Commentary Contraception

Advocates Call for Full Funding of Research on HIV and Contraception

Lillian Mworeko & Emily Bass

For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, a shortage of funding for the ECHO (Evidence for Contraceptive Options and HIV Outcomes) trial is an unacceptable development.

A clinical trial known as Evidence for Contraceptive Options and HIV Outcomes (ECHO)—originally designed to answer important questions about possible connections between risk of HIV infection and the use of non-barrier hormonal contraceptives—now hangs in the balance because of a funding shortfall. For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, this is an unacceptable development.

Women make up more than half of all people living with HIV worldwide, and they continue to bear the burden of new infections. Incidence rates vary by age and country, but remain unacceptably high in the context of comprehensive, state of the art prevention services. (As one example, in the VOICE trial of women’s HIV prevention options, overall incidence was nearly 6 percent.) HIV incidence rates are particularly high in adolescent girls and young women, and globally HIV is the leading cause of death of women of reproductive age. The same women who are most at risk of HIV are also in need of a variety of reliable methods of contraception—a glaringly unmet need in sub-Saharan Africa, where fewer than 20 percent of women use a modern contraceptive method.

For those women in sub-Saharan Africa who do have access to contraception, the majority use a hormonal method (an injectable or the oral contraceptive pill). Of these women, 60 percent use a long-acting injectable such as Depo or, less frequently, NET-EN. This prevalence of these methods does not accurately reflect women’s preference since in many settings, Depo is one of a limited number of options for women—and often the only long-acting, discrete method (versus a daily contraceptive pill). Expanding the range of available choices is another key policy and advocacy priority, in sub-Saharan Africa and around the world, including in the United States.

Contraception not only allows women to determine when and how often they become pregnant, it also saves their lives. Risk of maternal morbidity and mortality—already unacceptably high in many parts of the world—rises even more in the context of unplanned pregnancies. Lack of access to effective contraception is a health and human rights issue that cannot be ignored.

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At the same time, there are persistent questions about whether some contraceptive methods, particularly long-acting injectables like Depo, increase women’s risk of acquiring HIV. These questions arise from observational data. Some studies suggest that Depo does increase risk, while others do not. This is precisely the question that the ECHO trial is designed to answer.

According to the ECHO trial team, which has briefed civil society, it would cost roughly $60 million to conduct the ECHO trial—clearly a minimal investment when compared to the economic, social, and public health costs of HIV and AIDS, unplanned pregnancies, and maternal death and illness across sub-Saharan Africa. In fact, the ECHO trial seeks to answer a question raised 25 years ago: Do contraceptive methods, particularly hormonal contraceptive methods, increase women’s risk of HIV acquisition? The answer to this question is long overdue, and the lack of investment in such research reflects a lack of strategic and financial priority for a critical women’s health and rights question.

In discussing the trial, and other approaches to the current uncertainty, stakeholders have asked why the data are mixed, and whether it’s possible to gain clarity with the information available and/or with basic science studies. The main limitation of all of the existing data on both injectables and pills and potential HIV risk is that they come from observational trials that were not designed to answer the question directly. Confounding factors cannot be controlled for, and many trials rely on women’s self report about the method they were using. There simply aren’t enough women in sub-Saharan Africa using other strategies, like the implant or the intrauterine device, to gather even observational data. The existing information is, therefore, difficult to interpret, and leave unanswered critical questions that affect the lives and health of women who have urgent needs to both space or limit births and to protect themselves from HIV. The ECHO trial is designed to help answer these questions directly for Depo, the implant (Jadelle), and the copper intrauterine device—methods about which there are even less data. It has the potential to provide more definitive, actionable information than basic science research.

The ECHO trial is the type of research we have been waiting for, with great anticipation, since a 2012 World Health Organization (WHO) review of the existing data on hormonal contraceptives and HIV risk. In this review and in an update in July 2014, research is a clear priority. The document states, “WHO strongly supports the need for further research to identify definitive answers to these issues.”

