Research Briefs on Contraceptive Technology

Contraceptive and Reproductive Health Technologies Research and Utilization Program (CRTU)
Family Health International (FHI)

October to December 2006

Research
	Hormonal Contraception Does Not Appear to Increase Overall HIV Risk
	Neither combined oral contraceptives nor the injectable contraceptive depot-medroxyprogesterone acetate (DMPA) increases a woman's overall risk for acquiring HIV infection, according to a large study led by Family Health International. The study, published in the January 2, 2007 issue of the journal AIDS, is the largest, most comprehensive study to date that compares use of the most commonly prescribed forms of hormonal contraception to risk of infection with HIV. The study results mean that, for now, current international medical guidelines for hormonal contraceptive use remain the same. This is reassuring for women in regions, such as sub-Saharan Africa, where hormonal contraceptives are the most common form of modern contraception and 60 percent of all adults living with HIV are women. The study enrolled 6,109 HIV-uninfected women from family planning clinics in Uganda, Zimbabwe, and Thailand. Participants received HIV testing quarterly for 15 to 24 months. By the time the study ended, 217 women had become infected with HIV. When all HIV cases were analyzed, researchers found no statistically significant difference in the risk of HIV acquisition between users of combined oral contraceptives or DMPA and women not using these hormonal contraceptives. The study also looked at whether having various other sexually transmitted infections changed hormonal contraceptive users' risk of acquiring HIV. It found that the risk of HIV acquisition was higher among women who were infected with genital herpes than those who were not. This is consistent with many other published studies. Among women who were not infected with genital herpes, hormonal contraceptive users had a higher risk of HIV acquisition. Researchers said this finding was unexpected and has no clear biological mechanism. They noted that further research is needed to confirm and explain this finding. For more information on this study see http://www.fhi.org/en/AboutFHI/Media/Releases/121206HCandHIV.htm. 
	
	Source
	Morrison C, Richardson B; Mmiro F, et al. Hormonal contraception and the risk of HIV acquisition <http://www.aidsonline.com/pt/re/aids/abstract.00002030-200701020-00011.htm;jsessionid=FH7PjHkyHJqsGTTTGJn2D6wSprvZqRSlS93tTCPkfppdF0xbyLB4!-1770056926!-949856145!8091!-1> . AIDS 2007; 21(1): 85-95.

	
	Less is More in Helping Women Understand What to Do When They Miss Contraceptive Pills
	Unintended pregnancies resulting from women missing their oral contraceptive pills could be reduced if women better understood what to do when they forget to take their daily pill. USAID-funded research from Family Health International demonstrates that instructions explaining the steps to take when pills are missed are more readily comprehended when in graphic format, featuring simplified information. Conducted at 12 sites in Jamaica, the study involved over 800 current or past users of 21- and 28-day oral contraceptive pill packs, equally assigned to four groups of instructions that covered several scenarios. Most women in the study correctly specified what to do when one pill is missed but poorly identified steps to take when multiple pills are missed. This suggests that, as instructions become more complex, they also become less understandable. As a result of these findings, the World Health Organization's expert working group modified its Selected Practice Recommendations for Contraceptive Use (SPR), a version of which was used in the study. The modified SPR has been disseminated in the United Kingdom by the Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit and by USAID through James Shelton's e-mail distribution list for Pearls of Contraception. Providing women with simplified instructions for what to do when pills are missed, as well as counseling women on the need to follow these instructions, gives women who use oral contraceptives greater control in avoiding unintended pregnancies. To read more about this study see http://humrep.oxfordjournals.org/cgi/content/abstract/del290?ijkey=5aJuwL6kfo6ecK2&keytype=ref.
	
	Source
	Chin-Quee D, Wong E, Cutherbertson C. Evaluating information on oral contraceptive use: a randomized controlled trial to assess missed pill instructions. Hum Rep 2006;21(12):3137-3145.

	
	Findings Suggest How to Improve Vasectomy Success Rates 
	Early recanalization―frequently associated with vasectomy failure―is more common than previously recognized, according to a USAID-supported study conducted by Family Health International, Laval University, and EngenderHealth. The study, published in the journal BMC Urology, charted patterns of early recanalization (a spontaneous reconnection of the two ends of the severed vas deferens) in two rigorous studies of vasectomy techniques. One study tested the effectiveness of fascial interposition among 826 men in seven countries, while the other examined the effectiveness of cautery among 389 men in four countries. The researchers estimated that early recanalization occurred in 13 percent of study participants overall-a surprisingly high percentage for a method considered 99 percent effective-and was associated with more than four-fifths of vasectomy failures overall. The risk of recanalization depended on the vasectomy technique; it was highest for ligation and excision without fascial interposition (25 percent) and lowest for thermal cautery with fascial interposition (0 percent). The authors caution that further research is needed to clarify the full implications of these results for clinical practice because what seem like small differences in surgical technique may lead to significant differences in effectiveness. However, researchers said these findings reinforce recommendations to avoid ligation and excision, and support the use of cautery with fascial interposition as probably the most effective way of occluding the vas. High risk of early recanalization with ligation and excision without fascial interposition may partly explain the unacceptably high contraceptive failure rate following vasectomy observed in countries where this occlusion technique is still the most commonly performed. To read the full study, visit http://www.biomedcentral.com/1471-2490/6/25.
	
