Hormonal contraceptive methods and risk of HIV acquisition in women: a systematic review of epidemiological evidence

Whether use of various types of hormonal contraception (HC) affect risk of HIV acquisition is a critical question for women's health. For this systematic review, we identified 22 studies published by January 15, 2014 which met inclusion criteria; we classified thirteen studies as having severe methodological limitations, and nine studies as “informative but with important limitations”. Overall, data do not support an association between use of oral contraceptives and increased risk of HIV acquisition. Uncertainty persists regarding whether an association exists between depot-medroxyprogesterone acetate (DMPA) use and risk of HIV acquisition. Most studies suggested no significantly increased HIV risk with norethisterone enanthate (NET-EN) use, but when assessed in the same study, point estimates for NET-EN tended to be larger than for DMPA, though 95% confidence intervals overlapped substantially. No data have suggested significantly increased risk of HIV acquisition with use of implants, though data were limited. No data are available on the relationship between use of contraceptive patches, rings, or hormonal intrauterine devices and risk of HIV acquisition. Women choosing progestin-only injectable contraceptives such as DMPA or NET-EN should be informed of the current uncertainty regarding whether use of these methods increases risk of HIV acquisition, and like all women at risk of HIV, should be empowered to access and use condoms and other HIV preventative measures. Programs, practitioners, and women urgently need guidance on how to maximize health with respect to avoiding both unintended pregnancy and HIV given inconclusive or limited data for certain HC methods.     

Use of injectable progestin contraception and risk of STI among South African women

Objective

This study was conducted to determine the association between the use of injectable progestin contraception (IPC) and the risk of infection with Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), bacterial vaginosis (BV) and Trichomonas vaginalis (TV) among women in South Africa.

Methods

From August 1999 through May 2001, 643 HIV-1-negative women were recruited from family planning clinics in Orange Farm, South Africa. IPC [norethisterone enanthate (NET-EN) and depot medroxyprogesterone acetate (DMPA)] users and nonhormonal contraception users were recruited in approximately equal numbers. Eligible participants were seen at enrolment and on four follow-up visits over a 12-month period; 567 returned for at least one follow-up visit. Multivariable Poisson regression models with generalized estimating equations were used to compute the incidence rate ratios (IRRs) for infections with GC, CT, BV and TV by use of NET-EN or DMPA relative to nonuse during follow-up.

Results

In multivariable models, the use of DMPA slightly increased the risk of infection with CT [IRR=1.24; 95% confidence interval (95% CI)=0.80–1.94] and GC (IRR=1.30; 95% CI=0.58–2.98), although these associations were not statistically significant. In contrast, DMPA appeared to be protective for TV (IRR=0.35; 95% CI=0.12–1.01), although this estimate was very imprecise. The use of both DMPA and NET-EN was associated with a decreased risk of BV.

Conclusions

The use of DMPA among women in this study population was associated with an increased — but not statistically significant — risk of cervical infection with chlamydia and gonorrhea, and a decreased risk of TV and BV. Given the inconsistencies and limitations of the data describing an increased risk of CT and GC with IPC use, the potential risk of sexually transmitted infections (STIs) must be balanced against the risk of unintended pregnancy and its health consequences, especially in developing countries. Women opting to use IPC should be counseled to use condoms to protect against STIs and HIV.     

Depo-Provera: use of a long-acting progestin injectable contraceptive in Turkish women

OBJECTIVE: To assess the demographic and clinical characteristics and experience of Turkish women treated with depot medroxyprogesterone acetate (DMPA). STUDY DESIGN: This prospective clinical study was carried on 9262 subjects, treated with DMPA at Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey, between 1996 and 2004. RESULTS: The mean age of study population was 28.4+/-4.6 years; 1759 (19%) subjects were breast-feeding at the time of the first injection. Eight (0.08%) pregnancies occurred, within 3 months of injection in 9262 women. Of 9262 cases, irregular bleeding occurred in 80% (7410) of the women. Discontinuation rate with this contraceptive method was recorded as 71% (6576) of the subjects. The rate of other predominant side effects was observed as follows: 8% for increase in weight, 8% for breast engorgement, 7% for mastalgia, 5% for headache. CONCLUSION: The results of this study suggest that DMPA may be an attractive contraceptive choice for both the patient and the physician in some clinical situations, especially in women at risk for complications with oral hormonal contraceptives and women who have had low compliance with other contraceptive methods. Moreover, DMPA contraception might be particularly appropriate in some cases such as in the postpartum period and in lactating women.     