ECHO was proposed to meet this identified need. It is a randomized clinical trial that would look at whether the three options—Depo, Jadelle, and the copper intrauterine device—affect HIV-negative women’s risk of acquiring HIV.

Advocates for HIV-positive women, HIV prevention advocates, and sexual and reproductive health advocates have been following this issue closely. We are united in the conviction that women should be fully informed in their contraceptive choices and that we should not have to choose between HIV prevention and safe and effective contraception. We are also united in the need to broaden the range of contraceptive options available and accessible to all women—in the context of complete data about their risks and benefits.

The concerns related to HIV risk have to be considered in the context of the health risks of pregnancy, particularly unintended pregnancies. Epidemiologists have calculated the new HIV acquisitions that might be attributable to Depo, in the event that it does increase risk, and the rates of maternal deaths and live births that would occur if Depo were to be withdrawn, without an immediately acceptable and accessible replacement. In both instances, the greatest impact on women is in east and southern Africa.

Given the level of maternal death and illness, not to mention other public health outcomes of unintended pregnanciesy, an increase in risk of HIV acquisition by users of Depo must be weighed against the risks associated with unintended pregnancies. But context does not mean conflict—and the urgent need for a mix of effective contraceptive methods does not outweigh the need for clarity about how methods affect women’s risk of HIV acquisition. No one wants to swap illness and death associated with HIV acquisition for pregnancy-related morbidity and mortality.

And, indeed, no one is advocating for Depo to be removed without providing affordable, accessible alternative contraceptives. But the status quo cannot stand because of the challenges ahead. Current WHO guidance on Depo states that “women at high risk of HIV infection should be informed that progestogen-only contraceptives may or may not increase their risk of HIV infection.”

Not only is the message confusing, but it is also incredibly challenging for those working in public health clinics to communicate. Without the ECHO trial, this confusing message will continue being given to women currently using or initiating Depo—if they receive any message at all. Even as other methods, such as the contraceptive implant, gain popularity in some regions, some women will still only have access to Depo and they will still be told “this might increase your risk; it might not”—unless a trial like ECHO takes place.

Unfortunately, the international funding community has not adequately committed to this research. Even before the current ECHO protocol was put on hold, it had already been scaled back once due to budget concerns. This trial design should be driven by scientific questions and women’s needs, not funding.

We call on the donors to ensure the trial is fully funded without additional budget cuts or delays. We call on funders who have stepped up to date, including the Bill & Melinda Gates Foundation, USAID, the South African government, the South African Medical Research Council, the Wellcome Trust, and the UK Medical Research Council to maintain and/or expand on existing funding commitments. We challenge the U.S. National Institutes of Health and the European & Developing Countries Clinical Trial Partnership to confirm their partnership with and support for this research. And we urge these funders to work together to undertake vigorous advocacy that bridges the HIV and contraceptive research agendas. Each of these organizations have spoken about the need to promote women’s health and now they must invest in doing so. The amount of funding needed is minimal compared to investments in many other HIV prevention trials. These price tags reflect vastly different research questions and infrastructure requirements—however the point remains that this is a relatively small investment to answer a question of enormous importance.

Some funders, scientists, and advocates have raised issues about whether the trial is necessary or feasible. One argument is that the world can go ahead and increase method mix, moving away from Depo and toward other methods, without the ECHO trial. This would mean expanding access to other hormonal methods without any additional information about their relationship to HIV. The question about whether the trial is feasible—whether women will enroll, accept randomization, remain on methods, and so on—is valid, and can only be answered by attempting the trial. ECHO investigators say the research would be implemented with monitoring that would gauge feasibility in real time—allowing the trial to be stopped or altered if it was necessary.

Although concerns about the trial are fair, a $60 million investment in this set of questions is one of the best research investments that could be made in reproductive health and rights in the context of women and HIV today. As women in all our diversity, this advocacy—and the clarity it can engender about our contraceptive choices—is long overdue. Women at risk of HIV deserve to know whether their choice of contraception affects their chances of acquiring HIV. Now is no time to turn back.

