An interview with Dr. Timothy Flanigan, an authority on HIV/AIDS prevention and treatment.
by JOAN FRAWLEY DESMOND
The Bill and Melinda Gates Foundation held a July 11 summit designed to
raise an estimated $4 billion to promote contraception in the
The Gates campaign comes amid new research suggesting that use of
hormonal contraception doubles the risk of both transmission and
acquisition of HIV in regions like sub-Saharan Africa. Register senior
editor Joan Frawley Desmond turned to HIV/AIDS expert Dr. Timothy
Flanigan to explain how this research is likely to transform
Flanigan offers insight into understanding how big global health
organizations and foundations approach these issues and how they
perceive natural family planning. He also answers the burning questions:
Why is pregnancy presented as a dangerous medical condition? Are there
new opportunities to promote natural family planning?
Flanigan is a professor of medicine and infectious diseases at Brown
University Medical School and practices at Miriam and Rhode Island
Hospitals in Providence, R.I. He has been caring for patients with
HIV/AIDS for 25 years, and his research on HIV prevention and treatment
has been funded by the National Institutes of Health and the Centers for
Disease Control and Prevention. He is the father of five and is
enrolled in the deacon program for the Providence Diocese.
You’re an authority on HIV/AIDS who has published hundreds of
peer-reviewed studies on HIV/AIDS transmission, participated in global
conferences and cared for patients with HIV/AIDS near your home in Rhode
Island. What are your concerns about the promotion of contraception in
Africa and other parts of the developing world?
New research raises serious concerns about whether hormonal
contraception — Depo-Provera and oral contraception pills (OCT) —
actually doubles the risk of a woman acquiring HIV if she is exposed.
And if an HIV positive woman is on oral contraception, it may double the
risk that she can transmit it to her partner.
How was the study conducted?
It was a very large study that involved seven African countries. The
researchers looked at couples with one HIV-positive spouse and one
The study was designed to look at whether suppressing the herpes virus
would decrease HIV transmission. They enrolled well over 3,000 couples,
mostly from sub-Saharan Africa.
Since hormonal contraceptives, especially Depo-Provera, are widely
promoted in sub-Saharan Africa, the study provided an opportunity to see
whether oral or injectable contraception would increase or decrease the
risk of HIV transmission. What they found was very concerning: The
hormonal contraception widely touted and promoted doubles the risk of
acquisition and transmission of HIV.
The study was very well done, coordinated by the University of
Washington in Seattle. The results are alarming and have significant
implications for programs that actively promote the use of hormonal
Since the study was published, the National Institutes of Health (NIH),
UNAIDS and the World Health Organization (WHO) have convened panels to
review the research about how hormonal contraception increases the risk
of heterosexual transmission of HIV.
How will the study’s conclusion likely affect large-scale
contraception promotion campaigns like the Gates Foundation’s global
There is great concern, because hormonal contraception has been seen as
the solution for reproductive-health challenges. This alarming data
must lead to a reconsideration of the whole reproductive-health agenda,
which has relied on the promotion of hormonal contraception.
How long will it take for this research to result in a broader reassessment of the present strategy?
The data have been rapidly disseminated, but the change in practice
takes a long time. The field is confused, in disarray and uncertain
about how to proceed.
In the broader family-planning field, there has been an attempt to
assert that post-conception drugs designed to prevent pregnancy do not
work as abortifacients.
There is a whole separate issue going on in this field: An effort is
being made to say that post-conception contraception does not work as an
abortifacient. The reason for this aggressive effort is to normalize
This is on the cutting edge of the HHS [Health and Human Services]
mandate controversy. People are sympathetic to the Catholic Church’s
position that it should be able to deny coverage for abortifacients in
its employee health plan. When you poll Americans on this issue, you get
very different responses if you explain that abortifacients are
Many who oppose artificial contraception on moral or health grounds
wonder why global public-health organizations and foundations focus so
heavily on contraception promotion and provide fewer resources for other
health needs. Is this a fair assessment?