Injectable progestin contraceptive use and risk of HIV infection in a South African family planning cohort

OBJECTIVE: To investigate whether the incidence of HIV infection is higher among sexually active women using depot medroxyprogesterone acetate (DMPA) or noresthisterone enanthate (NET-EN) injections for contraception than among women using nonhormonal or no contraception. METHODS: Five hundred and fifty-one initially HIV-negative women were followed up for a total of 491 person-years. Participants were interviewed, counselled, examined, tested for HIV and other STIs, and treated, at three monthly intervals for 1 year. RESULTS: There was no significant association between progestin contraceptive use and HIV infection (rate ratio 1.1, 95% CI 0.5 to 2.8; log-rank test, p=.73). In proportional hazards regression, the only significant hazard ratios for HIV acquisition were prevalent Neisseria gonorrhoea (5.2; 95% CI 1.1 to 23.7, p=.035) and Trichomonas vaginalis (4.8; 95% CI 1.0 to 22.8, p=.049); bacterial vaginosis was marginally significant (2.8; 95% CI 1.0 to 8.3, p=.057). The adjusted hazard ratios for NET-EN and DMPA were 1.76 (95% CI 0.64 to 4.84) and 0.46 (95% CI 0.06 to 3.79), respectively, relative to nonuse. Five hundred and twelve of 551 women had one or more confirmed STIs during the study. CONCLUSIONS: There is no evidence of an association between HIV infection and injectable contraceptives. Due to the limited power of this study and because similar studies have not included young women using NET-EN, we recommend that further research be carried out to focus on the use of NET-EN and HIV acquisition in high risk groups.     

Birth intervals and injectable contraception in sub-Saharan Africa

OBJECTIVE: The interval between births is associated with child survival in the developing world. We aimed to investigate associations between use of depot-medroxyprogesterone acetate and other reversible contraception and short birth intervals in sub-Saharan Africa. METHODS: Data from successive Demographic and Health Surveys undertaken in nine African countries were analyzed. Logistic regression was used to explain changes in the proportion of short birth intervals in four countries with relatively high use of reversible contraception. FINDINGS: The overall odds ratio for the trend was 0.90 (95% CI 0.84 to 0.95) and this was unaffected by adjusting for the other variables. The odds of a short birth interval were reduced by exclusive breastfeeding (OR 0.67, 95% CI 0.58 to 0.78) and increased by use of injectable contraception (OR 1.23, 95% CI 1.11 to 1.38). CONCLUSION: The proportion of short birth intervals has changed little over the last decade in a context of very low use of the intrauterine device. Widespread adoption of injectable contraception is associated with greater odds of a short birth interval, thus not contributing favorable conditions for improved child health.     

A prospective study of immediate initiation of depo medroxyprogesterone acetate contraceptive injection

Traditional protocols for depo medroxyprogesterone acetate (DMPA) initiation mandate that women start the method during the first 5-7 days of the menstrual cycle. Women who do not have their initial clinic visit during this time period are generally instructed to return to clinic during menses to begin DMPA, which often leaves them insufficiently protected from pregnancy. An alternative approach is to give women the injection immediately during the clinic visit, regardless of menstrual cycle day. In this prospective study, we evaluated a protocol for immediate DMPA initiation among 149 women who presented on cycle day 8 or later. Ninety-two percent (n = 137) of subjects returned for a follow-up pregnancy test, but half of all subjects required multiple reminders to return for the visit. There were three pregnancies. Forty-seven percent (n = 70) continued to a second DMPA injection or another contraceptive method within 14 weeks of their initial clinic visit. Factors associated with returning for repeat injection included satisfaction with DMPA, older age and finding it easy to return for the follow-up pregnancy test visit.     

Immediate monthly combination contraception to facilitate initiation of the depot medroxyprogesterone acetate contraceptive injection

Conventional clinical protocols specify that women initiate depot medroxyprogesterone acetate (DMPA) within 7 days of the onset of menses, and product labeling specifies initiation within 5 days. Women outside of this window should wait until next menses to begin, often leaving them with inadequate interim contraceptive protection. An alternative is for women to initiate monthly hormonal contraception immediately, as a bridge to DMPA, with a scheduled follow-up appointment about 4 weeks later. We evaluated bridge preferences and DMPA initiation among 150 women requesting DMPA who were ineligible for their first injection at the time of clinic visit due to menstrual cycle day. Ninety-eight percent (n = 147) rejected the standard protocol of waiting with condoms or abstinence in favor of a hormonal bridge method. Ninety-seven percent follow-up (n = 146) showed that 86% were satisfied with their bridge method. There were no posttreatment pregnancies, and 55% (n = 81) of participants had initiated DMPA or another long-term contraceptive within 4 weeks of their initial clinic presentation.     

