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Injectable contraceptive associated with increased risk for HIV acquisition
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Women using the injectable hormonal contraceptive depot medroxyprogesterone acetate, or DMPA, have a moderately increased risk for acquiring HIV, according to new data published in The Lancet Infectious Diseases.
“Whether this increased risk merits withdrawal of DMPA needs to be balanced against the known benefits of highly effective contraception, such as their role in preventing unintended pregnancy and its associated morbidity and mortality,” Lauren J. Ralph, MPH, an epidemiologist at the University of California at Berkeley, told Infectious Disease News. “Current modeling studies suggest that withdrawal of DMPA would not be warranted in most countries for women in the general population.”
According to Ralph, there are 3 decades of research that have examined whether hormonal contraception increased a women’s risk for HIV, and study results have conflicted. To synthesize the evidence quantitatively, Ralph and colleagues conducted a systematic review and meta-analysis to determine the risk for HIV among women using hormonal contraception. They identified 26 studies; 12 met inclusion criteria for the analysis. All of the studies were conducted in sub-Saharan Africa.
Lauren J. Ralph
In a pooled analysis, use of DMPA was associated with an increased risk for HIV acquisition (HR=1.4; 95% CI, 1.16-1.69) compared with those who use nonhormonal contraception or no contraception. In a subgroup analysis, the pooled HR from three prospective cohort studies was 1.44 (95% CI, 1.04-2.01). There were eight studies that included women in the general population, and the pooled estimate also suggested a higher risk for HIV acquisition (HR=1.31; 95% CI, 1.1-1.57). A pooled estimate for studies conducted among high risk women, for example those in serodiscordant partnerships or commercial sex workers, was not calculated due to heterogeneity.
“There were only two studies conducted among these high-risk women that met the inclusion criteria for our study, and although they both reported a significant association between the use of DMPA and HIV risk, we would be very cautious to broadly generalize findings based on this small number of studies,” Ralph said. “Additional evidence regarding the magnitude and mechanism of the DMPA-HIV link among high-risk women is urgently needed.”
The researchers found no increased risk for HIV acquisition associated with oral contraceptives or with norethisterone enanthate, another injectable hormonal contraceptive.
Ralph said that context will be critical to determine how these findings will influence practice. For example, DMPA is one of the more popular contraceptive methods used by women in sub-Saharan Africa, she said, but it is less popular in the United States, where HIV prevalence and incidence is lower and concentrated in different subgroups.
In an accompanying commentary, Christopher J. Colvin, PhD, of the University of Cape Town, and Abigail Harrison, PhD, of Brown University School of Public Health, said there are significant debates over the link between HIV and DMPA that have focused on whether a large, randomized controlled trial is necessary.
“Like many scientific controversies, views have become hardened, personal, financial, or political agendas have been suggested, and there has even been intrigue in the form of leaked copies under peer review,” the authors wrote. “Both sides have raised important, compelling arguments, but their partisan character can weaken the quality of the debates and restrict the view of the complex relation between evidence, policy and practice.” – by Emily Shafer.
For more information:
Colvin CJ. Lancet Infect Dis. 2015;doi:10.1016/S1473-3099(14)71076-X.
Ralph LJ. Lancet Infect Dis. 2015;doi:10.1016/S1473-3099(14)71052-7.
Disclosure: Colvin, Harrison, Ralph and the other researchers report no relevant financial disclosures.