Heterosexual couples in which one partner had HIV were studied in seven African countries. The participants were sexually active, not pregnant, and not on antiretroviral medicines. Women were HIV-tested quarterly and asked at those times about their contraceptive use.

The researchers found that unprotected sex and sex with other partners was more likely when women used a hormonal contraceptive, but even when they controlled for this, the risk of HIV infection was higher in women using injectable contraceptives compared to oral or no hormonal birth control. Risk of infection in uninfected men from their infected partners was also higher.

The study was limited in that it relied on women’s self-reporting of contraception use and methods. The way participants were selected could have biased the results, and condom use was also self-reported. The study did not randomize women to a birth control method, nor was it designed from the outset as a test of HIV risk and specific types of contraceptive use. It also could not clearly evaluate any risk associated with oral birth control, because there were not enough users of the pill in the study.

Despite these limitations, there is reason to be concerned about whether there is a link between Depo Provera or its generic forms and risk of HIV infection. There are several ideas about how the drugs could potentially increase risk, but the HIV question has been around since at least 1996. That year, researchers working with monkeys and implantable contraceptives published a study suggesting increased risk of a similar virus. Researchers involved with early work on this subject have responded:

How many years has it been that the non-human primate model, and other researchers, have been warning about this and being ignored? What, 15 years now? Shocking.
and
It’s not like we did our work and it was published in an obscure journal. There’s absolutely no excuse for people doing contraceptive work to not have known this, and not to have taken this forward in the late ’90s. We should have had this answered [in humans] ten years ago.

Global health programs often promote long-acting methods like Depo Provera for women in areas where access to regular medical care is difficult and maternal mortality is high. These same areas often have high rates of HIV. I find it unacceptable that the question of contraceptive use and HIV risk has been around for years, and we don’t appear to be much closer to a clear answer. As Charles Morrison wrote in an accompanying editorial:

The question of hormonal contraceptive use and risk of HIV acquisition remains unanswered after more than two decades. Active promotion of DMPA in areas with high HIV incidence could be contributing to the HIV epidemic in sub-Saharan Africa, which would be tragic. Conversely, limiting one of the most highly used effective methods of contraception in sub-Saharan Africa would probably contribute to increased maternal mortality and morbidity and more low birthweight babies and orphans—an equally tragic result. The time to provide a more definitive answer to this crucial public health question is now; the donor community should support a randomised trial of hormonal contraception and HIV acquisition.

Such a trial would require careful design in order to minimize any risk to participants and to stop as soon as any increased risk of one method is clear. It might be impossible to get funding for, but we owe it to women, who deserve clear and accurate information about the potential risks of injectable and all forms of contraception.

• well-woman visits
• screening for gestational diabetes
• HPV testing
• STI counseling
• HIV screening and counseling
• contraception methods and counseling
• breastfeeding support, supplies, and counseling
• screening and counseling for domestic and interpersonal violence

Coverage for these services is expected to begin Aug. 1, 2012.

There is one caveat for some women regarding access to contraception without a co-pay — a provision that “Group health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services.”

An announcement at the HealthCare.gov site indicates that public comment is welcome on this provision. Although I haven’t yet been able to locate it on Regulations.gov, instructions for comment and more detail about the exemption is provided in this document.

It was not clear, however, whether birth control would be included as a preventive service. It seems obvious to us, but the Institute of Medicine was asked to make some recommendations about which preventive services for women should be included, and included birth control in those recommendations, released yesterday.

If they are adopted, preventive services including birth control could become much more affordable and accessible to women in the United States.

The Institute, after reviewing the rate and consequences of unintended pregnancy, effectiveness of birth control, and cost and access concerns, concluded:

The committee recommends for consideration as a preventive service for women: the full range of Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.

In addition to copay-free coverage of birth control, the Institute recommended:

• screening for gestational diabetes
• human papillomavirus (HPV) testing as part of cervical cancer screening for women over 30
• counseling on sexually transmitted infections
• counseling and screening for HIV
• lactation counseling and equipment to promote breast-feeding
• screening and counseling to detect and prevent interpersonal and domestic violence
• yearly well-woman preventive care visits to obtain recommended preventive services

You can view the Institute’s press release, recommendations, report brief, and full report, “Clinical Preventive Services for Women: Closing the Gap,” online. The Department of Health and Human Services will still need to adopt this list of recommendations for the care to be covered under the Affordable Care Act.