闵行区新婚女性对避孕方法的知晓和使用情况调查

目的:了解闵行区新婚女性对避孕方法的知晓及使用情况,为进一步实施干预和提高育龄妇女的生殖健康水平提供依据。方法:采用面对面的方式对450名登记结婚的新婚女性进行避孕知识问卷调查。结果:调查对象对避孕套、口服避孕药的知晓率较高,达到95%以上,避孕率为83.33%;使用率最高的避孕方法是避孕套,满意率最高的是口服避孕药;避孕知识主要来源于报刊、杂志、书籍。结论:生殖健康服务要真正实现避孕知情选择,必须开展各种形式的健康教育,让人们全面、正确地掌握避孕知识和信息,提高其避孕知识水平和避孕意识。     

The acceptability of reuse of the female condom among urban South African women

This study assessed whether reuse of the female condom was acceptable among two groups of women in central Johannesburg, South Africa, who were taking part in two separate studies of female condom reuse. The first group consisted of women (aged 17 to 43years) attending a family planning/sexually transmitted infections (STIs) clinic who were participating in a cross-sectional survey of the acceptability of female condoms reuse (n=100). The second group included women (aged 18–40 years) at high risk for STI (80% self-declared sex workers) who were taking part in an ongoing cohort study to investigate the safety of reuse of the female condom through a structural integrity and microbial retention study (n=50). Among women participating in the acceptability study, 83% said that they would be willing to reuse the female condom, and 91% thought the idea of reuse, of the female condom was acceptable. All women taking part in the safety of reuse study and who reused the female condom up to seven time (n=49) reported that the steps involved in reusing the device were easy to perform and acceptable. All 49 women said they would reuse the female condom at least once, while 45% said they would use it a maximum of seven or eight times. From the results of the interviews with both study groups, it can be concluded that, among women in a South African urban environment who have used a male and/or female condom, the concept of reuse of the female condom is acceptable and thought to be a good idea.     

Trends and correlates of hormonal contraceptive use among HIV-infected women in Rakai, Uganda, 1994-2006

Background

Little is known about what factors correlate with hormonal contraceptive (HC) use in HIV-infected women in sub-Saharan Africa.

Methods

We assessed the trends in HC use among HIV-infected women in Rakai, Uganda; determined factors associated with HC use and considered whether those factors changed over time.

Results

HC use among HIV-infected women in Rakai increased from 5.7% in 1994 to 19.2% in 2006, but nearly half of all pregnancies in this population were unintended. Variables associated with increased HC use included higher education, socioeconomic status, parity, sexual frequency, being currently married or in a relationship, discussion of family planning with a partner and receipt of HIV results. Variables negatively associated with HC use included symptoms suggestive of opportunistic infections, having no sex partner in the past year, condom use, breastfeeding and older age. Most associations remained stable over time.

Conclusion

Although contraceptive use by HIV-infected women has increased three-fold in this rural population, unintended pregnancies persist, placing women and their children at risk of adverse consequences.     

Pregnancy preferences and contraceptive use among US women

ObjectivesAn understanding of the relationship between individuals’ pregnancy preferences and contraceptive use is essential for appropriate patient-centered counseling and care. We examined the relationship between women’s pregnancy preferences and contraceptive use using a new prospective measure, the Desire to Avoid Pregnancy (DAP) scale.Study DesignAs part of a study examining women’s suspicion and confirmation of new pregnancies, we recruited patients aged 15 – 45 from seven reproductive health and primary health facilities in Arizona, New Jersey, New Mexico, South Carolina, and Texas in 2016–2017. We used multivariable logistic, multinomial logistic, and linear regression models to examine the associations among DAP scores (range: 0 – 4) and contraceptive use outcomes and identify factors associated with discordance between DAP and use of contraception.ResultsParticipants with a greater preference to avoid pregnancy had higher odds of contraceptive use (aOR = 1.63, 95% CI: 1.31, 2.04) and used contraceptives more consistently (aβ = 8.9 percentage points, 95% CI: 5.2, 12.7). Nevertheless, 63% of women with low preference to avoid pregnancy reported using a contraceptive method. Higher preference to avoid pregnancy was not associated with type of contraceptive method used: women with the full range of pregnancy preferences reported using all method types.ConclusionWhen measured using a rigorously developed instrument, pregnancy preferences were associated with contraceptive use and consistency of use. However, our findings challenge assumptions that women with the highest preference against pregnancy use more effective methods and that women who might welcome pregnancy do not use contraception.ImplicationsWomen’s preferences about pregnancy contribute significantly to their use of contraception. However, health care providers and researchers should consider that contraceptive features besides effectiveness in preventing pregnancy shape contraceptive decision-making and use.     

