Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs
Identifieur interne : 003988 ( Istex/Corpus ); précédent : 003987; suivant : 003989Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs
Auteurs : Charles S. MorrisonSource :
- International Journal of Epidemiology [ 0300-5771 ] ; 2007-02.
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DOI: 10.1093/ije/dyl304
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all rights reserved.</p></licence><p scheme="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-GTWS0RDP-M">oup</p></availability><date>2007-01-24</date></publicationStmt><notesStmt><note type="review-article" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-L5L7X3NF-P">review-article</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a">Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs</title><author xml:id="author-0000"><persName><forename type="first">Charles S</forename><surname>Morrison</surname></persName><email>cmorrison@fhi.org</email><affiliation>Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA.</affiliation></author><idno type="istex">B0F9C961658CB9F8C8F1AACEE23B51B47B6E4619</idno><idno type="ark">ark:/67375/HXZ-JD1KMDS3-D</idno><idno type="DOI">10.1093/ije/dyl304</idno></analytic><monogr><title level="j">International Journal of Epidemiology</title><idno type="pISSN">0300-5771</idno><idno type="publisher-id">ije</idno><idno type="PublisherID-hwp">intjepid</idno><imprint><publisher>Oxford University Press</publisher><date type="published" when="2007-02"></date><biblScope unit="volume">36</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="175">175</biblScope><biblScope unit="page" to="177">177</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2007-01-24</date></creation><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>Depo-provera</term></item><item><term>heterosexual transmission</term></item><item><term>HIV acquisition</term></item><item><term>hormonal contraception</term></item><item><term>oral contraceptives</term></item><item><term>research</term></item><item><term>women</term></item></list></keywords></textClass><textClass><keywords scheme="Journal Subject"><list><head></head><item><term>HIV/AIDS</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2007-01-24">Created</change><change when="2007-02">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/B0F9C961658CB9F8C8F1AACEE23B51B47B6E4619/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus oup, element #text not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="utf-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="article-commentary">
<front>
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<journal-title>International Journal of Epidemiology</journal-title>
<issn pub-type="ppub">0300-5771</issn>
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<publisher-name>Oxford University Press</publisher-name>
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<article-id pub-id-type="doi">10.1093/ije/dyl304</article-id>
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<subject>HIV/AIDS</subject>
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<article-title>Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs</article-title>
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<contrib-group>
<contrib contrib-type="author" corresp="yes">
<name><surname>Morrison</surname><given-names>Charles S</given-names></name>
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<aff>Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA.</aff>
<author-notes>
<corresp>E-mail: <email>cmorrison@fhi.org</email></corresp>
</author-notes>
<pub-date pub-type="ppub">
<month>2</month>
<year>2007</year>
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<day>24</day>
<month>1</month>
<year>2007</year>
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<volume>36</volume>
<issue>1</issue>
<fpage>175</fpage>
<lpage>177</lpage>
<history>
<date date-type="accepted">
<day>13</day>
<month>12</month>
<year>2006</year>
</date>
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<copyright-statement>Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2007; all rights reserved.</copyright-statement>
<copyright-year>2007</copyright-year>
<kwd-group><kwd>Depo-provera</kwd><kwd>heterosexual transmission</kwd><kwd>HIV acquisition</kwd><kwd>hormonal contraception</kwd><kwd>oral contraceptives</kwd><kwd>research</kwd><kwd>women</kwd></kwd-group>
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</front>
