Pope Francis’s comments on contraception last week may prove to be a turning point in the fight against the Zika virus. While the pope stopped short of endorsing artificial contraception, his moderate stance on the issue could open the door to broader birth control access in Latin America. That could have a particularly big impact on the poor women who are at the greatest risk for Zika infection and babies born with microcephaly.
As with many diseases, the poor are especially susceptible to the Zika virus. People who live in homes without air conditioning, as well as homes located near standing water or uncollected trash, are at greater risk of infection. Poorer women around the world also have a hard time accessing effective contraception. As a result, over 50% of pregnancies in Latin America are unplanned.
The issues of poverty and contraception have also been central to efforts to combat HIV. In plotting a way forward with Zika, therefore, it’s helpful to look at one tactic that’s been particularly successful in stopping the spread of HIV in Africa.
After three clinical trials demonstrated that medical (as opposed to traditional) male circumcision reduces the risk of female-to-male transmission of HIV by 60%, the World Health Organization and United Nations organization UNAIDS recommended that men be offered voluntary circumcision in countries with high rates of HIV. Since 2011, more than 10 million men in 14 countries in eastern and southern Africa have been circumcised.
This wasn’t an easy task. Men are understandably afraid that circumcision will be painful or could compromise sexual pleasure. Social norms and religious beliefs can also be barriers. Even for those seeking circumcision, access to trained medical professionals who could perform the procedure was scarce.
To address these issues, African countries needed to pursue a range of strategies that would scale up male circumcision. Some countries are using mobile clinics, predominantly run by non-governmental organizations (NGOs), to provide outreach to rural and impoverished areas where men would otherwise lack access to circumcision services.
Others are partnering with the private sector. In South Africa, for example, private providers were trained to perform male circumcisions. They were then reimbursed at a rate lower than their usual charge by the Centre for HIV and AIDS Prevention Studies, a South African NGO funded largely by the US Agency for International Development. The arrangement still works to private companies’ benefit: Demand for circumcisions increased significantly because they were provided free of charge to patients.
IUDs and hormonal implants are the most reliable form of reversible contraception, with failure rates of less than 1%. They’re also long-lasting: Hormonal IUDs and implants prevent pregnancy for three to five years, while copper IUDs last at least a decade. But only 7.2% of women of childbearing age in the Carribean and Latin America currently use IUDs, while just 4.5% use hormone injections or implants.
Latin American countries and nonprofits should move quickly to scale up access to the contraceptives we know to be most effective and long-lasting. Private providers could be trained to insert IUDs and place hormonal implants in exchange for providing the service at no charge to poor women. This training would help them to command generous reimbursement from private patients who also want access to IUDs and implants.
Meanwhile, manufacturers could provide IUDs and implants at low or no cost. They have a strong incentive to do so: once women are familiar and comfortable with one form of birth control, they are often married to that method for life. So by giving women an incentive to use their products, IUD and implant manufacturers would win themselves loyal customers.
We should, of course, make sure that other contraceptive options are also available to women through routine health services. Contraceptive stock-outs, in which health facilities and pharmacies run out of contraceptives, are common throughout Latin America because of problems along the supply chain. This makes it difficult for women to use birth control pills, patches, vaginal rings and other shorter-acting options consistently.
As with many epidemics, there isn’t a single solution to the Zika outbreak. We’ll need a combination of strategies, ranging from developing a vaccine to mosquito control, family planning, better treatment for Zika virus victims and comprehensive care for babies (and later children and adults) with microcephaly. But we should make expanding access to effective, long-lasting contraception an immediate priority. This will buy us time as the global medical community works to prevent Zika infections in pregnancy.