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Lantz AM, Cottrell ML, Corbett AH, Chinula L, Kourtis AP, Nelson JAE, Tegha G, Hurst S, Gajer P, Ravel J, Haddad LB, Tang JH, Nicol MR. Vaginal microbiome, antiretroviral concentrations, and HIV genital shedding in the setting of hormonal contraception initiation in Malawi. AIDS 2023; 37:2185-2190. [PMID: 37877275 PMCID: PMC10605758 DOI: 10.1097/qad.0000000000003686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The aim of this study was to understand how vaginal microbiota composition affects antiretroviral concentrations in the setting of hormonal contraception initiation. METHODS Cervicovaginal fluid (CVF) concentrations of tenofovir, lamivudine, and efavirenz from 73 Malawian women with HIV were compared before and after initiation of depot-medroxyprogesterone acetate (DMPA) or levonorgestrel implant. We evaluated antiretroviral concentrations and vaginal microbiota composition/structure in the context of contraception initiation and predicted genital shedding using multivariable repeated measurements models fit by generalized estimating equations. RESULTS Mean lamivudine CVF concentrations decreased 37% 1 month after contraception initiation. Subgroup analyses revealed a 41% decrease in women 1 month after initiating levonorgestrel implant, but no significant difference was observed in DMPA group alone. Tenofovir, lamivudine, and efavirenz CVF concentrations were positively correlated with anaerobic bacteria associated with nonoptimal vaginal microbiota. Risk of genital HIV shedding was not significantly associated with tenofovir or lamivudine CVF concentrations [tenofovir relative risk (RR): 0.098, P = 0.75; lamivudine RR: 0.142, P = 0.54]. Lack of association between genital HIV shedding and efavirenz CVF concentrations did not change when adjusting for vaginal microbiota composition and lamivudine/tenofovir CVF concentrations (RR: 1.33, P = 0.531). CONCLUSION No effect of hormone initiation on genital shedding provides confidence that women with HIV on either DMPA or levonorgestrel implant contraception will not have compromised ART efficacy. The unexpected positive correlation between antiretroviral CVF concentrations and certain bacterial taxa relative abundance requires further work to understand the mechanism and clinical relevance.
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Affiliation(s)
- Alyssa M Lantz
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis
| | | | - Amanda H Corbett
- Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy
| | - Lameck Chinula
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
| | - Athena P Kourtis
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie A E Nelson
- Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Stacey Hurst
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Pawel Gajer
- Institute for Genome Sciences
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jacques Ravel
- Institute for Genome Sciences
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lisa B Haddad
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
- Center for Biomedical Research, Population Council, New York, New York, USA
| | - Jennifer H Tang
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
| | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis
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Influence of Hormonal Contraceptive Use and HIV on Cervicovaginal Cytokines and Microbiota in Malawi. mSphere 2023; 8:e0058522. [PMID: 36622252 PMCID: PMC9942570 DOI: 10.1128/msphere.00585-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Important questions remain on how hormonal contraceptives alter the local immune environment and the microbiota in the female genital tract and how such effects may impact susceptibility to HIV infection. We leveraged samples from a previously conducted clinical trial of Malawian women with (n = 73) and without (n = 24) HIV infection randomized to depot medroxyprogesterone acetate (DMPA) or the levonogestrel implant in equal numbers within each group and determined the effects of these hormonal contraceptives (HCs) on the vaginal immune milieu and the composition of the vaginal microbiota. Longitudinal data for soluble immune mediators, measured by multiplex bead arrays and enzyme-linked immunosorbent assays (ELISAs), and vaginal microbiota, assessed by 16S rRNA gene amplicon, were collected prior to and over a period of 180 days post-HC initiation. DMPA and levonogestrel had only minimal effects on the vaginal immune milieu and microbiota. In women with HIV, with the caveat of a small sample size, there was an association between the median log10 change in the interleukin-12 (IL-12)/IL-10 ratio in vaginal fluid at day 180 post-HC compared to baseline when these women were classified as having a community state type (CST) IV vaginal microbiota and were randomized to DMPA. Long-lasting alterations in soluble immune markers or shifts in microbiota composition were not observed. Furthermore, women with HIV did not exhibit increased viral shedding in the genital tract after HC initiation. Consistent with the results of the ECHO (Evidence for Contraceptive Options and HIV Outcomes) trial, our data imply that the progestin-based HC DMPA and levonorgestrel are associated with minimal risk for women with HIV. (This study has been registered at ClinicalTrials.gov under registration no. NCT02103660). IMPORTANCE The results of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial, the first large randomized controlled clinical trial comparing the HIV acquisition risk of women receiving DMPA, the levonorgestrel (LNG) implant, or the copper intrauterine device (IUD), did not reveal an increased risk of HIV acquisition for women on any of these three contraceptives. Our study results confirm that the two different progestin-based hormonal contraceptives DMPA and levonogestrel will not increase the risk for HIV infection. Furthermore, DMPA and levonogestrel have only minimal effects on the immune milieu and the microbiota in the vaginal tract, attesting to the safety of these hormonal contraceptives.