<body><p>Hormonal methods of contraception—primarily combined oral contraceptives (COC) and injectable progestin-only contraception—are among the most widely used forms of reversible contraception worldwide. Over 100 million women use these methods<xref ref-type="bibr" rid="B1"><sup>1</sup></xref> and use is particularly high in many areas, such as sub-Saharan Africa, where HIV and other sexually transmitted infections (STIs) are highly prevalent. Use of injectable, progestin-only contraceptives including the 3-monthly injectable depot-medroxyprogesterone acetate (DMPA) and the 2-monthly injectable norethindrone enanthate (NET-EN) appear to be increasing rapidly in such areas. Thus, understanding whether women's use of hormonal contraception increases their risk of HIV acquisition is critically important.</p>
<p>Conclusive evidence of a relationship between hormonal contraceptive use and HIV acquisition would disrupt family planning programmes in areas with high HIV prevalence. Many women might discontinue hormonal methods, either switching to a less effective method of contraception or none at all. As a result, unintended pregnancies would likely increase and be accompanied by increased maternal mortality and morbidity due to childbirth and illegal abortions. An increase in unintended pregnancies would also likely occur among women who (knowingly or unknowingly) are already HIV-infected, with a consequent increase in the numbers of perinatally HIV-infected children.</p>
<p>The issue of a possible relationship between hormonal contraceptive use and HIV acquisition is particularly salient for South Africa, where the study reported by Myer and colleagues<xref ref-type="bibr" rid="B2"><sup>2</sup></xref> in this issue of IJE was conducted. Hormonal contraception is popular in South Africa, with 43% of sexually active women of reproductive age (15–49 years) using it. Use of injectables (particularly NET-EN) is especially high—more than double that of COC.<xref ref-type="bibr" rid="B2"><sup>2,</sup></xref><xref ref-type="bibr" rid="B3"><sup>3</sup></xref> Notably, few studies have reported on the effect of NET-EN use on HIV acquisition; thus, this study is timely and pertinent.</p>
<sec><title>Previous research on hormonal contraceptive use and HIV acquisition</title>
<p>Previous research conducted among macaques suggests that use of progestin-only contraception, in particular DMPA, increases the risk of simian immunodeficiency virus (SIV) acquisition.<xref ref-type="bibr" rid="B4 B5 B6"><sup>4–6</sup></xref> In addition, levels of post-infection viraemia are higher in DMPA-treated macaques than in DMPA-naïve macaques.<xref ref-type="bibr" rid="B4"><sup>4,</sup></xref><xref ref-type="bibr" rid="B6"><sup>6,</sup></xref><xref ref-type="bibr" rid="B7"><sup>7</sup></xref> Conversely, macaques treated with oestrogen appear to be protected against vaginal SIV transmission.<xref ref-type="bibr" rid="B5"><sup>5,</sup></xref><xref ref-type="bibr" rid="B8"><sup>8</sup></xref> This suggests that the hypoestrogenic effect associated with DMPA use may be responsible for the increase in SIV acquisition.<xref ref-type="bibr" rid="B5"><sup>5,</sup></xref><xref ref-type="bibr" rid="B8"><sup>8</sup></xref></p>
<p>However, evidence that hormonal contraceptive use affects women's risk of HIV acquisition is far less clear. In brief, of seven previous prospective studies examining DMPA use and HIV acquisition among women, two have found statistically significant increased HIV risk.<xref ref-type="bibr" rid="B9"><sup>9</sup></xref> Of the 12 previous prospective studies examining COC use and HIV acquisition, two have found a statistically significant increased risk (several others have found raised relative risks that were not statistically significant). Reviews of research on the possible association between COC use and HIV acquisition have reached opposite conclusions.<xref ref-type="bibr" rid="B10"><sup>10,</sup></xref><xref ref-type="bibr" rid="B11"><sup>11</sup></xref> Results of the recently published ‘Hormonal Contraception and Risk of HIV Acquisition (HC-HIV) Study’—the largest and most rigorous study of this issue among women from a general population group—found no overall increased risk of HIV acquisition among COC and DMPA users in Uganda and Zimbabwe.<xref ref-type="bibr" rid="B9"><sup>9</sup></xref> The results of the Myer analysis also suggest that women from the general population who use DMPA, NET-EN or COCs are not at increased risk of HIV acquisition.<xref ref-type="bibr" rid="B2"><sup>2</sup></xref></p>
