Highly effective contraception and acquisition of HIV and other sexually transmitted infections

Behavioral and Biomedical Research Division, Family Health International, Research Triangle Park, NC 27709, USA.
Best practice & research. Clinical obstetrics & gynaecology (Impact Factor: 1.92). 03/2009; 23(2):263-84. DOI: 10.1016/j.bpobgyn.2008.11.004
Source: PubMed

ABSTRACT A key question for clinicians is whether an aetiological association exists between highly effective contraceptive methods and women's risk of acquiring sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). The authors searched the peer-reviewed literature for prospective studies published from January 1966 to August 2008 that assessed contraception and STI/HIV risk. The focus was on combined oral contraceptives (OCs), depot-medroxyprogesterone acetate (DMPA), the T380a copper intra-uterine device (IUD) and the risk of infection with HIV, Chlamydia trachomatis and Neisseria gonorrhoeae. Current data suggest that neither OCs nor DMPA increase HIV risk among women in the general population. Data are equivocal for women in high-risk groups (e.g. sex workers). Current data suggest an increased risk of chlamydial infection associated with OC use, with weaker evidence supporting a harmful effect of DMPA. Reports of OCs and gonococcal infection are inconsistent, and DMPA does not appear to be associated with gonorrhoea acquisition. Data suggest no increased STI/HIV risk among copper IUD users. Prospective data on highly effective contraceptive methods and women's STI/HIV risk are limited, and many studies have important methodological weaknesses. Additional information about the STI/HIV risks associated with these highly effective contraceptive methods is needed.

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    • "This paper addresses these issues by using information available about the competing risks of unwanted birth and HIV acquisition. The strengths and weaknesses of previous observational studies on HIV acquisition risk associated with hormonal contraception have been reviewed by many researchers [2] [3] [4] [5]. The elevated HIV acquisition risk with hormonal contraception estimated in these studies may be an artifact of some of the methodological issues and behavioral factors, and to some extent may also reflect the biological effect of hormonal contraception. "
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    ABSTRACT: BACKGROUND: A recent observational study among HIV-1 serodiscordant couples (uninfected women living with an infected partner) raised concerns about the safety of injectable contraceptives, especially depot medroxyprogesterone acetate (DMPA). The purpose of this paper is to assess the implications of potentially elevated risk of Human Immunodeficiency Virus (HIV) acquisition with the use of hormonal contraceptives for individual users and public policies. STUDY DESIGN: Two indicators expressing costs (additional unwanted births and additional maternal deaths) in terms of the same unit of benefit (per 100 HIV infections averted) are estimated by using data on competing risks of unwanted birth and HIV acquisition associated with the use of various contraceptive methods. Elevated HIV acquisition risks associated with hormonal contraception observed in the observational studies of family planning users, sex workers and HIV-1 serodiscordant couples are used. Other relevant data for Kenya, South Africa and Zimbabwe are used to illustrate the potential effect of withdrawal of DMPA at the population level. RESULTS: Both the risks of unwanted birth and HIV acquisition with sterilization, intrauterine devices (IUDs) and implants at the individual level are lower than those with DMPA. A shift from DMPA to an oral contraceptive (OC) or male condom by an individual could result in about 600 and a shift to no method in about 5400 additional unwanted births per 100 HIV infections averted. At the population level, the withdrawal of DMPA from Kenya, for example, could result in 7600 annual additional unwanted births and 40 annual additional maternal deaths per 100 HIV infections averted. CONCLUSION: Individual DMPA users may be advised to shift to sterilization, IUD or implant depending upon their reproductive needs and circumstances, but not to no method, OC or even condom alone. At the macro level, the decision to withdraw DMPA from family planning programs in sub-Saharan Africa is not warranted.
    Contraception 04/2012; 86(6). DOI:10.1016/j.contraception.2012.03.008 · 2.34 Impact Factor
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    • "In an effort to prevent both unintended pregnancy and STI, guidelines for adolescents recommend encouraging the use of both male condoms and another contraceptive: “… sexually active adolescents should be encouraged to use condoms in conjunction with a more effective method of contraception to provide both effective pregnancy prevention and protection against STIs” [10], although it is not known how compliant health care providers are with this recommendation. There are data to suggest that the use of some HCs may potentiate the risk of HIV infection for purely biological reasons, although study findings are inconsistent [11, 12]. On the other hand, condoms, which are highly effective in preventing sexually transmitted infection and transmission, are less effective than HCs in preventing pregnancy, both in typical and perfect use. "
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    ABSTRACT: Adolescent girls and young women who are at risk for unplanned pregnancy and sexually transmitted infection (STI), including HIV, are frequently counseled to use a hormonal contraceptive to protect against the former and condoms to protect against the latter, for example, American College of Obstetricians and Gynecologists, 2011. The present paper reviews the literature on multiple risk messages, compliance with this dual-use recommendation, predictors of dual use, and interventions developed to encourage dual use. Data indicate that simultaneous use of these two methods is not common, and that efforts to encourage dual use have not yielded promising results. An alternative is to recommend condom use alone, since condoms protect very well against STI and HIV, and quite well against pregnancy when used consistently and correctly. The availability of emergency contraception is relevant here. Research utilizing a randomized controlled trial is recommended.
    Infectious Diseases in Obstetrics and Gynecology 11/2011; 2011:691210. DOI:10.1155/2011/691210
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    • "Some hormonal contraceptives have been shown to potentially increase the risk of HIV-1 transmission through either physically changing the surface area of the vagina or through potentially increasing HIV-1 RNA viral load (VL) [3] [4] [5]. Studies have found that depot-medroxyprogesterone acetate (DMPA) increased the risk of acquiring HIV by potentially changing the surface area of the vagina, while inhibiting the production of Toll-like receptor 9 and interferon-␣ by plasmacytoid dendritic cells [3] [6]. Increases in the prevalence of VL in cervical secretions were found by Wang et al. in a prospective study of 216 HIV-1 positive women who initiated hormonal contraception during study enrolment [7]. "
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    ABSTRACT: Background: To assess hormonal contraceptive use and response to antiretroviral therapy (ART) as measured by changes in HIV-1 RNA viral load (VL) and CD4+ cell counts in HIV positive female adolescents on ART. Material and Methods: This study used prospective longitudinal data from the REACH cohort to compare the response to ART in adolescent females using hormonal contraception to the response to ART in adolescent females not using hormonal contraception. Outcome measures were VL and CD4+ T cell counts assessed every 3 months. The association between hormonal contraception exposure and the response to ARTwasassessed using repeated measures multivariate analysis while adjusting for additional covariates. Results: The majority of participants were African American (73%). Median baseline age was 17 years (IQR 16 - 18). VL of ART users decreased over time in both hormonal contraception users (-0.0152 log copies/ml per day) and non-users (-0.0154 log copies/ml per day). However, the decrease was slightly lower (1.2×10-3, 95%CI: 6.2×10-5-2.4×10-3 copies/ml log VL per day, p-value = 0.03) among hormonal contraceptive users. Conclusions: This study shows a significant association between hormonal contraception use and a diminished response to ART. However, the impact of hormonal contraception on HIV-1 acquisition, progression, and treatment is still not clear. © 2011 Published by Elsevier Urban & Partner Sp. z.o.o. on behalf of Polish AIDS Research Society.
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