In May 2017, Natural Womanhood and FACTS put out a call for people to sign their petition asking CDC to “update its website to reflect the best data available and to cite the individual effectiveness rate of each unique type of evidence-based fertility awareness based method (FABM)”, asserting that the CDC website currently “misrepresents the actual effectiveness of individual modern FABMs” by reporting a typical failure rate for all FABMs of 24%. They state that data on effectiveness of FABMs on the CDC website is based on “one study with a low quality research design, which explains why its conclusions are so far from what quality studies show us”. They posit “bias” in this estimate as it is based on a retrospective survey, and as it lumps together variants of calendar rhythm plus other FABMs. The assertions in this petition raise multiple concerns (outlined below).
Hormonal contraceptive methods and risk of HIV acquisition in women: an updated systematic review (2016)
For many years, scientists have tried to answer several questions about whether various hormonal contraceptive methods (i.e., pills, injectables, implants, hormone-releasing IUDs, patches, and vaginal rings) impact various HIV-related risks. Key questions on this subject include:
The first question is the most controversial, and is a critically important question for women's health - particularly for those living in high HIV prevalence countries, including many in Eastern and Southern Africa. However, for a number of methodological reasons (many of which are detailed in this paper), it is extremely complex to design studies that will provide definitive answers.
At the request of the World Health Organization, I've had the opportunity to lead incredible teams of researchers to conduct systematic reviews of the evidence on this issue (as well as on some of the other questions noted above). Systematic reviews collect, evaluate, and summarize all available studies on a given question to try to clarify what the best available evidence tells us. Our first systematic review on this topic was completed in 2012 and published in 2013 in Lancet Infectious Diseases. The evidence base continued to grow, and we were asked to conduct an updated review on this topic in 2014, which we published in the journal Contraception.
In the last two years, the evidence based has continued to grow rapidly, and the quality of studies has continued to improve over time. We were recently asked by WHO to conduct a third systematic review on this issue, which we recently published in the journal AIDS. This updated review includes all scientific studies on this topic published through January 15, 2016 (and at the time of writing this blog in October 2016, I am not aware of any new relevant studies published since January 15, 2016).
The full text of the systematic review is available here (click where it says "Article as PDF" under the "Article Tools" bar on the right), and a press release is available here. In brief, we concluded that existing evidence suggests a reassuring lack of increased risk of HIV acquisition for users of oral contraceptive pills, the NET-EN injectable contraceptive (which is used mostly in South Africa), and contraceptive implants. However, new data on intramuscular depot medroxyprogesterone acetate (DMPA), an injectable contraceptive most commonly sold as Depo Provera, heightens existing concerns about a possible increase in risk of HIV acquisition in women who use the method.
WHO monitors this evidence on an ongoing basis, in efforts to keep guidelines like the Medical Eligibility Criteria for Contraceptive Use aligned with scientific data on a continuous basis. In response to our review, WHO issued a statement, and noted that:
The World Health Organization will convene an expert review group later in 2016 to examine the links between the use of various hormonal contraceptive methods and women’s risk of HIV acquisition. The expert review group will assess whether current WHO guidance needs to change in the light of a new review of data, published in AIDS on 9 August 2016, which was commissioned by WHO.
People interested in this topic should stay tuned for the results of the WHO meeting. For those interested in some of the other key questions noted above, here are some additional resources:
In January 2016, I attended the fourth International Conference on Family Planning. I've been very fortunate to be able to attend all four of these incredible gatherings: in Uganda in 2009, in Senegal in 2011, in Ethiopia in 2013, and in Indonesia in 2016.
At these conferences, I'm always reminded what it feels like to be surrounded by everyday heroes working in reproductive health, and I inevitably come home more inspired and reinvigorated. This year was particularly energized because of the large youth delegation that brought incredible spirit and talents to the conference!
As part of my interest in expanding the evidence base on various contraceptive options, I am currently collaborating on a systematic review of the effectiveness of various fertility awareness-based methods (FABMs) of contraception (note: this is not the same as the rhythm method, more on that another day). Working in this area has led to a number of fascinating connections and dialogues. Most recently, a Fertility Awareness Educator named Sarah Bly asked if I'd be willing to give a lecture on scientific literacy to her new class of students. This seemed like a nice science communication opportunity, a fun chance to present on much broader topics than I usually do, and a good way connect with new (to me) folks working directly with women on issues in contraception.