<p>Several factors may contribute to these contradictory findings. First, methodological differences among studies are important. Of the published research in this area, only the HC-HIV Study was specifically designed to examine the impact of hormonal contraceptive use on the risk of HIV acquisition.<xref ref-type="bibr" rid="B9"><sup>9</sup></xref> Most other studies that have addressed this research issue have had serious methodological flaws. These include few hormonal contraceptive users and low study power, poor measurement of hormonal contraceptive use and potential confounding variables, lack of adjusted analyses and poor follow-up. In addition, due to the practical and ethical difficulties of randomizing women to various contraceptive methods—some of which (such as condoms only) are less effective in preventing pregnancy—all the studies have been observational. Thus, selection and confounding biases were possible.</p>
<p>The Myer analysis in this issue reports on a population drawn from a cervical cancer screening trial and focuses on a group—women from 35–49 years of age from a general population cohort—that has rarely been studied.<xref ref-type="bibr" rid="B2"><sup>2</sup></xref> The analysis has a number of strengths: its study population (4200 women) was large, it had a moderately large number of study outcomes (111 incident HIV infections) and it examined several hormonal contraceptives (DMPA, NET-EN, COCs). However, it also has a number of methodological weaknesses: its study population was at lower HIV risk compared with younger women; relatively few women used NET-EN (199 women) and COCs (94 women), resulting in imprecise effect estimates; and the average time between study visits (and thus assessment of contraceptive use and HIV infection) was almost 8 months. Furthermore, the study was not designed to follow up the entire study cohort at each visit, and measurement of HIV infection was restricted to use of an ELISA assay (rather than more sensitive HIV testing such as PCR), resulting in possible imprecision in the measurement of the timing of HIV infections.<xref ref-type="bibr" rid="B2"><sup>2</sup></xref></p>
<p>Second, the research populations have important differences in HIV risk status. Most studies finding evidence of an increased HIV risk among hormonal users were conducted among known high-risk groups such as sex workers or women attending STI clinics. In contrast, studies conducted among general population groups (e.g. women seeking family planning services) have generally found little increased HIV risk associated with hormonal contraceptive use. To the extent that high-risk populations represent high levels of exposure to HIV this finding is logical, as factors that increase a woman's susceptibility to HIV will only be of consequence in women actually exposed to infection.</p>
<p>Third, other STIs may play a modifying role in the hormonal contraception and HIV infection association. The HC-HIV study found a strong (but unexpected) modification effect according to the herpes simplex virus (HSV-2) infection status of women. Among women <italic>not</italic> infected with HSV-2, hormonal contraceptive use increased HIV risk, while among women infected <italic>with</italic> HSV-2, it did not.<xref ref-type="bibr" rid="B9"><sup>9</sup></xref> Previous studies have been conducted among populations with diverse HSV-2 infection rates. Several previous studies are now examining stored specimens to measure HSV-2 status so that a possible modification effect can be independently assessed.</p>
<p>Finally, other characteristics such as age that vary across study populations could modify the effect of hormonal contraception on HIV risk. Young women tend to use progestin-only injectable contraception disproportionately. For example, injectable use (and particularly NET-EN use) is especially high among young women and adolescents in South Africa where about half of all sexually active women aged 15–24 years use them.<xref ref-type="bibr" rid="B3"><sup>3</sup></xref> Notably, young women acquire HIV rapidly in South Africa: 17% of 15- to 24-year-old women are infected and HIV prevalence among young women is approximately four times that for young men of the same age group.<xref ref-type="bibr" rid="B12"><sup>12</sup></xref></p>