Detection of raised FSH levels among older women using depomedroxyprogesterone acetate and norethisterone enanthate

The objective of this study was to investigate whether follicle-stimulating hormone (FSH) levels can be used reliably to indicate approaching menopause in older (aged 40-49), long-term users of depomedroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN). One-hundred and seventeen women using DMPA, 60 NET-EN users and 161 nonusers of contraception were recruited. At recruitment, serum FSH levels were measured and questions were asked regarding menopausal symptoms, menstrual cycle and date of last injection. Results of the recruitment blood test showed that 32% of the nonusers had FSH levels in the menopausal range >25.8 mIU/mL compared to 28% of the DMPA users and 9% of the NET-EN group. After adjusting for age, there was no significant difference between the 3 groups (p = 0.13). An increase of 1 year in age increased the FSH level by 3 mIU/mL (p < 0.001). All the hormonal contraceptive users were between 1 day and 12 weeks of their injection interval. Many had been using the injectable contraceptive method for over 10 years and almost all were amenorrheic at the time of recruitment. The data show that a raised FSH level can be detected during use of DMPA and NET-EN and could be used as a menopausal indicator without interrupting method use in this group of contraceptive users.     

HIV-status disclosure and depression in the context of unintended pregnancy among South African women

Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy.     

Predictors of dual method use for pregnancy and HIV prevention among adolescent South African women

INTRODUCTION: Dual contraceptive method use is advocated for adolescent women to prevent pregnancy, sexually transmitted diseases and HIV. METHODS: We examined data from a nationally representative sample of South African women aged 15-24 years to establish factors associated with dual method use. RESULTS: Only 7% of current contraceptive users reported using dual methods, although this percentage increased to 28.1% when women reporting hormonal contraception and condom use at last sex were included. In multivariate analyses, having talked about condoms with a partner was most strongly associated with dual method use (adjusted odds ratio (AOR), 12.3; 95% confidence interval (CI), 6.1-25.1) and suggests that communication skills might be the most effective way of increasing dual method use. Difficulty in accessing condoms was associated with lower odds of dual method use (AOR, 0.5; 95% CI, 0.2-1.0). CONCLUSION: We conclude with recommendations to increase male involvement and encourage communication between partners for the integration of HIV prevention and other reproductive health care services.     

Concordance of self-reported hormonal contraceptive use and presence of exogenous hormones in serum among African women

Objectives

Studies that rely on self-report to investigate the relationship between hormonal contraceptive use and HIV acquisition and transmission, as well as other health outcomes, could have compromised results due to misreporting. We determined the frequency of misreported hormonal contraceptive use among African women with and at risk for HIV.

Gender norms in South Africa: implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution

In post‐Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for women's ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively ‘privileged’ group, there is little information on gender norms that might shape responses to HIV‐prevention programmes. To elicit gender norms regarding women's and men's roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi‐structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV‐ and pregnancy‐prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of women's rights in the post‐Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co‐existence of traditional constructions of gender that operate to constrain women's freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote women's protection against unintended pregnancy and HIV/STIs.     

Provider determinants of emergency contraceptive counseling and provision in Kenya and Ethiopia

Background

In a majority of sub-Saharan African countries, counseling and provision of emergency contraception (EC) lag behind that of developed countries. As policymakers expand EC programs in the region, an understanding of provider knowledge and bias regarding EC is critical.

Study Design

Using data from recent surveys of Kenyan and Ethiopian health care providers in bivariate analyses and multivariate logit regression models, this study assesses whether variation in provider knowledge and bias regarding EC is associated with variation in EC counseling and provision.