There is an underlying philosophy that the root of almost all problems
is too many people and that the way to solve these problems is through
population control. That philosophy promotes contraception as the
centerpiece of its effort.
Authentic development should not rely on contraception, but on
economic, social and community development. When that takes place,
families plan their children, and population decreases at a level
consistent with improved development.
The other problem with this approach is that women and families want
children. Recently, I read an article that reported that women on
contraception were still getting pregnant, and they needed to be taught
to take their birth-control pills. But one reason they don’t take their
birth-control pills is because they desire children.
Why are experts in the field so unwilling to consider natural family planning?
Natural family planning (NFP) is wrongly associated with the “rhythm
method” promoted many decades ago, an approach that is not effective.
NFP has evolved, and today it relies on excellent science and is used by
couples to space children and to enhance fertility when a woman wants
to be pregnant.
Second, many in the field assume that it can only be used or understood by individuals who have advanced education.
That is not the case. But NFP does require that a woman develops an
understanding of her cycle and that a couple together make decisions
regarding their sexual relations during the appropriate time in the
cycle, as interpreted by the NFP program they use. If the couple is not
committed, it doesn’t work.
NFP is relatively complicated and isn’t easy to “dispense.” It’s easier
to give a shot once a month than to take the time to educate and then
discuss a woman’s questions about her cycle.
Finally, public-health organizations want a family-planning approach
that can be adopted by women in vulnerable, abusive circumstances, where
sexual relationships are harmful or exploitative, such as commercial
sex workers and prostitutes. In that context, the spousal consultation
that makes NFP a gift for married couples isn’t possible.
So because NFP is more of a challenge in non-marital relationships,
it is ignored by global health programs. Sounds like they have adopted a
Yes, that is true.
But there are programs being tested in resource-limited areas. For
example, the World Youth Alliance is working throughout the island of
St. Lucia to develop a knowledge-based reproductive-health program.
There, FEMM or “Fertility, Education and Medical Management” is doing
very promising work. It’s an example of the promotion of new forms of
reproductive health in an atypical setting. It is getting a lot of
positive response from the women and teenagers of St. Lucia, along with
the Ministry of Health.
Are you suggesting that educating people about NFP, along with
other promising reproductive-health programs, is still a work in
It’s always a work in progress, because it’s an intimate, complex
issue; and that’s true whenever you are doing work that involves human
relationships. No reproductive-health program can be applied in all
circumstances, but natural family planning is a beautiful gift that
should be promoted. And now that we know hormonal contraceptives carry
serious risks, a more holistic approach that includes natural family
planning may get consideration.
Many pro-life activists view the term “reproductive rights” with
suspicion because it is often linked to an abortion-rights agenda.
Reproductive health should be a top priority. And “reproductive rights”
should mean that a woman deserves the best health care possible for
her, her family and her children.
But reproductive rights have been hijacked. The term now emphasizes the
need for “safe abortion.” An “unsafe” abortion takes the life of a
child and risks the life of the mother as well. But the answer is not to
promote safe abortion, but to understand and support women so that
abortion is unthinkable.
A new study funded by the Gates Foundation concluded that effective
contraception could save the lives of the “358,000 women ... [who] die
each year because of complications related to pregnancy and
childbirth.” Clearly, the Gates Foundation is basing its campaign goals
on this study. If you had a chance to advise Melinda Gates, what would
you tell her?
Pregnancy can be an enormous challenge to women’s health, and they can
develop life-threatening problems. In the developing world, you address
the risks associated with pregnancy by providing trained health-care
providers such as midwives and providing access to Caesarean section for
It’s important to understand that the risk of pregnancy doesn’t mean
that women don’t want children. Look at China: Look at what challenges
women will overcome to have their children.
The Gates Foundation has been extraordinarily generous, but the idea
that the promotion of oral contraception is the No. 1 answer to maternal
health needs is misplaced.