<p>Hormonal contraception may affect young women differently (through changes in the vaginal epithelium or local immunological effects) than older women. These differences could be associated with HIV acquisition risk. For example in the HC-HIV study, among women 18–24 years, COC and especially DMPA use was significantly associated with an increased HIV risk compared with no hormonal contraceptive use. In contrast, among women 25–35 years of age, hormonal contraceptive use was associated with a statistically significant decreased risk of HIV acquisition (this relationship will be described more fully in a subsequent publication). A similar modifying effect of age was found in a study of injectable contraception and HIV acquisition conducted in South Africa (the Palesa Study), although the effect did not attain statistical significance.<xref ref-type="bibr" rid="B13"><sup>13</sup></xref></p></sec>
<sec><title>Future research needs</title>
<p>What are the ongoing research needs in the area of hormonal contraception and HIV acquisition? First, we await the results from other studies evaluating the modifying effect of HSV-2 infection on the HC-HIV relationship. Second, we need studies to more fully explore the potential modifying effect of age. Third, we should understand whether other forms of hormonal contraception (including the progestin-only implants Jadelle and Implanon), which contain different progestins from those found in DMPA and NET-EN, affect HIV acquisition risk differently. Finally, we need to determine the risks and benefits of hormonal contraceptive use among HIV-infected women. In particular, we need to better understand whether HIV-infected, hormonal contraceptive users are more infectious to a sex partner, whether they are more likely to have rapidly progressive HIV infection, and whether they can safely use commonly prescribed anti-retroviral therapies when compared with women not using hormonal contraception.</p></sec>
</body>
<back>
<ack><title>Acknowledgements</title>
<p>I would like to thank Dr Ward Cates and Ms Kim Best for their insightful reviews of this commentary.</p>
<p><bold>Conflict of interest:</bold> Charles Morrison owns stock in Pfizer, the manufacturer of Depo-provera.</p></ack>
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</article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo><title>Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs</title></titleInfo><titleInfo type="alternative" contentType="CDATA"><title>Commentary: Hormonal contraception and HIV acquisition—current evidence and ongoing research needs</title></titleInfo><name type="personal"><namePart type="given">Charles S</namePart><namePart type="family">Morrison</namePart><affiliation>Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA.</affiliation><affiliation>E-mail: cmorrison@fhi.org</affiliation></name><typeOfResource>text</typeOfResource><genre type="review-article" displayLabel="article-commentary" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-L5L7X3NF-P">review-article</genre><originInfo><publisher>Oxford University Press</publisher><dateIssued encoding="w3cdtf">2007-02</dateIssued><dateCreated encoding="w3cdtf">2007-01-24</dateCreated><copyrightDate encoding="w3cdtf">2007</copyrightDate></originInfo><subject><genre>keywords</genre><topic>Depo-provera</topic><topic>heterosexual transmission</topic><topic>HIV acquisition</topic><topic>hormonal contraception</topic><topic>oral contraceptives</topic><topic>research</topic><topic>women</topic></subject><relatedItem type="host"><titleInfo><title>International Journal of Epidemiology</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><subject><topic>HIV/AIDS</topic></subject><identifier type="ISSN">0300-5771</identifier><identifier type="PublisherID">ije</identifier><identifier type="PublisherID-hwp">intjepid</identifier><part><date>2007</date><detail type="volume"><caption>vol.</caption><number>36</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>175</start><end>177</end></extent></part></relatedItem><identifier type="istex">B0F9C961658CB9F8C8F1AACEE23B51B47B6E4619</identifier><identifier type="DOI">10.1093/ije/dyl304</identifier><accessCondition type="use and reproduction" contentType="copyright">Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2007; all rights reserved.</accessCondition><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-GTWS0RDP-M">oup</recordContentSource><recordOrigin>Published by Oxford University Press on behalf of the International Epidemiological Association © The Author 2007; all rights reserved.</recordOrigin></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/B0F9C961658CB9F8C8F1AACEE23B51B47B6E4619/metadata/json</uri></json:item></metadata><covers><json:item><extension>tiff</extension><original>true</original><mimetype>image/tiff</mimetype><uri>https://api.istex.fr/document/B0F9C961658CB9F8C8F1AACEE23B51B47B6E4619/covers/tiff</uri></json:item></covers><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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