Hormonal contraception and the risk of HIV acquisition among women in South  Africa

Morrison CS, Skoler-Karpoff S, Kwok C, Chen PL, van de Wijgert J, Gehret-Plagianos M, Patel S, Ahmed K, Ramjee G, Friedland B, Lahteenmaki P

doi:10.1097/QAD.0b013e32834fa13d

AIDS (London, England), 26(4), 497-504, 2011

Hormonal contraception and the risk of HIV acquisition among women in South Africa

Charles Morrison , Cynthia Kwok , Pai-Lien Chen

Author affiliations (8)

Durham University ROR
Family Health International 360 ROR
Triangle ROR
University of Limpopo ROR
Population Council ROR
University of Cape Town ROR
Perinatal HIV Research Unit ROR
Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Merseyside, United Kingdom.

DOI10.1097/QAD.0b013e32834fa13d PMID22156973

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Abstract

Objectives

To evaluate the effect of hormonal contraception including combined oral contraceptives (COCs), and the injectable progestins depo-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (Net-En) on the risk of HIV acquisition among women in South Africa. DESIGN/

Methods

We analyzed data from 5567 women aged 16-49 years participating in the Carraguard Phase 3 Efficacy Trial. Participants were interviewed about contraceptive use and sexual behaviors and underwent pelvic examinations and HIV testing quarterly. We used marginal structural Cox regression models to estimate the effect of hormonal contraception exposure on HIV acquisition risk among women overall and among young women (16-24 years) in particular.

Results

Two hundred and seventy participants became HIV-infected (3.7 per 100 woman-years); HIV incidence was 2.8, 4.6, 3.5 and 3.4 per 100 woman-years in the COC, DMPA, Net-En and nonhormonal contraceptive groups, respectively (P = 0.09). The adjusted hazard ratios (AHRs) were 0.84 [95% confidence interval (CI) 0.51-1.39], 1.28 (95% CI 0.92-1.78) and 0.92 (95% CI 0.64-1.32) among COC, DMPA and Net-En users, respectively, compared with the nonhormonal group controlling for covariates. Age modified the effect of hormonal contraception on HIV acquisition risk; among young women, the AHRs were 1.02 (95% CI 0.46-2.28) for COCs, 1.68 (95% CI 0.96-2.94) for DMPA and 1.36 (95% CI0.78-2.35) for Net-En users.

Conclusions

In this study conducted among South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.

Topics

Contraception/Comparison > Hormonal Contraceptives > HIV Risk Contraception/Comparison > Injectable Progestins > DMPA Side Effects General OB/GYN > Infectious Disease > Contraception and HIV

hormonal contraception HIV acquisition risk South Africa, DMPA injectable progestin HIV risk women, depo-medroxyprogesterone acetate HIV incidence prospective study, combined oral contraceptives norethisterone enanthate HIV acquisition, hormonal contraception immunodeficiency virus susceptibility, Carraguard trial contraceptive use HIV incidence South Africa, marginal structural Cox regression hormonal contraception HIV, injectable progestin young women HIV risk age modification, Morrison hormonal contraception HIV acquisition epidemiology, DMPA Net-En COC HIV risk comparison nonhormonal contraception

PMID 22156973 22156973 DOI 10.1097/QAD.0b013e32834fa13d 10.1097/QAD.0b013e32834fa13d

Cite this article

Morrison, C. S., Skoler-Karpoff, S., Kwok, C., Chen, P. L., van de Wijgert, J., Gehret-Plagianos, M., Patel, S., Ahmed, K., Ramjee, G., Friedland, B., & Lahteenmaki, P. (2012). Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS (London, England), 26(4), 497-504. https://doi.org/10.1097/QAD.0b013e32834fa13d

Keywords

Anti-Infective Agents, Contraceptives, Oral, Hormonal, Vaginal Creams, Foams, and Jellies, Medroxyprogesterone Acetate, Norethindrone Enanthate, Norethindrone

Contraception/ComparisonHIV RiskSafety OutcomesProspective Cohort Study

Prospective study of hormonal contraception and women's risk of HIV infection in South Africa

Myer L et al., 2007Int J Epidemiol

Many women using hormonal contraceptives are also at risk of sexually transmitted HIV infection, but data are mixed on whether hormonal contraception increases women's risk of HIV. We investigated associations between HIV incidence and use of combined oral contraceptives (COC), norethindrone enanthate (NET-EN) or depot medroxyprogesterone acetate (DMPA) in a cohort of South African women. Participants were 4200 HIV-negative women aged 35-49 years enrolled into a cervical cancer screening trial. At enrollment, women were tested for sexually transmitted infections and reported on their sexual behaviour and contraceptive use. During the 24 months of follow-up, women reported on their sexual behaviours and contraceptive use and underwent repeat HIV testing. During the 5010 person-years of follow-up, 111 incident HIV infections were observed (HIV incidence, 2.2 infections/100 person-years). At enrollment, 21% of women reported using hormonal contraception, primarily DMPA (14% of all women) or NET-EN (5%). After adjusting for sexual risk behaviours and sexually transmitted infections, the incidence of HIV was similar among women using COC, NET-EN or DMPA compared with women not using any hormonal method [incidence rate ratios and 95% confidence intervals, 0.65, 0.16-2.66; 0.79, 0.31-2.02 and 0.96, 0.58-1.59, respectively]. There was also no association between increased duration of DMPA use and HIV incidence (P-value for trend, 0.51). These findings contribute to the evidence from general population cohorts of women that hormonal contraceptive use is not associated with increased risk of HIV acquisition. Nonetheless, family planning services are an important venue for HIV prevention activities.

Contraception/ComparisonInfectious Disease RiskDepot Medroxyprogesterone AcetateHIV Acquisition

Hormonal contraceptive use, herpes simplex virus infection, and risk of HIV-1 acquisition among Kenyan women

Baeten JM et al., 2007AIDS

Studies of the effect of hormonal contraceptive use on the risk of HIV-1 acquisition have generated conflicting results. A recent study from Uganda and Zimbabwe found that women using hormonal contraception were at increased risk for HIV-1 if they were seronegative for herpes simplex virus type 2 (HSV-2), but not if they were HSV-2 seropositive. To explore the effect of HSV-2 infection on the relationship between hormonal contraception and HIV-1 in a high-risk population. Hormonal contraception has previously been associated with increased HIV-1 risk in this population. Data were from a prospective cohort study of 1206 HIV-1 seronegative sex workers from Mombasa, Kenya who were followed monthly. Multivariate Cox proportional hazards analyses were used to adjust for demographic and behavioral measures and incident sexually transmitted diseases. : Two hundred and thirty-three women acquired HIV-1 (8.7/100 person-years). HSV-2 prevalence (81%) and incidence (25.4/100 person-years) were high. In multivariate analysis, including adjustment for HSV-2, HIV-1 acquisition was associated with use of oral contraceptive pills [adjusted hazard ratio (HR), 1.46; 95% confidence interval (CI), 1.00-2.13] and depot medroxyprogesterone acetate (adjusted HR, 1.73; 95% CI, 1.28-2.34). The effect of contraception on HIV-1 susceptibility did not differ significantly between HSV-2 seronegative versus seropositive women. HSV-2 infection was associated with elevated HIV-1 risk (adjusted HR, 3.58; 95% CI, 1.64-7.82). In this group of high-risk African women, hormonal contraception and HSV-2 infection were both associated with increased risk for HIV-1 acquisition. HIV-1 risk associated with hormonal contraceptive use was not related to HSV-2 serostatus.