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HIV and contraception

Hormonal contraceptives associated with no added risk of HIV transmission

10 May, 12 | by Leslie Goode, Blogmaster

Does hormonal contraception raise the risk of HIV transmission?  Contraceptive choice may have an impact on sexual risk-taking behaviour, of course; but there has also been a concern that vaginal epithelium thinning arising from a progesterone-induced anovulatory state may reduce the efficacity of the vaginal barrier (Mitchell & Stephens, 2004).

Now a retrospective analysis of statistical data from an HIV-microbicide trial completed three years ago (HPTN 035) claims to offer reassuring evidence that injected forms of hormonal contraception are not associated with higher rates of HIV transmission.  Researchers from the Microbicides Trials Network (MTN) were reporting to the International Microbicides Conference (M2012), which met in Sydney 15th – 18th April.

These findings could hardly be more topical.  Last October a study published in the Lancet (Heffron, 2011) and subsequently reported in the New York Times, sent a wave of anxiety through the global health protection community with the claim that HIV-negative women might face a two-fold increased risk of acquiring the infection from their HIV-positive partners, and that HIV-positive women could have a two-fold increased risk of passing it on to the non-infected partners. The issue has enormous implications given the wide-scale use of injected hormonal contraception in areas of high HIV prevalence.  Around 12 million of all women in sub-Saharan Africa between the ages of 16 and 49, 6% of all women in this age-group, use this method.  Research, published in this journal and elsewhere, has emphasized, among its many advantages, the potential value of contraception as a prevention tool to combat vertical HIV transmission (mother to child) (Wilcher, Petruney, Reynolds & Cates, 2008; Reynolds, Janowitz, Wilcher, Cates, 2008; Reynolds, Steiner  & Cates, 2005).  Should the results of the Heffron study be even partially confirmed through further research, it is unclear how public health authorities would go about squaring the benefits of injectable hormonal contraception with increased HIV transmission risk.  In the meantime the World Health Organization and UNAID have not recommended any change in public health practice.

In such a context this report can hardly fail to make an impact, and the global public health community will no doubt be awaiting with interest the publication of the study.

H.S. Mitchell & E. Stephens, “Contraception Choice for HIV positive women”, Sexually Transmitted Infections 2004:80;3

[Abstract]  [Full text]  [PDF]

R. Wilcher, T. Petruney, H.W. Reynolds, W. Cates, “From effectiveness to impact: contraception as an HIV prevention intervention”, Sexually Transmitted Infections 2008:84;Suppl. 2

[Abstract][Full text][PDF]

H.W. Reynolds, B. Janowitz, R. Wilcher, W. Cates, “Contraception to prevent HIV-positive births: current contribution and potential cost savings in PEPFAR countries”, Sexually Transmitted Infections 2008:84 suppl.2

[Abstract][Full text][PDF]

H.W. Reynolds, M.J. Steiner, W. Cates, “Contraception’s proved potential to fight HIV” (Letter), Sexually Transmitted Infections:81;2

[Extract][Full text][PDF]

Renee Heffron, Jared Baeten et al., “Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study”, The Lancet Infectious Diseases, Vol. 12, Issue 1

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70247-X/abstract

For M2012 report see:

http://www.news-medical.net/news/20120418/No-added-HIV-risk-with-hormonal-contraceptives.aspx

 

Hormonal contraception doubles the risk of African HIV-1 transmission

11 Oct, 11 | by Leslie Goode, Blogmaster

What should be the policy on hormonal contraceptives in settings where the transmission of HIV is a serious concern – e.g. in sub-Saharan Africa?  Some studies have indicated the possibility of added risk of heterosexual transmission between sero-discordant partners where this method of contraception is used.  But given the need to balance that risk against the known benefit of hormonal contraception in reducing vertical transmission through unwanted pregnancy (also an important plank of public health policy), it is important to be as precise as possible about the extent and nature of the risk.  So the WHO has called for further research in this area.

Highly relevant to these concerns is a large prospective cohort study of 3,790 African heterosexual HIV 1 sero-discordant couples in seven sub-Saharan countries, recently reported in The Lancet Infectious Diseases.  This places the risk of transmission where hormonal contraception is used at approximately double – an adjusted hazard ratio of 1.98 of transmission from male to female partner, and of 1.97 from female to male.  It should be added that it is hormonal contraception by injection that is primarily at issue here; the number of participants taking oral pills was insufficient to warrant any firm conclusions.  These results bear out earlier findings concerning male to female transmission.  They also establish, for the first time, a similar level of risk for female to male transmission.

The causes of this added risk are hard to determine with any precision.  The participants in the present trial were recruited on the back of two longitudinal studies of HIV-1 incidence (2004-2010) – and required to complete standard questionnaires about their current contraceptive method at quarterly visits.  The authors draw attention to possible physiological factors that could be operating alongside behavioural ones in increasing the risk for hormonal contraception users.  But, as the authors themselves point out, it is hard to see how the respective influence of these or other factors could be determined without assigning groups of participants to specific contraceptive methods for the duration of the study – which is hardly feasible, or ethical!

There remains the question of how these findings should be embodied in health policy.  What is the balance that should be reached between the risks of vertical and horizontal transmission?  The authors confine themselves to emphasizing the importance of integrating contraceptive and HIV counselling and testing – as well as recommending that women should be warned of a potentially increased risk of horizontal transmission, and the value of dual protection (i.e. consistent condom use in addition to hormonal methods).

Renee Heffron, Jared M. Baeten et al., “Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study” in The Lancet Infectious Diseases, available online 3rd October, 2011

http://www.sciencedirect.com.libproxy.ucl.ac.uk/science/article/pii/S147330991170247X


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