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DMPA not associated with increased HIV infectivity in women on ART
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ATLANTA — There was no evidence that hormonal contraceptives increased HIV infectivity in women assigned antiretroviral therapy, according to study results presented here. The results are inconsistent with previous research in women not receiving antiretroviral therapy, which has led some experts to recommend that HIV-positive women stop hormonal contraceptive use.
“Following the publication of studies demonstrating [depot medroxyprogesterone acetate] may increase transmission of HIV, there has been some discussion of limiting its use in areas of high HIV seroprevalence,” study researcher Summer Day, MD, resident physician in pediatrics at Seattle Children's Hospital, told Infectious Disease News. “This strategy could lead to an increase in unplanned pregnancies, mother to child transmission, and maternal morbidity and mortality. Our results suggest that depot may not be associated with increased infectivity in HIV positive women who are adherent to effective ART regimens.”
Summer Day
Day and colleagues examined the link between depot medroxyprogesterone acetate (DMPA) use and detection of increased plasma and cervical HIV-1 levels in 99 women in a prospective cohort study. Plasma and cervical HIV-1 levels were assessed at baseline and every 3 months after ART initiation. Participants were interviewed at baseline and on a monthly basis. The researchers used generalized estimating equation models to determine the relationship between DMPA use and detection of plasma or cervical HIV-1 RNA.
Plasma viral load was <400 copies/mL at 787 (85%) visits. Cervical viral load was <400 copies/swab at 865 (94%) visits. Women were exposed to DMPA at 176 (19%) visits. DMPA use did not increase plasma HIV-1 detection (OR=0.64; 95% CI, 0.39-1.04) vs. no exposure, even after the researchers had adjusted for baseline plasma RNA, ART adherence and CD4 cell count (OR=0.81; 95% CI, 0.47-1.40).
Cervical swabs from women who were exposed to DMPA were no more likely to have detectable HIV-1 RNA vs. swabs from women who did not take hormonal contraception (OR=0.96; 95% CI, 0.44-2.11), and results were similar after adjusting for the same confounders (OR=1.38; 95% CI, 0.52-3.68). Controlling for current plasma HIV-1 RNA, the OR was 1.25 (95% CI, 0.41-4.41).
“In an era where we are increasingly utilizing ART for prevention, early ART initiation should certainly be considered as a part of comprehensive HIV care for women who desire hormonal contraception, regardless of whether they qualify for treatment initiation based on their CD4 count or disease stage,” Day said. – by John Schoen
For more information:
Day S. #29LB. Presented at: 2013 Conference on Retroviruses and Opportunistic Infections; March 3-6, 2013; Atlanta.
Disclosure: Day reports no relevant financial disclosures.
Perspective
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Elizabeth Connick, MD
Some studies have linked DMPA with increased vaginal viral load and HIV transmission in the absence of antiviral therapy. It is important to know that this is not the case in the setting of DMPA and ART. DMPA is one of the most effective birth control measures and enhances women’s health by preventing pregnancies. It is reassuring to HIV-infected women that they will not be putting their seronegative partners at increased risk of HIV acquisition if they use DMPA with ART. And, on a public health level, it is important to know that use of DMPA in conjunction with ART is unlikely to promote HIV transmission.
Perspective
Back to TopStephen Smith, MD
DMPA is a commonly used contraceptive agent in developing countries. Increasing data support the hypothesis that DMPA use in an uninfected woman increases her chance of HIV acquisition through vaginal intercourse. Fewer data on the relationship between DMPA and its effect on HIV replication exist. In 2004, Lavreys et al (J Infect Dis. 2004;189:303-311) established that women on DMPA at the time of HIV infection have higher HIV viral set points or viremia. These women were not on ART. In the Day et al study, the researchers examined the relationships between HIV viremia and cervical levels and DMPA in women on ART. Most women had undetectable HIV in both blood (85%) and cervical secretions (94%). DMPA exposure had no effect on the rate of women who had detectable levels of HIV in their blood or cervical secretions. The clinical implications of these findings are limited. The data suggest that DMPA in HIV-positive women on ART has no effect on their response to ART and, by inference, does not increase their “infectivity.” A much larger clinical trial would be required to measure the true effect of DMPA on female-to-male HIV transmission.
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