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Chapola JC, Hatfield-Timajchy K, Bula AK, Hurst S, Chinula L, Kourtis AP, Tang JH. Women's perspectives on relationship dynamics with their partners and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2021; 20:61-69. [PMID: 33685375 DOI: 10.2989/16085906.2021.1872664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Limited information exists about relationship dynamics and their role in HIV acquisition, HIV disclosure, hormonal contraceptive uptake, and condom use among women in Malawi.Methods: Ninety-seven women aged 18-45 years were randomly assigned to initiate the depot medroxyprogesterone acetate injectable or levonorgestrel implant from May 2014 to April 2015 in Lilongwe, Malawi. Women were recruited after randomisation to participate in semi-structured interviews about HIV and family planning using purposive sampling. Interviews were thematically analysed using within and between group comparisons.Results: We conducted individual interviews and/or focus group discussions with 41 women: 30 (73%) women living with HIV and 11 (27%) women not living with HIV. Most women living with HIV who participated in in-depth interviews disclosed their status to their partners, and most partners agreed to get HIV tested only after disclosure. Nearly all women said their partners agreed to use condoms, but few used them consistently. Nearly all women believed their current and former partners had outside partners. Most women living with HIV who participated in in-depth interviews believed their current or other serious partners were the source of their infection. Some women thought their partner's infidelity was due to their partner's disinterest in sex with them during menstrual/ breakthrough bleeding. Some women included their partners in contraceptive decision-making when the partner was supportive.Discussion: Relationship dynamics affected decision-making for contraceptive and condom use, as well as serodisclosure for the women living with HIV in the study. All women reported challenges with consistent condom use with their male partners, although contraceptive use was generally more acceptable. Women included their partners in their decision-making concerning contraceptive use when they were supportive.