News Politics

Anti-Choice Democrats: ‘Open The Big Tent’ for Us

Christine Grimaldi & Ally Boguhn

“Make room for pro-life Democrats and invite pro-life, progressive independents back to the party to focus on the right to parent and ways to help women in crisis or unplanned pregnancies have more choices than abortion,” the group said in a report unveiled to allies at the event, including Democratic National Convention (DNC) delegates and the press.

Democrats for Life of America gathered Wednesday in Philadelphia during the party’s convention to honor Louisiana Gov. John Bel Edwards (D) for his anti-choice viewpoints, and to strategize ways to incorporate their policies into the party.

The group attributed Democratic losses at the state and federal level to the party’s increasing embrace of pro-choice politics. The best way for Democrats to reclaim seats in state houses, governors’ offices, and the U.S. Congress, they charged, is to “open the big tent” to candidates who oppose legal abortion care.

“Make room for pro-life Democrats and invite pro-life, progressive independents back to the party to focus on the right to parent and ways to help women in crisis or unplanned pregnancies have more choices than abortion,” the group said in a report unveiled to allies at the event, including Democratic National Convention (DNC) delegates and the press.

Democrats for Life of America members repeatedly attempted to distance themselves from Republicans, reiterating their support for policies such as Medicaid expansion and paid maternity leave, which they believe could convince people to carry their pregnancies to term.

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Their strategy, however, could have been lifted directly from conservatives’ anti-choice playbook.

The group relies, in part, on data from Marist, a group associated with anti-choice polling, to suggest that many in the party side with them on abortion rights. Executive Director Kristen Day could not explain to Rewire why the group supports a 20-week abortion ban, while Janet Robert, president of the group’s board of directors, trotted out scientifically false claims about fetal pain

Day told Rewire that she is working with pro-choice Democrats, including Sen. Kirsten Gillibrand and Rep. Rosa DeLauro, both from New York, on paid maternity leave. Day said she met with DeLauro the day before the group’s event.

Day identifies with Democrats despite a platform that for the first time embraces the repeal of restrictions for federal funding of abortion care. 

“Those are my people,” she said.

Day claimed to have been “kicked out of the pro-life movement” for supporting the Affordable Care Act. She said Democrats for Life of America is “not opposed to contraception,” though the group filed an amicus brief in U.S. Supreme Court cases on contraception. 

Democrats for Life of America says it has important allies in the U.S. House of Representatives and the U.S. Senate. Sens. Joe Donnelly (IN), Joe Manchin (WV), and Rep. Dan Lipinski (IL), along with former Rep. Bart Stupak (MI), serve on the group’s board of advisors, according to literature distributed at the convention.

Another alleged ally, Sen. Bob Casey (D-PA), came up during Edwards’ speech. Edwards said he had discussed the award, named for Casey’s father, former Pennsylvania Gov. Robert P. Casey, the defendant in the landmark Supreme Court decision, Planned Parenthood v. Casey, which opened up a flood of state-level abortions restrictions as long as those anti-choice policies did not represent an “undue burden.”

“Last night I happened to have the opportunity to speak to Sen. Bob Casey, and I told him … I was in Philadelphia, receiving this award today named after his father,” Edwards said.

The Louisiana governor added that though it may not seem it, there are many more anti-choice Democrats like the two of them who aren’t comfortable coming forward about their views.

“I’m telling you there are many more people out there like us than you might imagine,” Edwards said. “But sometimes it’s easier for those folks who feel like we do on these issues to remain silent because they’re not going to  be questioned, and they’re not going to be receiving any criticism.”

During his speech, Edwards touted the way he has put his views as an anti-choice Democrat into practice in his home state. “I am a proud Democrat, and I am also very proudly pro-life,” Edwards told the small gathering.