	Source
	Labrecque M, Hays M, Chen-Mok M, et al. Frequency and patterns of early recanalization after vasectomy. BMC Urol 2006;6:25. 

	
	Evidence Inconclusive about Hormonal Contraceptive Use and Bone Fracture Risk 
	Whether hormonal contraceptive use increases the risk of bone fracture later in life cannot be determined from current data. This was the conclusion of a recent Cochrane review conducted by Family Health International, with funding from USAID. Use of hormonal contraceptives has been associated with changes in bone density in women. However, whether these changes increase the risk of bone fracture later in life remains undetermined. The authors reviewed 11 randomized controlled trials, none of which had bone fracture as an outcome. However, most had bone density as an outcome. Authors found that birth control methods with both estrogen and progestin did not appear to harm bone health. Two placebo-controlled trials showed bone mineral density increases when the progestin-only injectable depot-medroxyprogesterone acetate (DMPA) was used with an estrogen supplement. They showed decreases with DMPA plus placebo; however, whether this decrease is clinically important could not be determined. Results for progestin-only implants were inconsistent. While progestin-only injectables and implants may affect bone density, they provide effective birth control for women who want a long-term method. They are also considered appropriate for women who should avoid estrogen for medical reasons. The authors recommend that health care providers and women weigh the risks, costs, and benefits of each type when choosing to use a hormonal contraceptive. Read more about this review at http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006033/frame.html. 

	Source 
	Lopez LM, Grimes DA, Schulz KF, et al. Steroidal contraceptives: effect on bone fractures in women. Cochrane Database Syst Rev 2006,October 18(4):CD006033. 

	
	NSAIDs Reduce Bleeding and Pain Associated with IUDs
	Non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, can help reduce both pain and menstrual blood loss associated with intrauterine device (IUD) use. These findings, from a recent Cochrane review conducted by Family Health International with funding from USAID, may have implications for IUD continuation because cramping and heavy menstrual bleeding are among the most common reasons why women stop using IUDs. The review looked at 15 randomized controlled trials from 10 countries that studied use of NSAIDs as treatment of bleeding or pain associated with IUDs. The review found mixed results when considering trials of prophylactic use of NSAIDs around the time of IUD insertion. The authors encourage the use of NSAIDs as first line therapy when women with IUDs complain of pain and heavy menstrual bleeding, and they added that prophylactic use of NSAIDs around the time of IUD insertion appears unwarranted. Read more about this review at http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006034/frame.html. 

	Source 
	Grimes DA, Hubacher D, Lopez LM, et al. Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev 2006,October 18(4):CD006034.

	
	Oral Contraceptives Offer No Benefit for Functional Ovarian Cysts 
	Contrary to common clinical practice, combined oral contraceptives do not help functional ovarian cysts go away faster than they would without treatment, according to a recent Cochrane review conducted by Family Health International with partial funding from USAID. Since the early 1970s, clinicians have assumed that oral contraceptives can be used to treat these benign ovarian cysts because pill use has been associated with lower incidence of such cysts. However, the Cochrane review of four randomized controlled trials that included oral contraceptives used for treatment of functional ovarian cysts found no evidence that oral contraceptives had any affect on the time it took for cysts to resolve. In fact, most cysts resolved without treatment within a few cycles. The authors discourage the use of oral contraceptives as a treatment for functional ovarian cysts, but rather recommend watchful waiting over several cycles as the best approach. They noted, however, that some persistent cysts may require surgical removal. Read more about this review at http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006134/frame.html. 

	Source 
	Grimes DA, Jones LB, Lopez LM, et al. Oral contraceptives for functional ovarian cysts. Cochrane Database of Syst Rev 2006;October 18(4):CD006134. 