Some other coverage and discussion of this topic:

• NLIRH Applauds Panel’s Counsel to Cover Birth Control Under Health Reform – from the National Latina Institute for Reproductive Health
• Anti-Choicers Gear Up To Fight Guidelines on Preventive Care for Women – Jodi Jacobson at RHRealityCheck discusses the inevitable anti-choice backlash
• A Preventive Health Care Game-Changer for Women – at the Ms. Blog
• Statement from the March of Dimes commending the recommednations
• Doctors to HHS: Adopt Contraception Recommendations, Improve Women’s Health, Save Money – Press release from Physicians for Reproductive Choice and Health<
• Women’s Preventive Health Coverage Information Central – lots of news and resources on this topic from Raising Women’s Voices
• Women Should Get Free Birth Control, HHS-Backed Group Urges – at The Rundown, a PBS NewsHour blog

Seen other good links on this news? Leave ‘em in the comments!

The United Nations’s UN Women group released a report, “Progress of the World’s Women: In Pursuit of Justice,” which looks at the legal rights of women around the world, barriers to accessing and navigating the justice system, and the impact of war/conflict on women, among other issues. It also includes ten recommendations for making justice systems work for women.

The University of South Florida has begun offering students gender-neutral housing options in response to a transgender student who reported hostility and harassment in campus housing. The school is going to offer several housing options and allow students to indicate male, female, or transitioning on their campus housing applications.

NPR’s All Things Considered ran a piece yesterday on mother-to-child transmission of HIV in Mozambique; there is a related piece on breastfeeding and HIV in developing nations.

Childbirth Connection has launched the Transforming Maternity Care blog with Amy Romano, formerly of Science & Sensibility and part of the editorial team for the forthcoming edition of “Our Bodies, Ourselves.” It looks like the blog will focus on quality improvement, patient advocacy, and shared decision-making in maternity care.

Related resources:

• 2011 State of AIDS in Black America report, Deciding Moment – released today by the Black AIDS Institute
• Increasing HIV/AIDS Awareness among Blacks/African Americans – from the CDC; there are links to statistics at the bottom of the page
• HIV/AIDS Basics – from AIDS.gov

The biggest news focus coming out of the conference so far is about tenofovir gel, a vaginal microbicide. Tenovir has been part of the CAPRISA trial conducted in South Africa, and has shown some promise in preventing HIV transmission. According to a press release from the trial:

The microbicide containing 1% tenofovir—an antiretroviral drug widely used in the treatment of HIV—was found to be 39% effective in reducing a woman’s risk of becoming infected with HIV during sex and 51% effective in preventing genital herpes infections in the women participating in the trial. Should other studies of tenofovir gel confirm these results, widespread use of the gel, at this level of protection, could prevent over half a million new HIV infections in South Africa alone over the next decade.

The search for an effective microbicide has been ongoing for quite a few years now, as it could represent an important woman-controlled tool for reducing HIV infection, especially when women may not be able to insist on condom use. This is the first time a microbicide product has really been considered to show major promise for prevention.

As the New York Times explains, however, additional work will need to be done before this product becomes widely available to women who might benefit from it:

Broader trials are needed to confirm the results, and it will most likely be years before the product is publicly available, but if produced on a large scale the gel would cost less than 25 cents per application…Because the trial was relatively small and the gel was nowhere close to 100 percent effective, AIDS scientists and public health officials wanted to see another trial get similar results before they undertook the large fund-raising and public education efforts that would be needed to make billions of doses of the gel, as well as the applicators, which are more expensive, and then to persuade women to use them and governments of poor countries to adopt them.

Science magazine has made a paper with scientific details on the trial freely available to the public. The conference blog provides a number of relevant resources for those interested in learning more about this research.

Last night’s PBS Newshour had an interview with Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (part of the NIH), which I think did a great job of explaining the findings; a transcript of the video below is available online.

Also of interest is the Women ARISE coalition, consisting of international women’s groups and organizations whose stated mission is to:

…work together to galvanize and promote a common agenda on women and girls’ rights in the AIDS response and ensure that all women and women’s issues are central and visible in the objectives and program of the International AIDS Conference in Vienna.

The group’s founding document [PDF] outlines important principles and needs for addressing the concerns of women and girls in HIV/AIDS response efforts, including protecting and promoting the human rights (including reproductive and sexual rights) of women and girls, addressing violence against women as a cause and consequence of HIV, addressing sexual and reproductive health more broadly, developing the basic services needed by communities, including women’s leadership, and demanding accountability from the international community.

The International Women’s Health Coalition has also posted on the Women ARISE initiative in their post, Outspoken Women in Vienna Demand Rights and Inclusion, reporting directly from the conference on a demonstration at the conference plenary session intended to make it “clear that the only way to end this epidemic is through gender equality, empowering women, fulfilling our sexual and reproductive rights and health, and providing all young people with comprehensive sexuality education.”