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Affiliation(s)
| | | | - Agatha K Bula
- University of North Carolina Project, Lilongwe, Malawi
| | - Stacey Hurst
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Lameck Chinula
- University of North Carolina Project, Lilongwe, Malawi.,Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | - Jennifer H Tang
- University of North Carolina Project, Lilongwe, Malawi.,Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
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4
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Bula AK, Hatfield-Timajchy K, Chapola J, Chinula L, Hurst SA, Kourtis AP, Tang JH. Motivations to use hormonal contraceptive methods and condoms among HIV-positive and negative women randomized to a progestin contraceptive in Malawi: a qualitative study. BMC WOMENS HEALTH 2021; 21:114. [PMID: 33743659 PMCID: PMC7981805 DOI: 10.1186/s12905-021-01236-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 02/22/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although many countries have been promoting hormonal contraceptives to prevent unintended pregnancy and condom use to prevent HIV transmission, little is known about how women targeted by these messages have interpreted and internalized them. We describe HIV-positive and negative women's understanding of the benefits of contraception and condoms and their motivations to use them. METHODS This is a qualitative sub-study from a clinical trial evaluating the effects of progestin contraception on HIV-positive and negative women aged 18-45 years randomly assigned to depot medroxyprogesterone acetate (DMPA) injection or levonorgestrel (LNG) implant. We purposively recruited 41 women to participate in in-depth interviews (IDIs) and focus group discussions (FGDs) after randomization into the main study. We conducted a total of 30 IDIs and 6 FGDs comprised of 4-7 women (N = 32). All women were counselled about potential risks for HIV acquisition/transmission with progestin-only contraception, drug-drug interactions between the implant and efavirenz-based ART, and the need to use condoms with their assigned contraceptive to help prevent pregnancy and HIV acquisition and transmission. RESULTS All women understood that HIV is transmitted through unprotected sex and that HIV transmission can be prevented through condom use but not DMPA injection or LNG implant use. Nearly all HIV-positive women knew or suspected that their partners were also HIV-positive and were most interested in using condoms to prevent infection with a drug-resistant HIV strain to keep their HIV viral load low. Almost all reported that their partners agreed to condom use, but few used them consistently. Most women believed that condoms were effective at preventing both HIV and pregnancy if used consistently. Nearly all women considered contraception and condom use as important in preventing unintended pregnancy and HIV because partner disclosure of HIV status is low. CONCLUSION Our results showed that both HIV-positive and negative women understood modes of HIV transmission and prevention and were aware that hormonal contraceptives are only effective for preventing pregnancy and not HIV. Although both HIV-negative and positive women were motivated to use condoms to prevent both HIV acquisition and infection with other HIV strains respectively, they all faced challenges from their partners in using condoms consistently.
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Affiliation(s)
- Agatha K Bula
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.
| | | | - John Chapola
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - L Chinula
- UNC Project-Malawi, Private Bag A-104, Lilongwe, Malawi.,Department of OB-GYN, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
| | - Stacey A Hurst
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P Kourtis
- U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J H Tang
- Department of OB-GYN, University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
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5
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Tang JH, Davis NL, Corbett AH, Chinula L, Cottrell ML, Zia Y, Tegha G, Stanczyk FZ, Hurst S, Hosseinipour MC, Haddad LB, Kourtis AP. Effect of efavirenz on levonorgestrel concentrations among Malawian levonorgestrel implant users for up to 30 months of concomitant use: a subanalysis of a randomized clinical trial. Contracept X 2020; 2:100027. [PMID: 33364598 PMCID: PMC7752709 DOI: 10.1016/j.conx.2020.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022] Open
Abstract
Objectives Our primary objective was to compare geometric mean levonorgestrel concentrations between levonorgestrel implant users who were or were not taking the antiretroviral efavirenz, for up to 30 months after implant initiation. Our secondary objective was to evaluate the pregnancy rate among levonorgestrel implant users on efavirenz. Study design We performed a subanalysis of 42 Malawian women randomized to initiate the levonorgestrel implant as part of a parent randomized clinical trial. Our subset included 30 HIV-infected women taking efavirenz and 12 HIV-uninfected women not taking efavirenz. They underwent urine pregnancy testing every 3 months and serum levonorgestrel testing at day 3 and months 1, 3, 6, 12, 18, 24, 27 and 30 after implant initiation. Geometric mean levonorgestrel concentrations were calculated for efavirenz users and non-efavirenz users at each time point. Results The geometric mean levonorgestrel concentrations were lower for efavirenz users than non-efavirenz users at every time point; the geometric mean ratio for efavirenz users:non-efavirenz users ranged from 0.60 [90% confidence interval (CI) 0.46–0.79] at 1 month to 0.27 (90% CI 0.12–0.61) at 30 months after implant insertion. No pregnancies occurred over 60 woman-years of concomitant levonorgestrel implant and efavirenz use, although 11 women had levonorgestrel concentrations < 180 pg/mL (the previously suggested minimum threshold concentration for efficacy). Conclusions Efavirenz users had lower levonorgestrel concentrations than non-efavirenz users, and one third of our concomitant efavirenz and levonorgestrel implant users had concentrations < 180 pg/mL. Continued evaluation of the contraceptive efficacy of the levonorgestrel implant may be needed for efavirenz users. Implications Among 42 Malawian women using the levonorgestrel implant for contraception, women who were taking the antiretroviral efavirenz had lower serum levonorgestrel concentrations than women who were not taking efavirenz. However, none of the women who were taking efavirenz became pregnant over 60 women-years of follow-up.
