To get pregnant, women must have unprotected sex (assisted reproductive technologies are not available in Africa) and a man’s seminal emissions carries both sperm and HIV. To avoid pregnancy, a woman’s choices are now circumscribed by a new factor beyond those of her body’s’ tolerance for the particular contraceptive (her reaction to contraceptive hormones) and her partner’s willingness to use a male method (condoms or vasectomy)or joint method (withdrawal or periodic abstinence). Depo-Provera, which is widely used in Africa, because it requires no male cooperation, is long lasting and hidden and not dependent on daily usage or usage immediately before intercourse (the diaphragm or a sponge) or after (douching), now apparently leads to a doubling of the risk of infection. Injectables are a double edged sword – they can effectively reduce unintended pregnancy but subject the user to higher risk of HIV and other sexually –transmitted infections (STIs). While the simple answer is that couples, and especially males, should be encouraged to use condoms in addition to a woman-controlled method, this has been difficult to achieve. Women bear more risks of acquiring a sexually transmitted infection than males do. For instance with gonorrhea, a male has a 20% chance of becoming infected during a single act of unprotected intercourse with an infected woman, whereas, in the reverse case, the woman has a 60-80% chance. These risks to the woman include infertility, which puts an end to whatever her reproductive aspirations were (two-thirds of infertility in African women is caused by pelvic inflammatory disease). Unplanned pregnancies, unless terminated by abortion, and in Africa these have serious and dire health consequences, since they are done under unsafe conditions, can contribute to the inability of the mother to care for the children she already has, contributing to their early deaths. The recent push for male circumcision in Africa could compound the problem, as males may become even more unwilling to use condoms. Switching women to other hormonal contraceptives does not appear to be an answer, since the Pill has been found to lead to an increase in Chlamydia and gonorrhea and some studies indicate the same for the Pill and HIV.
So, what is a woman to do? What is society to do? Can we permit contraceptive technologies that allow women to control their reproduction, while simultaneously damaging their ability to reproduce? A woman is at risk, when she wants to become pregnant, from all the prior sexually activity and risk taking of her partner – the more HIV and STI prevalence in the society, the greater her risk, though she may have had nothing to do with it.
We have to remember that sexual and reproductive behavior is not logical, it is bio-logical. Man and women have reproductive goals, which may differ. Each seeks to control their reproduction to have the best chance that their progeny survive to adulthood in good health and, in turn, reproduce, ad infinitum. Men and women may have differing views on the number, sex and spacing of their children. Couples may not be contracepting perfectly and protecting themselves from disease because, separately or together, they either want a pregnancy or prefer the risk of pregnancy, or avoiding pregnancy, to the risk of disease, even a fatal one. The increased provision of HIV therapies in Africa may be leading to more sexual risk taking. Increased testing for STIs and HIV is clearly called for, as is the development of microbicides to kill these viruses. This is a time, until then, for increased investment in condom quality, use and promotion. The recent threats to reduce the US foreign aid budget are, to say the least, counterproductive, and counter-reproductive. Healthy parents giving birth to healthy children is a goal we should all unite behind.