Readers can get updates from the conference on Twitter (@aids2010), on Facebook, and on the conference blog.

Entrant: Steven Slosberg
Nominee: Betsy Ryan, RN

I’ve submitted a column I wrote about Betsy Ryan several years ago when I was a columnist for The Day, a daily newspaper in New London, Conn.

Betsy continues to work ardently as a nurse in the infectious diseases department at Lawrence & Memorial Hospital in New London, as well as in HIV/AIDS education and prevention in our community, and, as a breast cancer survivor, summons enviable energy in her commitment.

She is most deserving of this honor.

A reluctant hero on front lines of a long fight (originally published 10/01)

Knowing Betsy Ryan, I suspect the Alliance for Living first had to engrave and mail the invitations, post public notice in places beyond her reach and probably put a search party on standby before telling her she was going to be formally honored for her community service. There could be no way out of it.

Even then, says Peter Bowler, one of the Alliance for Living leaders, she tried to persuade the non-profit support group for people affected by HIV/AIDS in this region to give the award to more deserving folk or at least let them share it with her.

“I said, ‘Too late, Betsy,” said Bowler. “See you at the awards dinner.”

That would be next Wednesday night, at the Mystic Hilton, when Lizbeth Love Ryan, a registered nurse and longtime relentless advocate for HIV and AIDS education and prevention, is to receive the organization’s annual outstanding community service award as part of its Awards & Appreciation Night.

The thing is, Ryan, who works in Lawrence & Memorial Hospital’s infectious disease service, has yet to acknowledge that she will attend.

“If we have to track her down and hook her up to an ox and cart, she’ll be there,” said Bowler.

She is that modest, that reluctant to take a public bow, at least about her role in community HIV awareness, but absolutely not in her labors to make lives here better and safer.

There is Betsy Ryan, a slender figure, prim and proper might apply, standing in front of any group, demonstrating, step by step, the proper way to apply a condom, and candidly discussing spermicides and lubricants and why latex condoms are best because they’re man-made and the quality can be assured.

I saw her give such a demonstration for the first time before a roomful of politicians, educators, nurses and health care and human service agency workers at Ocean Beach one September day in 1989. She gave similarly straightforward demonstrations at Frank’s Place, a gay bar, in New London during the annual Celebration of Hope fund-raisers. She’s given hundreds and hundreds of them, all over the region.

She’s been admired as a caregiver and has served as an ad hoc spokeswoman for tracking HIV/AIDS here. Though not always the easiest person for a reporter to find at deadline, she has been consistently helpful in providing statistics, always protecting the confidentiality of those with the disease. She knows just what she can say and won’t be cajoled into saying more.

In her time here she’s coordinated the New London AIDS clinic, has been a mainstay of the AIDS care program at L&M and was president of the Women’s Center of Southeastern Connecticut. She moved here in 1972 and, except for a short time in Hawaii, has been a nurse at L&M. She started out in the emergency room. She’s in her early 50s, was raised in western Pennsylvania and for the last 15 years has lived with Ken Abrahms, who owns Art Unlimited in Ledyard. They have a home in Groton and one in Watch Hill.

Donna M. Greene, president of the Alliance for Living board, has known Ryan for nine years, since Greene was involved with Helping Our People Endure Foundation Inc. (HOPE), which, in April 1998, merged with the Southeastern Connecticut AIDS Project (SECAP) to form the Alliance for Living.

Greene, who works at Pfizer, has not always agreed with Ryan’s positions, notably Ryan’s opposition to needle exchange programs. But Greene admires Ryan’s courage of her convictions.

“She’s a very firm believer in what she stands up for,” says Greene. “She’s got all the facts. She really knows her business.”

She and Bowler and Michael Rosenkrantz, the executive director of Allliance for Living, decided it was time for Ryan to face facts, and receive the recognition.

“She’s one of the few people, out there in daily contact, in the front lines, who never loses her sunny disposition and always has her client’s best interest at heart,” said Greene.

Others will be honored at the dinner for volunteer work and Dr. Frederick Altice, an HIV specialist at Yale-New Haven Hospital, will be the keynote speaker.

Betsy Ryan will be recognized for her abiding dedication, and maybe the only way to assure her being there is the opportunity, with all those people gathered in one room, for her to unroll one more condom and deliver her unflinching AIDS 101 presentation, once again.