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Affiliation(s)
- Jennifer H Tang
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Nicole L Davis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Amanda H Corbett
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Lameck Chinula
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Mackenzie L Cottrell
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA
| | - Yasaman Zia
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Gerald Tegha
- UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Frank Z Stanczyk
- University of Southern California, Keck School of Medicine, Reproductive Endocrine Research Laboratory, 1321 N. Mission Road, Los Angeles, CA, 90033, USA
| | - Stacey Hurst
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Mina C Hosseinipour
- University of North Carolina at Chapel Hill, 111 Mason Farm Road, CB #7577; Chapel Hill, NC, 27599-7577, USA.,UNC Project Malawi, 100 Mzimba Drive, Private Bag A104, Lilongwe, Malawi
| | - Lisa B Haddad
- Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Athena P Kourtis
- US Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30329, USA
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Relaño-Rodríguez I, Muñoz-Fernández MÁ. Emergence of Nanotechnology to Fight HIV Sexual Transmission: The Trip of G2-S16 Polyanionic Carbosilane Dendrimer to Possible Pre-Clinical Trials. Int J Mol Sci 2020; 21:ijms21249403. [PMID: 33321835 PMCID: PMC7764023 DOI: 10.3390/ijms21249403] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 12/11/2022] Open
Abstract
Development of new, safe, and effective microbicides to prevent human immunodeficiency virus HIV sexual transmission is needed. Unfortunately, most microbicides proved ineffective to prevent the risk of HIV-infection in clinical trials. We are working with G2-S16 polyanionic carbosilane dendrimer (PCD) as a new possible vaginal topical microbicide, based on its short reaction times, wide availability, high reproducibility, and quantitative yields of reaction. G2-S16 PCD exerts anti-HIV activity at an early stage of viral replication, by blocking gp120/CD4/CCR5 interaction, and providing a barrier against infection for long periods of time. G2-S16 PCD was stable at different pH values, as well as in the presence of seminal fluids. It maintained the anti-HIV activity against R5/X4 HIV over time, did not generate any type of drug resistance, and retained the anti-HIV effect when exposed to semen-enhanced viral infection. Importantly, G2-S16 PCD did not modify vaginal microbiota neither in vitro or in vivo. Histopathological examination did not show vaginal irritation, inflammation, lesions, or damage in the vaginal mucosa, after administration of G2-S16 PCD at different concentrations and times in female mice and rabbit animal models. Based on these promising data, G2-S16 PCD could become a good, safe, and readily available candidate to use as a topical vaginal microbicide against HIV.