Citing his support for Medicaid expansion in Louisiana—which went into effect July 1—Edwards claimed he had run on an otherwise “progressive” platform except for when it came to abortion rights, adding that his policies demonstrate that “there is a difference between being anti-abortion and being pro-life.”

Edwards later made clear that he was disappointed with news that Emily’s List President Stephanie Schriock, whose organization works to elect pro-choice women to office, was being considered to fill the position of party chair in light of Rep. Debbie Wasserman Schultz’s resignation.

“It wouldn’t” help elect anti-choice politicians to office, said Edwards when asked about it by a reporter. “I don’t want to be overly critical, I don’t know the person, I just know that the signal that would send to the country—and to Democrats such as myself—would just be another step in the opposite direction of being a big tent party [on abortion].” 

Edwards made no secret of his anti-choice viewpoints during his run for governor in 2015. While on the campaign trail, he released a 30-second ad highlighting his wife’s decision not to terminate her pregnancy after a doctor told the couple their daughter would have spina bifida.

He received a 100 percent rating from anti-choice organization Louisiana Right to Life while running for governor, based off a scorecard asking him questions such as, “Do you support the reversal of Roe v. Wade?”

Though the Democratic Party platform and nominee have voiced the party’s support for abortion rights, Edwards has forged ahead with signing numerous pieces of anti-choice legislation into law, including a ban on the commonly used dilation and evacuation (D and E) procedure, and an extension of the state’s abortion care waiting period from 24 hours to 72 hours.

News Politics

Tim Kaine Changes Position on Federal Funding for Abortion Care

Ally Boguhn

The Obama administration, however, has not signaled support for rolling back the Hyde Amendment's ban on federal funding for abortion care.

Sen. Tim Kaine (D-VA), the Democratic Party’s vice presidential candidate, has promised to stand with nominee Hillary Clinton in opposing the Hyde Amendment, a ban on federal funding for abortion care.

Clinton’s campaign manager, Robby Mook, told CNN’s State of the Union Sunday that Kaine “has said that he will stand with Secretary Clinton to defend a woman’s right to choose, to repeal the Hyde amendment,” according to the network’s transcript.

“Voters can be 100 percent confident that Tim Kaine is going to fight to protect a woman’s right to choose,” Mook said.

The commitment to opposing Hyde was “made privately,” Clinton spokesperson Jesse Ferguson later clarified to CNN’s Edward Mejia Davis.

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Kaine’s stated support for ending the federal ban on abortion funding is a reversal on the issue for the Virginia senator. Kaine this month told the Weekly Standard  that he had not “been informed” that this year’s Democratic Party platform included a call for repealing the Hyde Amendment. He said he has “traditionally been a supporter of the Hyde amendment.”

Repealing the Hyde Amendment has been an issue for Democrats on the campaign trail this election cycle. Speaking at a campaign rally in New Hampshire in January, Clinton denounced Hyde, noting that it made it “harder for low-income women to exercise their full rights.”

Clinton called the federal ban on abortion funding “hard to justify” when asked about it later that month at the Brown and Black Presidential Forum, adding that “the full range of reproductive health rights that women should have includes access to safe and legal abortion.”

Clinton’s campaign told Rewire during her 2008 run for president that she “does not support the Hyde amendment.”

The Democratic Party on Monday codified its commitment to opposing Hyde, as well as the Helms Amendment’s ban on foreign assistance funds being used for abortion care. 

The Obama administration, however, has not signaled support for rolling back Hyde’s ban on federal funding for abortion care.

When asked about whether the president supported the repeal of Hyde during the White House press briefing Tuesday, Deputy Press Secretary Eric Schultz said he did not “believe we have changed our position on the Hyde Amendment.”

When pushed by a reporter to address if the administration is “not necessarily on board” with the Democratic platform’s call to repeal Hyde, Schultz said that the administration has “a longstanding view on this and I don’t have any changes in our position to announce today.”