Entrant: Maureen Reinsel
Nominee: John Varallo, MD, MPH, Senior Technical Advisor

Obstetricians and gynecologists choose to dedicate themselves to women’s health, but that alone does not qualify them as a Women’s Health Hero. A hero humbly exceeds the average expectations to create true and lasting positive change. Dr. John Varallo, through his selfless and untiring contributions to women’s health in the United States, Guyana, Tanzania, Uganda, Belize, Guatemala, and Australia, is a Women’s Health Hero.

While I know him through his work on cervical cancer prevention and treatment in Guyana, it is far from his only contribution to women’s health globally. Dr. Varallo works with the most vulnerable women, and inspires others to join him through education and collaboration.

Dr. Varallo has contributed to improved prevention and treatment of cervical cancer, particularly among HIV positive women. Cervical cancer, caused by the sexually transmitted Human Papilloma Virus (HPV), is a preventable disease that kills an estimated 253,500 women worldwide annually (National Cervical Cancer Coalition, www.nccc-online.org). The burden of disease is particularly onerous among HIV positive women, who have a more difficult time clearing the virus from their system and in whom the cancer moves significantly more quickly.

Dr. Varallo’s efforts have led to a considerable expansion in coverage of cervical cancer prevention, detection, and treatment. In Guyana alone, he has trained 23 physicians, advance practice nurses, and registered nurses in one year to detect and treat pre-cancerous lesions. His work in Guyana has led to the Ministry of Health instituting a national cervical cancer prevention and treatment program, and he was the principle author of the country’s cervical cancer prevention and treatment policy and guidelines.

Providers trained by Dr. Varallo have screened more than 5,000 women in one year, providing approximately 800 women with preventative treatment. In addition to his work in Guyana, Dr. Varallo has trained health care providers in cervical cancer prevention and treatment in five other countries, including the United States.

Dr. Varallo provides hospitals, clinics, and providers with support on reducing maternal and infant mortality, improving family planning services, and integrating women’s health into HIV/AIDS care and treatment. In all of this work, he has dedicated himself to improvement of health care for society’s most vulnerable. In the United States, he works primarily with American Indian communities, having provided clinical services and leadership with the Indian Health Services in Montana, Arizona, and Alaska. He provides pro-bono clinical services for asylum seekers with Physicians for Human Rights. Not satisfied with sitting in an office to see patients, Dr. Varallo goes to meet women where they are.

He has led or participated in mobile clinics in Australia, Guatemala, Belize, Guyana, Uganda, and the United States (Australia, most notably), going into remote communities to see and treat women who rarely have the chance to receive health care services at all. Not only does Dr. Varallo treat these women; he also treats them well. In my experience and that of my colleagues, his visits to Guyana that include clinical days mean long lines of women, including health care workers, who demand to be seen by “Dr. John” because they appreciate his respectful and open bedside manner, which is in stark contrast to the condescending treatment they so often receive from other providers.

Dr. Varallo is a leader and educator; he does not provide these services alone, but rather builds the skills and commitment of other providers to join him in preventing the needless deaths of women wherever he is working. This might be the most critical element of his heroism: catalyzing the actions of others. He taught for three years at the Medical University of South Carolina, but then began to take his pedagogical skills global. He has provided Continuing Medical Education for health care professionals in Guyana, Belize, and the United States (Alaska) in topics as varied as:

• Gestational hypertension and hypertensive crises in pregnancy
• Pre-eclampsia and Eclampsia
• Prevention of mother-to-child transmission of HIV
• Postpartum hemorrhage
• Diabetes in pregnancy
• Cesarean section
• Family planning and modern contraception
• Cervical cancer
• Antibiotics
• Thromboembolism
• Abnormal uterine bleeding
• Uterine fibroids
• Management of unexpected labor and delivery
• Collaborative prenatal care

As someone who dreams of one day being a women’s health nurse and who works in the field of international public health, I am surrounded by people who spend their days endeavoring to improve health care globally. Nonetheless, Dr. Varallo stands out as someone with a unique level of commitment. He has inspired in me a real passion for preventing cervical cancer, and has earned my admiration through the genuine kindness and the respect that he demonstrates to everyone he works with, from clients to community health workers, from student nurses to the Minister of Health.

Dr. Varallo is my Women’s Health Hero.

Presenting with Lenhart was Kicesie Drew, who provides sex ed information via YouTube; Sally Swanson from the Adolescent Pregnancy Prevention Campaign of North Carolina, a group that usess texting to answer questions about sexual health; and Cornelis Rietmeijer, director of the Sexually Transmitted Disease Control Program/Denver Public Health.