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Affiliation(s)
- Ignacio Relaño-Rodríguez
- Head Section of Immunology, Molecular Immunology Laboratory, General Universitary Hospital Gregorio Marañón, C/Dr. Esquerdo 46, 28007 Madrid, Spain;
| | - Maria Ángeles Muñoz-Fernández
- Head Section of Immunology, Molecular Immunology Laboratory, General Universitary Hospital Gregorio Marañón, C/Dr. Esquerdo 46, 28007 Madrid, Spain;
- Health Research Institute Gregorio Marañon (IiSGM), C/Dr. Esquerdo 46, 28007 Madrid, Spain
- Spanish HIV HGM BioBank, C/Dr. Esquerdo 46, 28007 Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), C/Dr. Esquerdo 46, 28007 Madrid, Spain
- Correspondence: or ; Tel.: +34-91-586-8565
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7
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Nicol MR, Cottrell ML, Corbett AH, Chinula L, Tegha G, Stanczyk FZ, Hurst S, Kourtis AP, Tang JH. Endogenous Hormones and Antiretroviral Exposure in Plasma, Cervicovaginal Fluid, and Upper-Layer Packed Cells of Malawian Women Living with HIV. AIDS Res Hum Retroviruses 2020; 36:641-646. [PMID: 32390454 PMCID: PMC7414802 DOI: 10.1089/aid.2019.0278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Overlap in metabolism pathways of endogenous female sex hormones and antiretroviral drugs may lead to altered exposure to these compounds. In a family planning clinic in Lilongwe, Malawi, blood, blood cell, and cervicovaginal fluid (CVF) samples from seventy-three HIV positive Malawian women taken in follicular and luteal menstrual phases were assessed for estradiol and progesterone by chemiluminescent immunoassay, and for antiretroviral concentration by liquid chromatography-mass spectrometry. In both follicular and luteal phases, estradiol concentrations were lower in women receiving efavirenz compared with women on non-efavirenz regimens or no antiretroviral therapy (p < .01). Serum estradiol was moderately and negatively correlated with efavirenz plasma (r = -0.36, p < .001) and CVF (r = -0.50, p < .001) concentrations. Serum estradiol was a significant predictor of efavirenz CVF concentrations even after adjusting for efavirenz plasma concentrations (p = .02). In upper-layer packed cells (ULPCs), tenofovir diphosphate (TFVdp) concentrations were similar between follicular and luteal phases and were not correlated with estradiol or progesterone concentrations. Tenofovir concentrations in CVF were not associated with menstrual cycle or serum hormone concentrations. In CVF and plasma, efavirenz concentrations were negatively correlated with serum estradiol concentrations, suggesting a modulatory effect of estradiol on efavirenz metabolism and/or transport processes, and/or an effect of efavirenz on the metabolism of estradiol. Differences in CVF persisted even after adjusting for plasma concentrations, suggesting a mechanism specific to the female genital compartment separate from absorption or hepatic metabolism. In contrast, TFVdp concentrations in ULPC were not influenced by endogenous estradiol or progesterone concentrations.
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Affiliation(s)
- Melanie R. Nicol
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mackenzie L. Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amanda H. Corbett
- Division of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lameck Chinula
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
| | | | - Frank Z. Stanczyk
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Stacey Hurst
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Athena P. Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer H. Tang
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- UNC Project Malawi, Lilongwe, Malawi
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8
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Zia Y, Davis N, Wiener J, Hobbs MM, Lapple D, Chinula L, Tegha G, Msika A, Tang J, Kourtis AP. Factors associated with vaginal detection of prostate-specific antigen among participants in a clinical trial in Malawi. Sex Transm Infect 2020; 97:77. [PMID: 32527793 DOI: 10.1136/sextrans-2020-054566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 11/03/2022] Open
Affiliation(s)
- Yasaman Zia
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA .,Association of Schools and Programs of Public Health, Washington, DC, USA
| | - Nicole Davis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jeffrey Wiener
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marica M Hobbs
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Dana Lapple
- Division of Infectious Disease, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lameck Chinula
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Project, Lilongwe, Central Region, Malawi
| | | | | | - Jennifer Tang
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,UNC Project, Lilongwe, Central Region, Malawi
| | - Athena P Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Brief Report: HIV Shedding in the Female Genital Tract of Women on ART and Progestin Contraception: Extended Follow-up Results of a Randomized Clinical Trial. J Acquir Immune Defic Syndr 2020; 81:163-165. [PMID: 31095006 DOI: 10.1097/qai.0000000000002011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progestin contraception has been linked to higher risk of female to male sexual HIV transmission. SETTING A clinical trial among HIV-infected women in Lilongwe, Malawi, randomized to initiation of depomedroxyprogesterone acetate injectable or levonorgestrel implant, and followed for up to 33 months, with the outcome of HIV shedding in the genital tract. METHODS We compared the frequency and magnitude of HIV genital shedding before and after initiation of contraception and between study arms among women receiving antiretroviral therapy (ART). Genital HIV RNA was measured in TearFlo Strips using the Abbott RealTime HIV-1 assay. RESULTS Among 68 HIV-infected Malawian women on ART, randomization to depot medroxyprogesterone acetate compared with the levonorgestrel implant was not associated with genital shedding and neither progestin contraceptive was associated with increased HIV genital shedding, for up to 33 months after contraceptive initiation. Having detectable plasma HIV [adjusted risk ratio (RR) 10.5; 95% confidence interval (CI): 3.18 to 34.7] and detectable genital shedding before contraceptive initiation (adjusted RR 3.53; 95% CI: 1.31 to 9.47) were associated with a higher risk of detectable genital shedding after contraceptive initiation. Higher plasma efavirenz concentrations were associated with a lower risk of detectable genital shedding (adjusted RR 0.85; 95% CI: 0.73 to 0.99, per increase of 1000 ng/mL). CONCLUSION Among HIV-infected women receiving ART, our results provide evidence that progestin contraception does not impact women's risk of transmission of HIV to partners. Our finding that detectable genital shedding before contraceptive initiation independently predicts shedding suggests that there may be other individual-level biological or behavioral factors that increase the risk for shedding.
