Last week, the New York Times published a front-page article with the results of a study on the effect of contraceptives on HIV tranmission in Africa (sorry, I know I am now a week late on this post, but that’s how things work in Burkina Faso – slow). A recent study suggests that injectable contraceptives, which are widely used in Africa, may increase the risk of HIV transmission and infection. The hormones in the shot seem to have some physiological effect on women, although it is unclear what exactly that effect is and why it doubles the risk of transmission and infection. The study followed couples where one partner was already infected with HIV. In couples where the hormone shot was used, the uninfected partner was almost twice as likely to become infected with HIV during the two years of the study compared to those that did not use the shot. (The study also recorded condom use. Couples using another method of family planning are less likely to use a condom. However, researchers controlled for that and were able to eliminate that as a cause for the increased risk in HIV transmission and infection.) Although the study focuses on eastern and southern Africa, it still applies here in Burkina Faso. While the HIV prevalence rate in Burkina Faso (and West Africa) is much lower than it is in eastern and southern Africa, it is still present and people need to learn how they can protect themselves.
Family Planning in Burkina Faso
Family planning is a huge priority health initiative in Burkina Faso. Education and awareness are really important. During pre-natal consultations, I commonly see women coming in on their 9th pregnancy (although usually not all 8 children are still living). However, especially in a place where maternal and post-natal health care are sub-standard and women generally have to do a lot of physical work often very soon after giving birth, multiple pregnancies without appropriate spacing exhaust a woman’s body and increase the risk for complications. In addition, there are economic and social consequences if you do not have the resources to support all your children. The availability of family planning methods greatly increases the health of women as well as the economic and social dynamics of a community. At the end of the day, there are some people in Burkina Faso that understand the importance of family planning. But there are also some that don’t or don’t accept it and don’t want to talk about it. And even among those who understand the importance, it is hard to translate that attitude into practice for many reasons. There are always exceptions (positive deviants as we like to call them in Peace Corps). I have many conversations in the market about family planning. One man called me over, knowing I work with the CSPS (health center), to show me his wife’s health card and confirm her next rendez-vous at the CSPS for the next dose of the hormone shot. He was involved and supportive of his wife. I have others ask me about the different methods available and where they can go to get them. While I haven’t done much work on family planning in my first year, I definitely want to in my second year and these instances of openness are encouraging, especially knowing there will be just as many instances of restraint and resistance.
According to documents in my health center (CSPS), about 13% of women of procreating age use some method of family planning through the CSPS (hormone shots or pills). This number does not include those who use only condoms, which are available at the CSPS as well as the boutique/store and one of the bars in my village. This may seem low, but considering the cultural norms, access, and education, this is actually pretty good, although there is still much room for improvement. The injectable (hormone shot, what the article is talking about) is by far the most common family planning method used. It is a much more realistic form of family planning here. First – it’s once every three months instead of remembering to take a pill every day. Second, for women whose husbands are not supportive, they can do it quietly at the health center, without their husbands knowing. If she has to take the pill, it is much more likely her husband would find out. (Just to be clear, this is obviously not ideal. It is much more ideal for the men to be supportive and implicated in family planning, not just leave it as a burden for the women or even worse, prohibit it. However, we do not live in an ideal world.) It is always important to emphasize that neither of these methods protect against HIV – condoms do. So even if another method of family planning is being used, condoms should still be used as well. But again, in the case of a husband who refuses to use a family planning method, the shot at least does something. There are other methods of family planning, like implants and intrauterine devices, however those are not available at my health center, but in our district hospital.
HIV in Burkina Faso
The HIV prevalence rate in Burkina Faso, like most West African countries, is much lower than other African countries. Here are some HIV prevalence rates from UNAIDS.
Burkina Faso: 1.2%
Ghana: 1.8%
Côte d’Ivoire: 3.4%
Benin: 1.2%
Togo: 3.2%
Niger: 0.8%
Botswana: 24.8%
Kenya: 6.3%
Uganda: 6.5%
South Africa: 17.8%
United States: 0.6%
Education and awareness are really important in Burkina Faso, both to prevent future transmission of HIV and lower the present rate. There are many misconceptions and just total lacking of information about what HIV is and how it is transmitted. In addition, knowledge on prevention is low and there is still a stigma against those living with HIV. While I do not have a rate for just my health region, I would guess (and it seems to be confirmed through my observations at the CSPS), that it might be slightly higher than the national average because we are by a border and the mines in the region attract many young men from my village to live and work there. These factors and the social effects of them make the population more vulnerable to HIV.
Impact of the study
It seems like officials are trying to be cautious – rightfully so. Sending out alarm signals too soon on the number one family planning method could unnecessarily place women in increased risk. While it is certainly irresponsible to knowingly do something that makes a patient more vulnerable to HIV, the dangers of discrediting or warning against injectable contraceptives in Burkina Faso (I can only speak from my experience here, but it can probably apply elsewhere) are also quite serious. It may mean some women no longer use any family planning method, increasing unwanted and improperly-spaced pregnancies, which would in turn increase injury, illness, and death from complications in childbirth. However, it is just as serious if it is proven true; the public health sector here would have to immediately educate people about other safe forms of family planning and make them available in addition to continuing education on HIV prevention.
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