A few weeks before my presentation, Sarah shared with me that through years of using alternative medical approaches in her personal and family life, her ways of understanding health and healing are rooted in primarily in personal experience, and secondarily in science. I appreciated her sharing this with me for a few reasons. First, considering the different approaches by which people obtain and interpret medical information helped me be more explicit in my presentation about the specific elements that make me place great trust in science (while still trying to acknowledge/articulate areas for improvements). Second, I applaud people who invite constructive interaction and exchange with folks who have potentially divergent perspectives. So, I'm grateful to Sarah for the invitation, and to the students for the great discussions afterward - it was lots of fun!
The 50-minute talk was presented online, and the recording is linked below. A few brilliant folks on Twitter (shout out to Dr. Liz Allen & others!) suggested it might also be useful to provide links to shorter thematic clips - that's below, as well. As a talk geared primarily towards an audience with limited familiarity on certain scientific concepts - I'd welcome feedback from scientists and non-scientists alike on what could be improved for next time!
I am enormously grateful to Georgewilliam Kalibbala, Scott Fabricant, and Dr. Ronald Gray for nominating me to the 120 under 40 campaign!
My profile was posted today, along profiles of many other nominees, including Patrick Segawa - who I blogged about just yesterday. Kudos, Patrick!
It's inspiring to read about young folks around the world doing all kinds of important work. I hope everybody interested in building the next generation of leaders in reproductive health will consider making a nomination today!
Tomorrow, I leave for Indonesia to attend the International Conference on Family Planning! This incredible conference began in Uganda in 2009, was in Senegal in 2011, then Ethiopia in 2013, and will be in Bali this year. I've been incredibly fortunate to be able to participate at each one! It always re-energizes me to be surrounded by everyday heroes doing work in international reproductive health!
This year, I had an opportunity to volunteer to be a mentor to a youth attendee. As luck would have it, I was matched with a young Ugandan man who I've been linked with for some time on social media - the incredibly dynamic Patrick Segawa. Patrick's organization, PHAU (Public Health Ambassadors of Uganda), focuses on "edutainment" to raise awareness for sexual and reproductive health and rights in Uganda. Among other incredible activities, PHAU organizes dancing flash mobs in Uganda - please check out their website for more information about this great organization! Patrick was also recently nominated in the 120 under 40 campaign, which highlights young leaders in reproductive health from around the world. He is a rising star in our field, and I am very much looking forward to finally meeting him in person.
This evening, the ever-fabulous Alice Dreger brought an important ongoing Twitter conversation to my attention. Several folks, including Amanda Michelle and others, had sounded the alarm about a company, Use to Believe, that was making misleading, scientifically-unsupported claims about products being sold on their website.
For example, the website claims that their lubricant, ProLube, can protect against HIV and other sexually transmitted infections.
This summer, Georgetown University hosted a meeting, organized by Vicki Thorn, founder of the National Office for Post Abortion Reconciliation and Healing, entitled Contraceptive Conundrum: A Symposium of Scientific Research.
But slapping the word "scientific" on the event title does not ensure a balanced, accurate discussion of data.
Thorn provided this rationale for the conference: "The research is showing over and over that oral contraception is simply not good medicine, but this is motivated by the agendas of population control and controlling our bodies chemically."
As an epidemiologist with knowledge in contraceptive safety research, who attended the symposium with an open mind, I do not think a compelling case for Thorn's statement was made. Nonetheless, students and laypeople in attendance might have been misled with misinformation being metaphorically paraded around in a lab coat.
While a tiny minority of the speakers delivered credible, scientific presentations, the meeting as a whole was not a “scientific symposium”: it included several low scientific quality presentations; materials distributed contained poorly-balanced content; there was a lack of invited speakers with specific expertise in contraceptive research; and the organizers made several inaccurate remarks which were further promoted on Twitter.
In this Storify, I review many of the Tweets from and about this conference, which lacked a sincere attempt to strive towards objectivity. I hope it helps to advance the call for more honest, accurate discussions on the risks and benefits of various contraceptive options, so that we can ensure true informed consent, and better support happier, healthier women and couples.
On March 30, 2015, Governor Doug Ducey of Arizona signed into law Senate Bill 1318, which requires doctors to tell women* getting an abortion that "it may be possible to reverse the effects of a medication abortion if the woman changes her mind, but that time is of the essence", and that "information on and assistance with reversing the effects of a medication abortion is available on the Department of Health Services' website".
In the US, medication abortion is typically a two-step procedure, first involving taking mifepristone, and within two days or so, taking misoprostol. On its face, SB 1318 seems intended to inform people that if they change their mind during that window between the two medications, an evidence-based medical procedure is available to help "reverse" the effects of the mifepristone (spoiler: the bill doesn't actually accomplish this goal).
People should have evidence-based information about all of their reproductive options, so they can make the best choice for their own individual circumstances. Even though the proportion of women who wish to terminate a pregnancy and then change their mind after taking mifepristone is likely to be small, any such person should absolutely be made aware of any scientifically proven intervention that can help them safely achieve their reproductive goals. So, is there scientific evidence for abortion reversal?
