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Thursday 21.07.2016 -Hormonal Contraception and HIV: A Review of the Science and Research, and their implications for Research, Programme and Policy.
Some studies suggest an association between specific hormonal contraception methods and HIV acquisition. DMPA has been mostly implicated. Information has come from observational studies alone.
Chelsea Polis, US, presented an updated systematic review,updating their previous 2014 review, Ten new and 21 studies from past review were included in the analysis.
Patches, rings, Hormonal IUDs: no data
Implants: very limited data on LNG implants, does not suggest increased risk.
OCPs [Oral contraceptive pills]: substantial amount of data, does not suggest increased risk.
DMPA [depot medroxyprogesterone acetate ]: substantial amount of data, newer data are increasingly concerning and converging around 1.2 -1.6.
NET-EN [norethisterone enanthate (NET-EN) ]: limited data; less concerning than 2014 review, still worthy of investigation.
Questions were raised regarding the reliability of the results considering the nature of the studies, none being RCTs in particular relating selection bias. ie. Women at higher risk for HIV choosing DMPA.
Another delegate stated that pregnancy per se increases risk of HIV acquisition by around two fold and there is a need for reliable contraception; hence findings of any small increases in risk of HIV acquisition with DMPA should be considered in context.
Jared Baeten, US, Update on ECHO Multi Centre, Open Label, Randomised trial on HIV acquisition among users of different hormonal contraception methods [DMPA, LNG implant, Cu IUCD].
N=7800 f/u , 12 sites in Kenya, South Africa (9), Swaziland and Zambia. 18 mths per women. Quarterly follow up with usual standard of care.
Started in 2015 and will go on for ~36 mths.
This is a very important study.
Janet Hapgood, SA, Biological/immunological mechanisms for an association between HC and HIV.
Very interesting presentation with regard to progestogens: different doses, methods of delivery, duration, inter-individual variation, differ in their off-target effects via different steroid receptors which predicts different side effects. DMPA has activity like cortisol.
Conclusion: Collectively, clinical, animal, and ex vivo studies are broadly consistent and show that DMPA increases permeability of the female genital tract and compromises select FGT and systemic immune responses. This most likely leads to increases in HIV acquisition via multiple mechanisms more so in some individuals than others.
Andy Gray, South Africa, presented on Interactions between HC methods and ART- updated systematic review. This review was to update the evidence on which the WHO guidance and local policy is bases.
ART and HC effectiveness
· Efavirenz – most clinically significant interactions were with Efavirenz.
Implant users: pregnancy rates from 5-15 per 100 w-y. (c.f 0-2 per 100 w-y)
Combined oral contraceptive pill: 13-15 per 100 w-y.
DMPA: not impactecd.
· Nevirapine – No significant impact.
HC and ART effectiveness – No significant effect noted.
DMPA and PrEP – no significant effect.
· Current published data do not support limiting access to any HC.
· Full range of HC options should be made available
· More well designed studies are required to study drug interactions