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Hormonal Contraception & HIV Transmission Risk: 3 Recent Studies Published, 'Condoms Critical To Prevent Transmission'
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WHO: "Consistent and correct use of condoms, male or female, is critical for prevention of HIV transmission to non-infected sexual partners"
"The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male or female, as hormonal contraceptives are not protective against HIV transmission or acquisition.......Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not show this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures."
3 Recent Studies Published
Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study - (10/05/11)
The Lancet Infectious Diseases, Early Online Publication, 4 October 2011
Renee Heffron, Deborah Donnell, Helen Rees, Connie Celum, Nelly Mugo, Edwin Were, Guy de Bruyn, Edith Nakku-Joloba, Kenneth Ngure, James Kiarie, Robert W Coombs, Jared M Baeten, for the Partners in Prevention HSV/HIV Transmission Study Team
"Use of hormonal contraceptives was associated with a two-times increase in the risk of HIV-1 acquisition by women and HIV-1 transmission from women to men. Injectable methods were the most common form of hormonal contraception used by our study population and subgroup analyses showed significantly increased HIV-1 risk associated with injectable use. Few women used oral contraceptives in our study; oral contraceptive use was associated with a non-significant increase in HIV-1 risk and our results are insufficient for drawing definitive conclusions about oral contraceptive use and HIV-1 risk....."
Hormonal contraception and HIV: an unanswered question EDITORIAL - (10/05/11)
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Hormonal contraception and the risk of HIV acquisition among women in South Africa
AIDS: 20 February 2012, Morrison, Charles S, FHI 360, Durham, North Carolina et al
Author Conclusion: "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......"
"We found no increased risk of HIV acquisition overall among women using DMPA, COCs or Net-En among South African women participating in the Carraguard Microbicide Trial. However, we found modest evidence of an increased HIV acquisition risk among young women who used DMPA, whereas there was no statistically significant increased risk among young women using COCs or Net-En. We also found modest evidence of decreased HIV acquisition risk among older women who used Net-En but not among older women who used DMPA or COCs.......Women in areas of high HIV incidence should be counseled about the need for condom use and maintaining a monogamous relationship. This may be especially important for younger women and particularly those who use DMPA as their contraceptive method. Efforts should also be made to expand women's access to highly effective nonhormonal (e.g. IUDs) and low-dose hormonal (e.g. implants) methods. Moreover, to resolve this important public health question, we need to conduct a randomized trial to clarify the relationship between hormonal contraception and HIV acquisition, particularly among young women."
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The effects of injectable hormonal contraceptives on HIV seroconversion and on sexually transmitted infections
AIDS: 28 January 2012, Wand, Handana; Ramjee, Gitab, aThe Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia bHIV Prevention Research Unit, Medical Research Council, Durban, South Africa.
"Using hormonal injectables during the study was significantly associated with increased risk for HIV-1 infection [adjusted hazard ratio 1.72, 95% confidence interval (CI) 1.19Ð2.49, P = 0.005]; hormonal injectables were also significantly associated with higher prevalent of C. trachomatis infections (adjusted odds ratio 2.46, 95% CI 1.52Ð3.97, P < 0.001).....
Hormonal contraceptives, particularly injectables, play important role in improving maternal and child health by reducing unplanned pregnancies. Although these woman-controlled methods empower women and increase reproductive health, they do not protect against HIV-1 and other STIs. Results from this study reinforce the importance of comprehensive contraceptive counseling of women regarding increased risk of HIV-1 and other STIs and importance of dual protection, such as dual condom and hormonal contraceptive use"
Discussion
In this study, we found that injectable hormonal contraceptive use was significantly associated with increased risk of HIV-1 and C. trachomatis infections among women in Durban, South Africa. At the enrollment, women were encouraged to use at least one form of effective contraceptive; however, they were not excluded if they chose not to use them. Nevertheless, the majority (92%) of the women were using at least one form of contraceptive, particularly injectables. This is consistent with the pattern of contraceptive use in sub-Saharan Africa [8,20]. Women using effective forms of nonbarrier methods, such as injectables and pills, may be less likely to use condoms [21] and this was supported by this study. Compared with women who reported using condoms as their preferred form of contraceptive, those who reported using injectables were less likely to use condoms in their sexual acts.
The most recent study has indicated that users of hormonal contraceptives (oral or injectable) were more likely to both acquire and transmit HIV [18]. The increased likelihood of transmission was thought to be a result of elevated genital HIV viral loads in hormonal contraceptive users. This effect was driven by users of injectable hormonal methods, who had 67% increased odds of having a detectable genital viral load [18].
Decisions about contraceptives should reflect both the need to prevent unplanned pregnancies and the need to prevent HIV and other STIs. Condoms, which are currently the most widely available and most effective method for prevention of HIV and STIs, may not necessarily be the most effective contraceptive under typical conditions [7]. The combination of a barrier method with a more effective contraceptive could potentially maximize the dual protective effect. Yet not all participants may be empowered to use dual protective methods, as cultural proscriptions on the use of barrier contraceptives may exist [22,23], and women may not be able to insist upon their use [24]. Two potentially woman-controlled barrier methods currently exist: the female condom and the vaginal diaphragm. Although the vaginal diaphragm could potentially be used independently of the cooperation of a male partner, it has not conclusively been shown to prevent the acquisition of HIV [25]. The female condom, although probably effective as an anti-HIV measure [26,27], has been somewhat limited in use and uptake owing to cost and policy factors [28,29]. Although, they do not protect against HIV and other STIs, intrauterine contraceptive devices are also considered to be one of the most effective female-controlled contraceptive methods and may play important role in dual protection if woman does not want to use hormonal injectables or pills. New research efforts are being made toward the development of dual protective woman-controlled technologies, such as intravaginal rings, in which both contraceptive and microbicidal agents are combined [30], although wide availability of such methods is likely to be several years distant.
Our findings add to the current body of knowledge surrounding the relationship between hormonal contraception and risk of HIV-1 [18]. However, some caution should be exercised in the interpretation of the data, as the women involved were participants in a clinical trial and were considered to be at particularly high risk for acquisition of HIV-1. Contraception use was also self-reported; thus, data may have been subject to recall bias. Like previously published studies, these findings were derived from observational data, which may be biased by self-selection. Therefore, results may not be widely generalizable but, at the least, may inform local healthcare guidelines.
Conclusion
Hormonal contraceptives, particularly injectables, play important role in improving maternal and child health by reducing unplanned pregnancies. Although these woman-controlled methods empower women and increase reproductive health, they do not protect against HIV-1 and other STIs. Results from this study reinforce the importance of comprehensive contraceptive counseling of women regarding increased risk of HIV-1 and other STIs and importance of dual protection, such as dual condom and hormonal contraceptive use Table 2.
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