Urgent Need to Reconsider Clinical Guidelines in Canada on Depo-Provera® to Better Protect Sexual and Reproductive Health & Rights of Marginalized Women
We are writing to share with you a new peer review report published this month by the Gender and Sexual Health Initiative (www.gshi.cfenet.ubc.ca) in one of the top sexual health journals (British Medical Journal STI) demonstrating concerning evidence of linkage between hormonal injectable contraceptive (DMPA, Depo-Provera®) and increased rates of Herpes simplex 2 (HSV-2) acquisition among marginalized women.
Access to effective, safe and acceptable contraceptives that are tailored to individual women’s needs is crucial to women’s reproductive choice and control. In particular, hormonal injectable contraceptive methods offer a highly effective female-controlled option that does not require daily compliance. Unfortunately, a growing body of evidence suggests that depot medroxyprogesterone acetate (DMPA, Depo-Provera®), one of the most widely used hormonal injectable contraceptives, may increase the risk of acquiring and transmitting HIV and other sexual transmitted infections (STIs) among women. However, to date, this evidence has largely been drawn from general population of women in sub-Saharan Africa, and limited consideration among other marginalized populations with high unmet sexual and reproductive health needs outside SSA.
In the current study, a longitudinal cohort of 800 women in street and off-street sex work (2010-2014), among previously HSV-2 negative women (n=143), we documented high incidence rates of HSV-2 (median follow-up of 18.6 months); among the highest ever reported worldwide. DMPA was an independent predictor of HSV-2 acquisition, with disproportionately higher use of DMPA among the most marginalized women in our study, including Indigenous and street-involved women. These results held when restricting the analysis to HIV-negative women, and even after adjusting for socio-demographics and condom use.
HSV-2 is a lifelong sexually transmitted infection that is associated with a large burden of disease globally; typically involving periodic outbreaks of painful genital ulcers as well as substantial psychological morbidity. In addition, HSV-2 infection has been associated with increased risk of acquiring HIV and other STI infections. DMPA has a history of being preferentially recommended to marginalized and street-involved communities as a means of reproductive control. Taken together, findings from our study raise serious concerns about how to provide the provision of optimal reproductive and sexual health care and rights amongst marginalized women in Vancouver.
These results point to the urgent need to actively engage women sex workers in the development of tailored health services that comprehensively address sex workers specific reproductive and sexual health needs and rights. In addition, further research is needed to better understand associations between different contraceptives and risk of HSV-2, HIV and other STIs to help inform the development of safer reproductive choices for women worldwide.
Alongside recent evidence further confirming linkages of Depo Provera with HIV, this evidence suggests an urgent need to review clinical guidelines in Canada and internationally and prescribing practices for clinicians for Depo-Provera and impacts on sexual and reproductive health and rights of marginalized communities.