Hormonal Contraceptive Use and HIV-1 Disease Progression
Hormonal Contraceptive Use and HIV-1 Disease Progression
Background: For HIV-1-infected women, hormonal contraception prevents unintended pregnancy, excess maternal morbidity, and vertical HIV-1 transmission. Hormonal contraceptives are widely used but their effects on HIV-1 disease progression are unclear.
Methods: In a prospective study among 2269 chronically HIV-1-infected women from seven countries in eastern and southern Africa and with enrollment CD4 cell counts at least 250 cells/μl, we compared rates of HIV-1 disease progression among those using and not using hormonal contraception (i.e. oral or injectable methods). The primary outcome was a composite endpoint of CD4 decline to less than 200 cells/μl, initiation of antiretroviral therapy, or death.
Results: Three hundred and seventy-two women experienced HIV-1 disease progression during 3242 years of follow-up (incidence rate = 11.5 events per 100 person-years). Rates of HIV-1 disease progression among women who were currently using and not using hormonal contraception were 8.54 and 12.31 per 100 person-years, respectively (adjusted hazard ratio 0.74, 95% confidence interval 0.56–0.98, P = 0.04). Rates were 8.58 and 8.39 per 100 person-years for the subsets using injectable and oral contraception (adjusted hazard ratio = 0.72, P = 0.04 for injectable users and adjusted hazard ratio = 0.83, P = 0.5 for oral users compared to women not using hormonal contraception). Sensitivity analyses assessing enrollment or cumulative contraceptive use during the study demonstrated risk estimates closer to 1.0 with no evidence for accelerated disease progression.
Conclusion: Among African women with chronic HIV-1 infection, use of hormonal contraception was not associated with deleterious consequences for HIV-1 disease progression.Introduction
For HIV-1-infected women, effective and well tolerated contraception is important to reduce unintended pregnancy and, thus, avoid excess maternal morbidity and risk of vertical HIV-1 transmission. It has been hypothesized that hormonal contraceptives could accelerate HIV-1 disease progression by increasing viral diversity, viral replication, or the set point viral load. In secondary data analysis of a clinical trial evaluating the safety of different contraceptive methods among HIV-1-infected Zambian women, women using hormonal methods [either injectable depot medroxyprogesterone acetate (DMPA) or oral contraceptive pills) had accelerated HIV-1 disease progression relative to women using an intrauterine device (IUD). However, several observational studies have not consistently demonstrated increased risk for faster HIV-1 disease progression with hormonal methods.
Understanding the scope of risks and benefits associated with different contraceptive methods is critical to counseling messages for women with HIV-1 and for development of public health policies. At a recent WHO technical consultation on hormonal contraceptives and HIV-1 risk, experts recommended that no restrictions be placed on the use of hormonal contraceptives by HIV-1-infected women. However, the body of evidence for hormonal contraceptives and HIV-1 disease progression was determined to have data limitations and further research was recommended. We assessed the relationship between hormonal contraceptive use and HIV-1 disease progression in a large and geographically diverse cohort of chronically HIV-1-infected African women prior to their initiation of antiretroviral therapy (ART).
Abstract and Introduction
Abstract
Background: For HIV-1-infected women, hormonal contraception prevents unintended pregnancy, excess maternal morbidity, and vertical HIV-1 transmission. Hormonal contraceptives are widely used but their effects on HIV-1 disease progression are unclear.
Methods: In a prospective study among 2269 chronically HIV-1-infected women from seven countries in eastern and southern Africa and with enrollment CD4 cell counts at least 250 cells/μl, we compared rates of HIV-1 disease progression among those using and not using hormonal contraception (i.e. oral or injectable methods). The primary outcome was a composite endpoint of CD4 decline to less than 200 cells/μl, initiation of antiretroviral therapy, or death.
Results: Three hundred and seventy-two women experienced HIV-1 disease progression during 3242 years of follow-up (incidence rate = 11.5 events per 100 person-years). Rates of HIV-1 disease progression among women who were currently using and not using hormonal contraception were 8.54 and 12.31 per 100 person-years, respectively (adjusted hazard ratio 0.74, 95% confidence interval 0.56–0.98, P = 0.04). Rates were 8.58 and 8.39 per 100 person-years for the subsets using injectable and oral contraception (adjusted hazard ratio = 0.72, P = 0.04 for injectable users and adjusted hazard ratio = 0.83, P = 0.5 for oral users compared to women not using hormonal contraception). Sensitivity analyses assessing enrollment or cumulative contraceptive use during the study demonstrated risk estimates closer to 1.0 with no evidence for accelerated disease progression.
Conclusion: Among African women with chronic HIV-1 infection, use of hormonal contraception was not associated with deleterious consequences for HIV-1 disease progression.Introduction
Introduction
For HIV-1-infected women, effective and well tolerated contraception is important to reduce unintended pregnancy and, thus, avoid excess maternal morbidity and risk of vertical HIV-1 transmission. It has been hypothesized that hormonal contraceptives could accelerate HIV-1 disease progression by increasing viral diversity, viral replication, or the set point viral load. In secondary data analysis of a clinical trial evaluating the safety of different contraceptive methods among HIV-1-infected Zambian women, women using hormonal methods [either injectable depot medroxyprogesterone acetate (DMPA) or oral contraceptive pills) had accelerated HIV-1 disease progression relative to women using an intrauterine device (IUD). However, several observational studies have not consistently demonstrated increased risk for faster HIV-1 disease progression with hormonal methods.
Understanding the scope of risks and benefits associated with different contraceptive methods is critical to counseling messages for women with HIV-1 and for development of public health policies. At a recent WHO technical consultation on hormonal contraceptives and HIV-1 risk, experts recommended that no restrictions be placed on the use of hormonal contraceptives by HIV-1-infected women. However, the body of evidence for hormonal contraceptives and HIV-1 disease progression was determined to have data limitations and further research was recommended. We assessed the relationship between hormonal contraceptive use and HIV-1 disease progression in a large and geographically diverse cohort of chronically HIV-1-infected African women prior to their initiation of antiretroviral therapy (ART).