What is #365papers?
I already have a few New Year's resolutions (hello, my old friend Gym), but recently came across a science-related resolution that I really like and want to share.
#365papers is a challenge to read one peer-reviewed, scientific paper a day and to share something about it on Twitter. It was started by two professors in ecology and evolution, Meghan Duffy and Jacquelyn Gill.
There are many things I love about working in international public health. Among them are opportunities to work with inspiring scientists from around the world (such as my brilliant colleagues at the Rakai Health Sciences Program in Kalisizo, Uganda), and to meet vibrant young people of many different cultures, especially those excited to discuss science or public health.
Walking down the road one day in Kalisizo, I met a young man named Georgewilliam. He struck up a conversation, asking what I was doing in Uganda. When I mentioned being a public health scientist, his eyes lit up! He talked about his love for science, and was eager to discuss his studies in biology and chemistry. He was applying for a program in medical laboratory technology, and wanted advice on the application/interview process. I visited him the next day after work to talk about it, and we became fast friends.
This blog was written in conjunction with Kavita Nanda of FHI 360 and originally posted here on the K4Health website. It is republished here with permission. Disclaimer: Dr. Nanda and I were both directly involved in work on the 2014 WHO HC-HIV guidance and the USAID/PEPFAR briefer on hormonal contraception and antiretroviral medications.
Extraordinary gains have been made in the last decade towards increasing access to antiretroviral therapy (ART) for HIV. With an eye towards ending the AIDS epidemic by 2030, UNAIDS recently released bold targets related to HIV diagnosis and treatment. By the year 2020, their aim is to have 90% of all people living with HIV aware of their status, 90% of people diagnosed with HIV receiving sustained ART, and 90% of people on ART achieving viral suppression. As we move closer to these laudable public health goals, we must also consider how expansion of ART may affect and be affected by other health issues, such as prevention of unintended pregnancy among women living with HIV.
Among all people living with HIV in low- and middle-income countries, 52% are women (57% in sub-Saharan Africa). Most are of reproductive age, and many may wish to use a hormonal contraceptive method to prevent unintended pregnancy, such as oral contraceptive pills, injectables, implants, or hormonal intrauterine devices (IUDs). Access to highly effective contraception has other health benefits as well; it reduces maternal and infant morbidity and mortality, and is a necessary component in ending mother-to-child HIV transmission.
Therefore, an increasingly important issue is whether certain ART regimens are expected to have drug interactions when used with certain hormonal contraceptive methods.
* The views in this post are mine alone, and may not reflect the views of my previous or current employers, co-authors, or other colleagues *
As a young(ish) reproductive health epidemiologist whose scientific career will depend in part on publications, it is pretty scary to challenge a Goliath like Lancet journals. I respect these journals deeply. They bring important science to the forefront, they help us to improve health, medicine, and policy. Lancet journals, in particular, also engage admirably on social media and encourage researchers to do the same - better bringing science to the public.
But I experienced a terrible situation when publishing my work at Lancet Infectious Diseases, and it is important to challenge people, even our heroes, to do better. So, it's time to share my story. My intention is that this post contribute to efforts to protect other scientists and journals from experiencing the frustrating situation that I did, perhaps by stimulating more nuanced discussion on how to better prevent and address misconduct by peer reviewers (a topic which receives less attention than misconduct by authors). This issue may also be applicable to discussions on the pros and cons of open peer review. Please do share your thoughts in the comments section.
This past weekend, Dr. Alice Roberts published an article on the combined oral contraceptive pill in The Guardian. I was excited to see a media article on contraception by a scientist and a Professor of Public Engagement, assuming it'd be evidence-based and teach me more on writing about science for lay audiences.
The article implies a link between premenstrual dysphoric disorder (PMDD) and oral contraceptive pills, based in part on the opinion of Peter Greenhouse, a consultant in sexual health who sat next to Roberts at a conference dinner. Roberts writes:
"[T]here was something else that Greenhouse said that immediately caught my attention: for some women with more extreme cyclical mood changes, going on the pill could be disastrous."
A strong assertion! Intrigued, I kept reading, eager for a discussion of the epidemiological evidence behind this statement (which contradicts information in resources like the evidence-based, frequently-updated book, Contraceptive Technology).
Science reporting and evidence on contraception: women deserve to know the good, the bad, and the uncertain
When reporting on new scientific research, journalists sometimes seem to sacrifice accurate representation of scientific data for an eyeball-catching headline/story. The scarier the news, the more compelling the headline.