	
	
Research to Practice
	Workshop in Uganda Explores Community-Based Distribution of DMPA 
	The injectable contraceptive depot-medroxyprogesterone acetate (DMPA) is safe, effective, and very popular. What's more, with improved tools to guide and support its community-based distribution (CBD), policy-makers, program managers, and funders are now carefully considering how to add DMPA to CBD programs. To that end, use of community reproductive health workers to administer DMPA was explored at a workshop in Kampala in early October. Approximately 80 policy-makers, program managers, and funders attended the workshop, which was sponsored by the Uganda Ministry of Health and Family Health International, with funding from USAID. CBD of DMPA is an approach currently underutilized in Africa, but experience in a number of settings demonstrates that CBD workers can safely give injections, refer clients to clinics when necessary, maintain supplies, safely dispose of needles and syringes, regularly administer DMPA every three months, and counsel clients about side effects. To access the final workshop report, see http://www.fhi.org/en/RH/Pubs/booksReports/CHWprov_DMPA.htm. 

	
	New Continuum Chart to Be Used in Family Planning Essentials
	USAID-supported research by Family Health International-showing that a simplified counseling chart can improve women's understanding of contraceptive effectiveness more than complex charts can-began a chain of events that could soon help family planning providers better ensure that their clients are making appropriate method choices. As a result of the research, a panel of experts assembled by the World Health Organization drafted three simplified contraceptive effectiveness charts that were subsequently tested in India and Jamaica. Before viewing the charts, women's contraceptive knowledge was poor: only 35 percent of women in the study in India and 58 percent of women in the study in Jamaica knew that oral contraceptives are more effective at preventing pregnancy than are condoms. While use of all three charts significantly improved the women's knowledge, the chart that presented contraceptive methods on a continuum from most to least effective was slightly more comprehensible than the others. This chart will be used in the World Health Organization's Family Planning Essentials: A Global Handbook for Providers and in the 19th edition of Contraceptive Technology (both forthcoming). To access the newest version of the chart, see http://www.fhi.org/nr/shared/enFHI/Resources/EffectivenessChart.pdf. For more about the research, published in the July 2006 issue of American Journal of Obstetrics and Gynecology, see http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16626610&query_hl=1&itool=pubmed_docsum 

	
	Workshop Bridges Gap Between Research and Practice
	A research utilization workshop conducted at the "Linking Reproductive Health, Family Planning and HIV/AIDS in Africa" conference October 9 and 10, 2006, in Addis Ababa, Ethiopia, sought to bridge the gap between research and practice by giving participants tools and resources to implement recommendations stemming from new research findings on family planning and HIV/AIDS integration. The workshop was sponsored by Family Health International with funding from USAID. Over 45 people were in attendance, including policy-makers and program managers interested in learning strategies for applying research findings in their home countries. Using case studies based on research findings on integration, facilitators helped participants identify key steps to move these findings into practice. Among guides and tools to support research utilization efforts were methods for adapting findings to participants' home countries and scaling up successful efforts. 

	
	"Network of Champions" Launched in Addis Ababa
	Four "champions" of family planning and HIV/AIDS service integration were on hand October 11 and 12, 2006 in Addis Ababa, Ethiopia to launch Family Health International's Network of Champions, following a conference on "Linking Reproductive Health, Family Planning and HIV/AIDS in Africa." The Network, sponsored by Family Health International and made possible by support from USAID, provides technical assistance, resources, and mentoring to help selected reproductive health professionals advocate for evidence-based innovation to reproductive health programs and policies in their home countries. The four champions-from Tanzania, Zambia, Nigeria, and Uganda, respectively-presented and received feedback on their specific advocacy plans for translating research findings on family planning and HIV/AIDS service integration into practice. The Network of Champions stems from behavioral theory asserting that access to, understanding, and uptake of research findings can be facilitated by influential local opinion leaders who assume the role of advocates or "change agents." The nine-month project seeks to reduce the time between availability and implementation of reproductive health research; facilitate the scale-up of effective programs, tools, and approaches; and increase partnerships in the field. For more information on Network of Champions integration advocacy activities in Africa, contact Ms. Erin McGinn at [log in to unmask]

	
	Experts Meet to Discuss Moving Vasectomy Forward
	A recent meeting, entitled "Moving Vasectomy Forward: An Expert Consultation on Priorities and Next Steps," brought together 40 representatives from reproductive health research, training, service delivery, advocacy, and donor organizations, as well as universities, to identify priorities for expanding vasectomy as a family planning method. Held in Washington, DC, on November 20, 2006, the meeting was organized by Family Health International and EngenderHealth, with funding from USAID. Several presentations noted that vasectomy remains the least known and least accessible of modern methods. The latest research findings on the effectiveness of vasectomy surgical techniques were presented, and participants recommended that more effective techniques, such as cautery, be introduced into existing programs. Speakers recommended a holistic, systems approach to revitalizing vasectomy services, as well as the need to identify and nurture champions at all service levels. Participants concluded the meeting by developing criteria for selecting countries for pilot vasectomy programs and identifying next steps for revitalizing and repositioning vasectomy. Proceedings will be available soon. 
	

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