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10
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Zia Y, Tang JH, Chinula L, Tegha G, Stanczyk FZ, Kourtis AP. Medroxyprogesterone acetate concentrations among HIV-infected depot-medroxyprogesterone acetate users receiving antiretroviral therapy in Lilongwe, Malawi. Contraception 2019; 100:402-405. [PMID: 31374188 DOI: 10.1016/j.contraception.2019.07.144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/04/2019] [Accepted: 07/24/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare medroxyprogesterone acetate (MPA) concentrations between HIV-positive women on antiretroviral therapy (ART) and HIV-negative women initiating depot medroxyprogesterone (DMPA) injectable. STUDY DESIGN Secondary analysis of 28 HIV-positive women on non-nucleoside reverse transcriptase inhibitor-containing ART regimens and 10 HIV-negative women randomized to initiate DMPA in a clinical trial of progestin contraception in Malawi. RESULTS MPA concentrations were significantly lower among HIV-positive women on ART, compared with HIV-negative women, at week 4 and week 13 (p=.03 for both), but not at day 3 or week 26 post-DMPA initiation. CONCLUSIONS Antiretroviral medications may affect MPA metabolism in HIV-positive African women.
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Affiliation(s)
- Yasaman Zia
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA; Association of Schools and Programs of Public Health, Washington, DC.
| | - Jennifer H Tang
- University of North Carolina- Chapel Hill, School of Medicine, Chapel Hill, NC; UNC Project-Malawi, Lilongwe, Malawi
| | | | | | | | - Athena P Kourtis
- Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA
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11
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Boodhram R, Moodley D, Abbai N, Ramjee G. Association of endogenous progesterone levels in young women using hormonal contraception with recent HIV-1 infection. BMC WOMENS HEALTH 2019; 19:63. [PMID: 31068152 PMCID: PMC6505278 DOI: 10.1186/s12905-019-0761-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 04/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND A high endogenous progesterone luteal state in the menstrual cycle has been independently associated with Human Immunodeficiency Virus (HIV) incidence in epidemiological studies. Hormonal contraception particularly high dose Depot Medroxyprogesterone Acetate (DMPA) is also thought to increase the risk of HIV acquisition. Inconsistent reports of this association have led us to hypothesize that unsuppressed endogenous progesterone level in women who reported hormonal contraception (HC) use may be an explanation for increased vulnerability to HIV. METHODS This pilot study was a secondary cross-sectional analysis of data and laboratory testing of stored specimens collected from women who participated in the SAMRC HIV prevention MDP 301 trial during 2005-2009 in South Africa. Serum progesterone levels were measured in 39 women at the point of first positive HIV diagnosis during study follow-up and 36 women who remained HIV uninfected at the 52-week study exit visit. RESULTS Overall, the median (IQR) progesterone level in 49 women using hormonal contraception was 0.39 ng/ml (IQR 0.13-0.45) and 48 (97.9%) women had a progesterone level < 3.0 ng/ml suggestive of adequate progesterone suppression for contraceptive efficacy. After excluding the one woman with a progesterone level of > 3.0 ng/ml, the median progesterone level in women using DMPA remained marginally higher at 0.42 ng/ml (IQR 0.27-0.45) than women using Norethisterone Enanthate (NET-EN) (0.31 ng/ml; IQR 0.13-0.41, p = 0.061). For women using hormonal contraception, the median progesterone level did not differ between women with recent HIV infection or women who remained HIV negative (0.39 vs 0.38 ng/ml, p = 0.959). Similarly, the median progesterone level in women using DMPA or NET-EN did not differ by HIV status (0.43 vs 0.41 ng/ml, p = 0.905; 0.24 vs 0.31 ng/ml, p = 0.889). CONCLUSION Among women using hormonal contraception, DMPA or NET-EN we did not observe a significant difference in progesterone levels between women with recently acquired HIV infection and women who remained HIV negative. Our findings suggest that endogenous progesterone levels remain suppressed in the presence of hormonal contraception and are not likely to be associated with HIV acquisition.