To my understanding, journalists don't always get to write their own headlines, but they do have control over the balance of reporting within the story. When reporting on issues related to contraception, some stories seem to focus exclusively on risks (or present risks out of context), without reporting the benefits of a given contraceptive method.
Women deserve to know both the risks and the benefits (and any lingering scientific uncertainties!) related to any contraceptive method they may consider using.
As an epidemiologist interested in research on the safety of contraceptive methods, a recent story by Val Willingham on CNN.com entitled "IUD may carry higher risk for breast cancer in certain women" caught my attention. Like many news stories, the study abstract was not directly linked (journalists, can we please fix this?). To Ms. Willingham's credit, she linked to the journal and provided the name of the first author (Dr. Tuuli Soini), so the actual study abstract was not too hard to track down (at least not for someone who regularly mucks around in scientific journals...).
The abstract clearly noted that among Finnish women treated with use of a levonorgestrel IUD for heavy menstrual bleeding, levonorgestrel IUD use appeared to be associated with several cancer-related outcomes. These outcomes (in the order in which they were reported in the abstract) included:
(1) A statistically significant 50% decreased risk of endometrial adenocarcinoma (which changed to a statistically significant 75% decreased risk for women who were presumed to have used a second LNG-IUD),
(2) a statistically significant 40% decreased risk of ovarian cancer,
(3) a statistically significant 50% decreased risk of pancreatic cancer,
(4) a statistically significant 32% decreased risk for lung cancer, and
(5) a statistically significant 19% increased risk of breast cancer.
This information was plainly available in the results section of the abstract, and also quite clearly summarized in the conclusion of the abstract, which reads:
[I'm not even going to scratch the surface of any epidemiological issues in this post, which is focused on the fidelity of what is reported in a scientific study (or even just the abstract!) to what is reported by a journalist. But, to add an obligatory epidemiological disclaimer: None of these associations are definitive; as these are observational data comparing observed cases of cancer to "expected" cases of cancer. To the credit of the study authors this is thoroughly discussed in the manuscript, and to Ms. Willingham's credit, her story notes that: "The research does not say that this type of IUD causes breast cancer" (Sadly, this important detail mattered little to some folks on social media...but that's for another post!)]
Despite the numbers above, Willingham's story focused almost exclusively on the possible 19% increase in breast cancer risk -- and not at all on the possible 32%-75% decreases in risk of other cancers.
About halfway through the article, Willingham writes: "Investigators found that over time, the device did not significantly raise the risk of uterine cancer or ovarian, pancreatic and lung cancers."
Err, yes, but!...
Not only did the levonorgestrel IUD "not significantly raise" those particular risks, but it appeared to be associated with a significant decrease in those risks. Is that not information that readers should know, too? That got lost in Willingham's report (except for a small quote by Dr. Soini buried near the end of the article, which mentions only endometrial cancer).
So, who cares? Well, given the current climate around contraception - such as the recent Hobby Lobby decision which stands to have serious consequences on a woman's ability to access the contraceptive method of her choice and on a physician's ability to provide highly effective contraceptive methods such as IUDs, and recent conversations about poorly researched materials focused exclusively on the risks of oral contraceptive pills (which could be more useful if evidence-based and balanced with discussion of method benefits) - there is an awful lot of misunderstanding (or even deliberate misinformation campaigning) around scientific evidence on contraception these days. I've spent the last few years of my professional life grappling with some of the fallout and confusion that occurred from articles like this one by Pam Belluck in the New York Times.
When I tried to discuss this issue with Ms. Willingham on Twitter, this was her initial response:
To which I said...
We simply need to expect more from journalists covering scientific issues, especially those in respected outlets like CNN.com. As Dr. Soini and colleagues note in the concluding sentence of their manuscript: "It is important to always counsel patients about the potential benefits and risks of hormonal therapies."
I couldn't agree more.
Soini T, Hurskainen R, Grénman S, Mäenpää J, Paavonen J, Pukkala E. Cancer Risk in Women Using the Levonorgestrel-Releasing Intrauterine System in Finland. Obstetrics and Gynecology 2014;doi: 10.1097/AOG.0000000000000356 (in press).
Willingham, V. "IUD may carry higher risk for breast cancer in certain women" Published on CNN Health, July 9, 2014. http://www.cnn.com/2014/07/08/health/iud-cancer-risk/
Thanks for visiting! I intend to start blogging here soon, but I'm also very interested in what you have to say! Please strike up a dialogue. I know some of the subjects I work on evoke strong emotions, so let's keep it respectful, and wherever possible, evidence-based.
I look forward to connecting and learning from you!
A reproductive health epidemiologist who hopes to transmute her rage at social injustice and scientific denialism into something useful.