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DMPA May Have STI Advantage Over Copper
IUD and Levonorgestrel Implant
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Download the PDF here
10th IAS Conference on HIV Science (IAS 2019), July 21-24, 2019, Mexico City
Mark Mascolini
Women using DMPA-IV contraception had lower rates of gonorrhea than copper intrauterine device (IUD) users and lower rates of chlamydia than levonorgestrel (LNG) implant users in the 7800-woman southern African ECHO trial [1]. Separately, ECHO researchers reported that HIV incidence stood at 4.51 per 100 person-years in these women and did not differ by contraceptive method [2].
ECHO randomized 7829 HIV-negative 16- to 35-year-old women in Kenya, Zambia, South Africa, and eSwatini to intramuscular depot medroxyprogesterone acetate (DMPA-IM), copper IUD, or LNG implant and tested them routinely for HIV infection and two other sexually transmitted infections (STIs), Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT). Health workers used nucleic acid amplification to test for the two bacterial STIs at study entry, at the final visit, and at interim visits if clinically indicated. Researchers estimated point prevalence for the two STIs by log binomial regression by assess pairwise comparisons by contraceptive device and STI outcome.
Among 7829 women in an intention-to-treat population and 6361 in a continuous-use population, almost two thirds were 24 years old or younger, about 17% were never pregnant, and about 20% earned their own income. Fewer than 10% had never used a contraceptive. Overall point prevalence for NG measured 4.7% at the screening visit and 4.8% at the final visit. Point prevalence for CT was 18.2% at the screening visit and 15.4% at the final visit. The researchers rated NG and CT risk "considerable" in these sexually active women, even though they received routine prevention counseling and syndromic management.
At both the screening visit and the final visit, point prevalence of NG and CT proved significantly higher in women 24 or younger than in older women: for screening visit, 5.4% versus 3.6% for NG and 21.5% versus 12.4% for CT; for final visit, 5.8% versus 3.2% for NG and 19.6% versus 8.2% for CT. The researchers saw no evidence of effect modification by age group.
Pairwise comparisons of point prevalence ratios for NG and CT at the final visit indicated a 30% lower NG rate with DMPA-IM than copper IUD (prevalence ratio 0.7, 95% confidence interval 0.5 to 0.9, P = 0.002) and a 20% lower CT rate with DMPA-IM than LNG implant (prevalence ratio 0.8, 95% confidence interval 0.7 to 0.9, P = 0.005).
The ECHO team suggested that between-group differences in sexual behavior after randomization may have affected results, and they are conducting additional analyses to address that possibility. They added that the high NG and CT rates at the final visit, particularly in younger women, underline the need for greater focus on NG and CT testing and treatment in this population and in their partners. The researchers stressed that "any true decreased risk [with DMPA-IM] must be evaluated along with all potential risks and benefits of the contraceptive methods."
References
1. Deese J, Philip NM, Lind M, et al. Risk of sexually transmitted infections among women randomized to DMPA-IM, the copper IUD, and levonorgestrel implant in the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial. 10th IAS Conference on HIV Science (IAS 2019), July 21-24, 2019, Mexico City. Abstract LBPEB16. For e-poster: https://programme.ias2019.org//PAGMaterial/eposters/4845.pdf
2. Palanee-Phillips T, Baeten J, Heller K, et al. High HIV incidence among young women in South Africa: data from the ECHO trial. 10th IAS Conference on HIV Science (IAS 2019), July 21-24, 2019, Mexico City. Abstract LBPEC23.
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