More health professionals are turning to innovative techniques and technologies to reach young and at-risk populations. I recently took part in a symposium, sponsored by Chicago Department of Public Health and the National LGBT Tobacco Control Network, on how public health workers can use social media to reach the LGBT community. We looked at some of the promises and obstacles that new communciation tools present. One of the most important lessons: Know how your audience uses technology, and go where they go.

I was honored to be on a panel with Lovette Ajayi, a superstar at Community Media Workshop and co-founder of the Red Pump Project, which raises awareness about the impact of HIV/AIDS on women and girls. And that brings me to the second point of this post: March 10 was National Women and Girls HIV/AIDS Awareness Day.

The Red Pump Project presents statistics about HIV/AIDS  and women — and the great disparities. Though black and Latina women represent 24 percent of all U.S. women combined, they account for 82 percent of the estimated total of AIDS diagnoses for women in 2005.  Consider that HIV is the:

* Leading cause of death for black women (including African American women) aged 25–34 years.
* 3rd leading cause of death for black women aged 35–44 years.
* 4th leading cause of death for black women aged 45–54 years.
* 4th leading cause of death for Latina women aged 35–44 years.
* The only diseases causing more deaths of women are cancer and heart disease.
* The rate of AIDS diagnosis for black women was approximately 23 times the rate for white women and 4 times the rate for Latina women.

These numbers illustrate the need for massive improvements in education, prevention and treatment — all topics the National STD Prevention Conference aims to address. High-priority issues are identified for each biennial conference, and this year’s top three issues couldn’t be more  relevant or directly worded.

The last point is a great reminder of how change is both incredibly simple and complex: “It is essential to find ways to move beyond our longstanding societal reticence to openly discuss sexual health issues and to normalize conversations around STD prevention.”

Plus: In related news, Washington, D.C. will make 500,000 female condoms available — for free. The condoms will be available in beauty salons, convenience stores and high schools in parts of the city with high HIV rates, reports the Washington Post. The project is funded through a $500,000 grant from the MAC AIDS Fund, a subsidiary of MAC Cosmetics.

The formal announcement was made in Atlanta last week at the Southeastern Urban Initiative for Reproductive Health Summit, a coalition of reproductive health advocates. The summit was hosted by SisterSong Women of Color Reproductive Health Collective.

The FC2 female condom is a second generation product developed by the Chicago-based Female Health Company. Currently available only to state health agencies and nonprofit organizations, the FC2 will be sold in CVS stores in the Washington, D.C. area starting in December, FHC’s senior strategic adviser Mary Ann Leeper told Reuters.

Washington, D.C. health officials released a report in March showing that at least 3 percent of District residents have HIV or AIDS — a rate that is on par with Uganda and some parts of Kenya.

Female Health Company is looking for a marketing partner to help promote FC2 directly to consumers.

“We need the other company to really make a dent into the consumer market,” said Leeper.

According to the Centers for Disease Control and Prevention (CDC), over the past two decades, the percentage of women among all people living with HIV in the United States has increased from 8 percent to 27 percent. African American women account for 66 percent of new AIDS cases among American women; they are 21 times more likely to contract HIV than white women, while Latino women are five times more likely.

“America’s HIV epidemic isn’t going away. In fact, it’s getting worse, and African American and Latino women are disproportionately impacted,” said Dazon Dixon Diallo, founder and president of SisterLove, a grassroots service organization that supports HIV/AIDS prevention and reproductive health programs for women in the Atlanta area. “It’s time to provide women in heavily impacted communities with expanded access to affordable women-controlled options, and the female condom becomes that choice. Women will use it if they have it.”

Female Health Company says the FC2 is thinner and quieter than its predecessor, the FC1 female condom. The FC2 is made of synthetic nitrile, a latex alternative, so it’s safe to use with both oil and water-based lubricants. Here’s information (pdf) about how to insert the condom. There’s also an animated video demonstration. More resources from FCH are available here.

FC2 may be purchased from the company’s two public sector distributors: Total Access Group, Inc. and Global Protection Corporation.

FHC has also launched a new site, www.fc2femalecondom.com, which includes tiered pricing information for ordering female condoms directly (minimum of 25,000). The maximum price of 82 cents per condom is 30 percent less than the price paid for FC1. A retail price has not been determined.

Though female condoms are not popular in the United States, the FC2 has been available in other countries since 2006. The U.S. Agency for International Development had lobbied for the FDA’s approval — a lengthy and expensive process – so it could be purchased for U.S.-funded global HIV-prevention programs.

Earlier this year, Audacia Ray, program officer for online communications and campaigns at the International Women’s Health Coalition, described other female condom prototypes that are being actively tested and promoted outside of the United States, especially in Africa.