When the Evidence Is Not Enough: Hormonal Contraception and HIV Webinar Recap

Uncertainty remains around hormonal contraception and its link to HIV acquisition.

Countries continue to grapple with how they can or should convey this uncertainty to their communities. As a part of this international discussion, the Health Communication Capacity Collaborative (HC3) hosted a webinar focusing on the Strategic Communication Framework for Hormonal Contraceptive Methods and Potential HIV-Related Risks. The webinar introduced the framework, provided discussion around the adaptation process in Malawi and Swaziland, and included the perspective of women living with HIV related to this important issue. The webinar consisted of five speakers, including myself, and was moderated by Nithya Mani, Division Chief, Implementation Support, Office of HIV/AIDS, United States Agency for International Development (USAID).

Presenter Dr. James Kiarie, from the World Health Organization (WHO) began the webinar by highlighting WHO guidelines and Medical Eligibility Criteria (MEC) for hormonal contraception for women at high risk or living with HIV. He discussed that some studies suggest women using progestogen only injectables may be at increased risk of HIV acquisition, while other studies have not found this association. Given the potential risk, it is WHO’s position that women at high risk of HIV should be informed that progestogen only injectables may increase their risk of HIV acquisition. It is because of this WHO statement that the Strategic Communication Framework was initially developed, enabling countries to develop communication strategies to address the issue and inform women of this potential risk, as well as helping them make an informed decision about their contraception use. Dr. Kiarie acknowledged uncertainty is difficult to communicate and health workers often need further training in communication skills, but the importance of disseminating this information remains. During the last meeting WHO held on this issue in December of 2015, there was strong support for the development of communication strategies where the messaging is critical to success and clarity.

I followed Dr. Kiarie with an overview of the Strategic Communication Framework contents, which guides countries through the creation of their own communication strategy by providing a four step “roadmap”:

Step 1: Understand the evidence base on hormonal contraception and HIV;

Step 2: Contextualize the evidence within the country (look into HIV prevalence, contraceptive usage rates and other sexual and reproductive health issues in the country);

Step 3: Adapt the Strategic Communication Framework to a country-specific strategy;

Step 4: Prepare for implementation.

The Strategic Communication Framework begins by walking users through the different parts of a communication strategy, provides guiding questions to conduct a situation analysis and then moves into audience segmentation. The Framework provides five primary audiences (sexually active women of unknown status or who are HIV negative, sexually active women living with HIV, health system managers, clinical providers and non-clinical service providers) and three secondary audiences (male partners, civil society stakeholders and media/journalists) in which to target and develop messages. For each audience, an example “audience profile” is provided along with communication objectives, a positioning statement, key messages, a strategic approach and illustrative activities that can be adapted. The Framework also provides a selection of illustrative indicators to measure the communication strategy’s success.

Following my presentation on the Framework there were presentations from Malawi and Swaziland, who have both adapted the Framework to develop a country-specific communication strategy. Triza Hara, Deputy Chief of Party for SSDI Malawi, presented the Malawian experience. Through strong leadership from the Malawi Ministry of Health, a communication strategy was created and is currently awaiting final approval from senior management. Materials were developed based on the strategy, including a brochure for women, a Frequently Asked Questions document for providers and flipchart pages to use with patients. Lindiwe Malaza from the Swaziland Ministry of Health presented work her country has done to adapt the Framework. They have an approved communication strategy focusing on dual protection and adapted materials to reinforce this. They are now in the process of printing a provider brochure and chart featuring the benefits of each contraception method available in Swaziland and the importance of using it with a condom.

Emily Bass from the International Community of Women Living with HIV concluded the webinar with a presentation on the view of HIV advocates. The issue of hormonal contraception and HIV acquisition has raised concern among advocates for multiple reasons: the current data leaves many unanswered questions and in some countries – especially in sub-Saharan Africa – women have a high lifetime risk of acquiring HIV, and in many of these countries progestogen only contraceptives are a high proportion of all methods used. Often, women are not provided with accurate or up-to-date information when making their decision about contraception options. Advocates have widely distributed the WHO technical statement in regards to the MEC on hormonal contraception, and have issued a statement asking WHO to take the lead in setting next steps regarding to hormonal contraception. Advocates continue to push this issue and have created an online platform to discuss and keep each other updated. They also continue to engage in webinars and the ECHO trial which is just beginning.

Emily also brought up that to date, the coordinated actions taken by the International Community of Women Living with HIV Eastern Africa and the Global Advocacy for HIV Prevention regarding this issue include a Pan African Women’s meeting in February of 2012, where the evidence was reviewed and discussed and recommendations were presented to WHO. The Strategic Communication Framework acts directly on one of the recommendations made at the 2012 Pan African Women meeting calling for a clear communication strategy for women, service providers, policy makers and other stakeholders to share the risks and benefits of this issue and what data exists. The presentation concluded with the recommendation that WHO and UNAIDS ensure that Advocates and women are involved in the on-going discussions, communication strategies and decisions about next steps on this issue.

A recording of the webinar as well the presentations can be accessed here.

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