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Contraception and prevention of HIV transmission: a potential conflict of public health principles
  1. Lisa B Haddad1,
  2. Sean Philpott-Jones2,
  3. Toby Schonfeld3,*
  1. 1Assistant Professor, Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, GA, USA
  2. 2Director, Center for Bioethics and Clinical Leadership, The Bioethics Program, Union Graduate College, Mount Sinai School of Medicine, New York, NY, USA
  3. 3Director, Master of Arts in Bioethics, Center for Ethics and Professor, School of Medicine, Emory University, Atlanta, GA, USA
  1. Correspondence to Dr Lisa B Haddad, Emory University School of Medicine, Department of Gynecology and Obstetrics, 49 Jesse Hill Jr Drive, Atlanta, GA 30303, USA; lbhadda{at}emory.edu

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Overview

Recent research suggests that HIV transmission and acquisition may increase with the use of some forms of hormonal contraception. Current data are not conclusive, but should it be determined that use of hormonal contraception can promote HIV spread, one consequence will be a competition between two important public health goals. The laudable goals of preventing HIV transmission and reducing rates of unintended pregnancy, particularly important in developing regions of the world like sub-Saharan Africa, will be in conflict. In this article we examine the different challenges raised by these competing goals and explore the broad range of factors at play using the six-part ethical framework developed by Baum et al. for managing ethical challenges in public health practice. We conclude that given the array of considerations required prior to restriction of hormonal contraceptive methods in resource-poor regions of the world, such restrictions should not be imposed, even if it were proven that some of these methods could exacerbate the spread of HIV among at-risk individuals.

Background

Of the estimated 33 million people living with HIV/AIDS worldwide, 16 million are women, and infection rates are increasing in women even as the epidemic stabilises globally.1 The countries with the highest rates of HIV also have low rates of contraception use and thus high rates of unintended pregnancy.2 Improving family planning services in these countries has been a key public health goal, as preventing unintended pregnancy reduces maternal and child mortality, reduces rates of mother-to-child (vertical) transmission of HIV, reduces poverty and improves educational and gender equity.

Until recently, researchers and policymakers have often overlooked the impact of pregnancy on HIV prevention research and practice. Due to a number of biological and socioeconomic factors, current HIV prevention tools – abstinence, male or female condoms, male circumcision and monogamy – are inaccessible …

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