The World Health Organization (WHO) has advised women on injectable hormonal birth control to use condoms to prevent HIV infection in light of possible HIV risks associated with "the shot", but HIV organizations and activists say this has not been effectively communicated to women.
In October 2011, a study published in the medical journal, The Lancet, suggested hormonal contraception doubled the risk of a woman contracting HIV - and of HIV-positive women transmitting the virus to their partners.
The study prompted WHO expert consultations to review available research on the topic in early 2012. On 16 February the WHO largely affirmed existing guidelines allowing all women to use hormonal contraception.
However, because the UN agency was unable to definitively rule out the possibility that progesterone-only birth-control shots like Depo-Provera posed no HIV risk, it is now strongly advising women at risk of or living with HIV to use condoms concurrently to prevent HIV infection or transmission.
HIV organizations, researchers and activists have criticized the WHO and UNAIDS for not clearly communicating the document's message to African women, who remain the most affected by the continent's high HIV prevalence rates.
Lillian Mworeko, regional coordinator for the International Community of Women Living with HIV Eastern Africa (ICWEA) was the only African civil society representative invited to speak at the WHO consultations on behalf of the continent's HIV-positive women.
"It's important for us to know the information [in the WHO statement] is being received in different ways by different people with clear communication that is going to get down to service providers and to women," Mworeko told IRIN/PlusNews. "When I look at the statement, I understand it because I attended the meeting but for someone who wasn't at the meeting, I'm not sure they will.
"We are at a point where we need to move very fast," she added. "As a woman who sat in on that meeting, I feel we are moving very slowly [to communicate this] and this is unacceptable."
Those in the HIV and family planning fields must find a way to translate the statement's nuanced messaging to women - communicating possible risks without turning women off from much needed services, noted Helen Rees, executive director of the Wits Reproductive Health and HIV Institute at the University of the Witwatersrand in Johannesburg, South Africa.
In the past two decades, Depo-Provera has topped the list of state-provided birth control in Africa. Countries such as South Africa, Uganda and Kenya all depend on family planning services to help reduce high rates of maternal and infant mortality by preventing unwanted pregnancies.
According to Mary Lyn Gaffield, a WHO epidemiologist who coordinated the recent meetings, the WHO has already begun translating the 16 February statement into multiple languages, and is developing tools for family planning and HIV service providers that will incorporate the need to caution women using progesterone-only contraception on possible HIV risks.
UNAIDS has already begun training its staff on the WHO's new advice.
Even with such UN guidance, putting the WHO's advice into practice will be difficult for health workers and women in high HIV prevalence countries, Rees said.
In South Africa, about 18 percent of adults are living with HIV. Every woman in South Africa is at risk of HIV - and many still cannot negotiate condom use, she told IRIN/PlusNews.
"Family planning programmes are going to have to rapidly re-look at the methods that are available and what we are [asking] health workers to promote," Rees said during AVAC's question and answer session. "Access to the female condom - it's an old [topic] that we've been talking about for a long time but it becomes imperative now."
South Africa is already moving towards lower dose hormonal contraception in new national guidelines, which will identify the potential HIV risk associated with hormonal contraception. According to Rees, more health workers are already being trained on lower dose, hormonal IUDs.
UNAIDS science adviser Cate Hankins also confirmed that UNAIDS would be advocating for more studies on the potential HIV risks associated with hormonal contraception.
No clinical trial has specifically looked at the issue. Researchers have relied on data gathered as part of other trials instead. For instance, the 2011 study used data obtained as part of two trials looking at the effects of herpes treatment on HIV transmission.
International health organizations like FHI360, formerly Family Health International, are already planning such trials, according to Charles Morrison, senior director of clinical sciences.
"The idea would be to take women who wished to be put on highly effective, long-acting contraception methods and randomize," he said during the teleconference. "The big issues are whether women would be willing to be randomized [or assigned a birth control method]; how well they'd adhere to one method and whether they would switch mid-trial."
However, these planned trials remain unfunded and - if funded - would take about five years to produce results, Morrison told IRIN/PlusNews.