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Affiliation(s)
- Resha Boodhram
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Dhayendre Moodley
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, 719 Umbilo Road, Durban, 4051, South Africa.
| | - Nathlee Abbai
- Department of Clinical Medicine Laboratory, School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa.,Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Global Health, University of Washington, Seattle, USA
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Effect of the depot medroxyprogesterone acetate injectable and levonorgestrel implant on HIV genital shedding: a randomized trial. Contraception 2018; 98:193-198. [PMID: 29746813 PMCID: PMC6143482 DOI: 10.1016/j.contraception.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 04/25/2018] [Accepted: 05/02/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the effect of the depot medroxyprogesterone acetate injectable (DMPA) and of the levonorgestrel (LNG) implant on genital HIV shedding among women receiving antiretroviral therapy (ART). METHODS We randomized HIV-infected Malawian women to either DMPA or LNG implant from May 2014 to April 2015. HIV RNA was measured in cervicovaginal lavage (CVL) fluid and TearFlo Strips (TFS), and HIV DNA was measured in cells collected by CVL. We compared the frequency and magnitude of HIV genital shedding before and for 6 months after initiation of contraception and between arms among women receiving ART. We also compared genital HIV RNA levels obtained by sample type (TFS versus CVL). RESULTS We analyzed data for 68 HIV-infected women receiving ART: 33 randomized to DMPA and 35 randomized to the LNG implant. Overall, HIV RNA was more often detectable and the quantity was higher on TFS compared with CVL. HIV DNA was detected very rarely in CVL cell samples (4 of 360 samples). The frequency of genital shedding and the genital HIV quantity did not increase after contraceptive initiation with either DMPA or LNG implant among women receiving ART. CONCLUSIONS HIV-infected women receiving ART initiating contraception with either DMPA or LNG implant did not have any increase in genital HIV shedding during the first 6 months of contraceptive use. These findings are consistent with growing evidence that progestin contraception is not associated with increased HIV transmission risk from such women to their male partners. Consistent with other studies, genital HIV RNA detection was higher in TFS than in CVL fluid. IMPLICATIONS In this randomized trial, neither DMPA nor the LNG implant, two of the most commonly used hormonal contraceptives among African women with HIV, was associated with increased genital HIV shedding in HIV-infected women receiving ART. These findings are reassuring and add to the currently limited information available for the highly effective contraceptive, LNG implant.
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Nwaohiri AN, Tang JH, Stanczyk F, Chinula L, Hurst S, Davis NL, Tegha G, Haddad L, Kourtis AP. Discordance between self-reported contraceptive use and detection of exogenous hormones among Malawian women enrolling in a randomized clinical trial. Contraception 2018; 97:354-356. [PMID: 29246819 PMCID: PMC5840008 DOI: 10.1016/j.contraception.2017.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective was to assess the extent of concordance between self-reported contraceptive use and the presence of contraceptive progestins in serum. STUDY DESIGN We evaluated self-reported contraceptive use by using radioimmunoassay to examine baseline serum levels of medroxyprogesterone acetate (MPA) and levonorgestrel (LNG) among 97 Malawian women enrolling in a contraceptive trial. RESULTS Twelve percent (12/97) of study participants who reported no hormonal contraceptive use in the previous 6months had either MPA or LNG detected in their serum. CONCLUSIONS The observed discordance between self-report and detection of exogenous hormones in serum indicates that caution is warranted when drawing conclusions based on self-reported contraceptive use.