Results

Survey results indicate that 54% and 31% of Kenyan and Ethiopian providers, respectively, display strong EC counseling behavior, while 61% and 55%, respectively, report having ever provided EC. Bivariate and multivariate results show that, in Kenya, increased EC counseling and provision behaviors are associated with higher levels of provider knowledge.

Conclusion

Training on EC can increase provider knowledge and lower bias, leading to improved access for clients.     

Symptoms of distress and posttraumatic stress among South African former political detainees

Considerable debate has centred on the question of traumatisation among individuals who have survived human rights violations in societies that have undergone political conflict. In order to gain an estimate of the extent of long-term traumatisation among political activists who experienced torture and abuse in detention during the apartheid era in South Africa, a sample of 148 survivors of such experiences were recruited in a cross-sectional study and asked to complete the Hopkins Symptom Checklist (HSCL), the Impact of Event Scale (IES), and the Trauma Symptoms section of the Harvard Trauma Questionnaire (HTQ). The proportions of the sample that scored above the clinical cut-points on these measures were calculated. On the HSCL, 14.19% of the sample scored above the cut-point for clinical significance of 44; on the IES, 17.57% scored above the clinical cut-point of 44; and on the HTQ, 37.83% scored above the cut-point of 75. Moreover, the sample's mean scores were significantly higher than the cut-point for clinically significant distress on the HSCL (p < 0.001); significantly lower than the cut-point for severe traumatisation on the IES (p < 0.001); and non-significantly lower than the cut-point for clinically significant traumatisation on the HTQ (p = 0.074). These results are considered in terms of current theoretical debates on the relevance and applicability of posttraumatic stress disorder as a circumscribed nosological entity in developing countries that are in the process of coming to terms with a history of political conflict.     

Progestogen-only contraceptive use among breastfeeding women: a systematic review

Background

The use of progestogen-only contraceptives by breastfeeding women raises theoretical concerns regarding possible adverse effects on breastfeeding success, and infant health or growth. This review was conducted to determine from the literature whether use of progestogen-only contraceptives by breastfeeding women leads to adverse effects on lactation, or infant growth or health when compared to nonuse.

Study Design

We searched the Medline, Popline, Cochrane and LILACS databases for all articles published from database inception through May 2009. Studies were included if they investigated the use of progestogen-only methods in breastfeeding women and reported on clinical outcomes in either women or their infants. Standard data abstraction templates were used to systematically assess and summarize. Summary odds ratios were not calculated, given the heterogeneity of interventions, results and non-quantifiable outcomes reported.

Results

We identified 43 articles for this review. Overall, five randomized trials and 38 observational studies demonstrated no adverse effects of various progestogen-only methods of contraception on multiple measures of breastfeeding performance through 12 months in women using these methods in the postpartum period. Many of these studies also demonstrated no adverse effects of progestogen-only methods on infant growth, health or development from 6 months to 6 years of age. Additional studies demonstrated no effects on infant immunoglobulins or sex hormones of exposed male infants. A single study of a desogestrel pill reported two cases of gynecomastia in exposed infants.

Conclusions

Evidence suggests that progestogen-only methods of contraception do not adversely affect breastfeeding performance when used during lactation. Evidence that progestogen-only contraception does not adversely affect infant growth, health, or development when used by breastfeeding women is consistent but methodologically limited.     

The relational dynamics of hegemonic masculinity among South African men and women in the context of HIV

In South Africa, the frequent positioning of men's sexual behaviours as a prime driver of the HIV epidemic has generated much interest in men's sexuality. However, the relational nature of dominant male norms that exacerbate the risk of HIV transmission is inadequately understood. This study used sexual biographies to explore how men and women negotiate gendered norms and how this affects their sexual and reproductive health (SRH). A total of 50 sexual-history interviews and 10 focus group discussions were conducted with men, and 25 sexual-history interviews with women, with participants sampled from three age categories (ages 18–24, 25–55 and 55+years), a range of cultural and racial backgrounds and urban and rural sites across five provinces in South Africa. The narratives illustrate that men and women's SRH is largely dependent on the type and quality of their relationships. Men's sexuality was regularly depicted as being detached from intimacy and uncontrollable, which was premised as being opposite from and/or superior to women's sexuality and could justify men's high-risk sexual behaviours. Yet many participants also supported gender equitable relationships and endorsed accountable and healthy SRH behaviours. The narratives reveal that HIV-risky dominant male norms should be addressed relationally for the sake of better SRH outcomes.