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Affiliation(s)
- Anuli N Nwaohiri
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Frank Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine
| | | | - Stacey Hurst
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nicole L Davis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gerald Tegha
- University of North Carolina Project, Lilongwe, Malawi
| | - Lisa Haddad
- Emory University, Department of Obstetrics & Gynecology, Atlanta, GA, USA
| | - Athena P Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Achilles SL, Mhlanga FG, Musara P, Poloyac SM, Chirenje ZM, Hillier SL. Misreporting of contraceptive hormone use in clinical research participants. Contraception 2017; 97:346-353. [PMID: 28966052 PMCID: PMC5858917 DOI: 10.1016/j.contraception.2017.09.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/18/2017] [Accepted: 09/23/2017] [Indexed: 12/21/2022]
Abstract
Objective Researchers traditionally rely on participant self-report for contraceptive use. We hypothesized that self-reported contraceptive use by clinical research participants may disagree with objectively measured hormonal status. Study design We enrolled women in Harare, Zimbabwe, aged 18–34, who by self-report had not used hormonal or intrauterine contraception for >30 days, or depot medroxyprogesterone acetate for >10 months, into a study designed to assess biologic changes with contraceptive initiation and use. Blood samples obtained at enrollment and each follow-up visit (N=1630 from 447 participants) were evaluated by mass spectrometry for exogenous hormones. We individually interviewed a subset of participants (n=20) with discrepant self-reported and measured serum hormones to better understand nondisclosure of contraceptive use. Results Discrepant with self-reported nonuse of hormonal contraception, synthetic progestogens were detectable in 120/447 (27%, 95% confidence interval 23%–31%) enrolled women. Measured exogenous hormones consistent with use of contraceptive pills (n=102), injectables (n=20) and implants (n=3) were detected at enrollment, with 7 women likely using >1 contraceptive. In-depth interviews revealed that participants understood the requirement to be hormone free at enrollment (100%). Most (85%) cited partner noncooperation with condoms/withdrawal and/or pregnancy concerns as major reasons for nondisclosed contraceptive use. All interviewed women (100%) cited access to health care as a primary motivation for study participation. Of participants who accurately reported nonuse of hormonal contraception at enrollment, 41/327 (12.5%) had objective evidence of nonstudy progestin use at follow-up that disagreed with self-reported nonuse. Conclusions Women joining contraceptive research studies may misrepresent their use of nonstudy contraceptive hormones at baseline and follow-up. Objective measures of hormone use are needed to ensure that study population exposures are accurately categorized. Implications statement Among Zimbabwean women participating in a contraceptive research study, 27% had objective evidence of use of nonstudy contraceptives at enrollment that disagreed with self-report. Studies that rely on self-report to identify contraceptive hormone exposure could suffer from significant misclassification.
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Affiliation(s)
- Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Center for Family Planning Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA.
| | - Felix G Mhlanga
- University of Zimbabwe-University of California at San Francisco Collaborative Research Unit (UZ-UCSF), Department of Obstetrics and Gynecology, Harare, Zimbabwe
| | - Petina Musara
- University of Zimbabwe-University of California at San Francisco Collaborative Research Unit (UZ-UCSF), Department of Obstetrics and Gynecology, Harare, Zimbabwe
| | - Samuel M Poloyac
- School of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zvavahera M Chirenje
- University of Zimbabwe-University of California at San Francisco Collaborative Research Unit (UZ-UCSF), Department of Obstetrics and Gynecology, Harare, Zimbabwe
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Center for Family Planning Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
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