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Liu M, Vicetti Miguel RD, Quispe Calla NE, Aceves KM, Fritts L, Miller CJ, Moss JA, Baum MM, Cherpes TL. Genital epithelial barrier function is conserved by intravaginal rings releasing etonogestrel and ethinyl estradiol. Tissue Barriers 2024; 12:2186672. [PMID: 36899465 PMCID: PMC10832912 DOI: 10.1080/21688370.2023.2186672] [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] [Received: 09/27/2022] [Accepted: 02/25/2023] [Indexed: 03/12/2023] Open
Abstract
The injectable progestin depot-medroxyprogesterone acetate (DMPA) is a popular contraceptive choice in sub-Saharan Africa although mouse models indicate it weakens genital epithelial integrity and barrier function and increases susceptibility to genital infection. The intravaginal ring NuvaRing® is another contraceptive option that like DMPA suppresses hypothalamic pituitary ovarian (HPO) axis function with local release of progestin (etonogestrel) and estrogen (ethinyl estradiol). As we previously reported that treating mice with DMPA and estrogen averts the loss of genital epithelial integrity and barrier function induced by DMPA alone, in the current investigation we compared genital levels of the cell-cell adhesion molecule desmoglein-1 (DSG1) and genital epithelial permeability in rhesus macaques (RM) treated with DMPA or a NuvaRing®re-sized for RM (N-IVR). While these studies demonstrated comparable inhibition of the HPO axis with DMPA or N-IVR, DMPA induced significantly lower genital DSG1 levels and greater tissue permeability to intravaginally administered low molecular mass molecules. By identifying greater compromise of genital epithelial integrity and barrier function in RM administered DMPA vs. N-IVR, our results add to the growing body of evidence that indicate DMPA weakens a fundamental mechanism of anti-pathogen host defense in the female genital tract.
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Affiliation(s)
- Mohan Liu
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
- Comparative Biomedical Sciences Graduate Program, OSU College of Veterinary Medicine, Columbus, OH, USA
| | - Rodolfo D. Vicetti Miguel
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
| | - Nirk E. Quispe Calla
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Kristen M. Aceves
- College of Veterinary Medicine, Western University of Health Sciences, Pomona, CA, USA
| | - Linda Fritts
- California National Primate Research Center, University of California, Davis, Davis, CA, USA
| | - Christopher J. Miller
- California National Primate Research Center, University of California, Davis, Davis, CA, USA
- Center for Comparative Medicine, University of California, Davis, Davis, CA, USA
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, CA, USA
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, CA, USA
| | - Thomas L. Cherpes
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
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Liu M, Miguel RDV, Calla NEQ, Aceves KM, Fritts L, Miller CJ, Moss JA, Baum MM, Cherpes TL. Loss of genital epithelial barrier function is greater with depot-medroxyprogesterone acetate than intravaginal rings that release etonogestrel and ethinyl estradiol. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.25.525538. [PMID: 36747683 PMCID: PMC9900856 DOI: 10.1101/2023.01.25.525538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The injectable progestin depot-medroxyprogesterone acetate (DMPA) is a popular contraceptive choice in sub-Saharan Africa although mouse models indicate it weakens genital epithelial integrity and barrier function and increases susceptibility to genital infection. The intravaginal ring NuvaRing® is another contraceptive option that like DMPA suppresses hypothalamic pituitary ovarian (HPO) axis function with local release of progestin (etonogestrel) and estrogen (ethinyl estradiol). As we previously reported that treating mice with DMPA and estrogen averts the loss of genital epithelial integrity and barrier function induced by DMPA alone, in the current investigation we compared genital levels of the cell-cell adhesion molecule desmoglein-1 (DSG1) and genital epithelial permeability in rhesus macaques (RM) treated with DMPA or a NuvaRing®re-sized for RM (N-IVR). While these studies demonstrated comparable inhibition of the HPO axis with DMPA or N-IVR, DMPA induced significantly lower genital DSG1 levels and greater tissue permeability to intravaginally administered low molecular mass molecules. By identifying greater compromise of genital epithelial integrity and barrier function in RM administered DMPA vs. N-IVR, our results add to the growing body of evidence that indicate DMPA weakens a fundamental mechanism of anti-pathogen host defense in the female genital tract.
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Affiliation(s)
- Mohan Liu
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
- Comparative Biomedical Sciences Graduate Program, OSU College of Veterinary Medicine, Columbus, OH, USA
| | - Rodolfo D. Vicetti Miguel
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
| | | | | | - Linda Fritts
- California National Primate Research Center, University of California, Davis, Davis, CA, USA
| | - Christopher J. Miller
- California National Primate Research Center, University of California, Davis, Davis, CA, USA
- Center for Comparative Medicine, University of California, Davis, Davis, CA, USA
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, CA, USA
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, CA, USA
| | - Thomas L. Cherpes
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University (OSU) College of Medicine, Columbus, OH, USA
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Deese J, Brache V, Bahamondes L, Salinas A, Jorge A, Veiga N, Fuchs R, Miller A, Taylor D, Halpern V, Dorflinger L. Contraceptive effectiveness, pharmacokinetics, and safety of Sayana® Press when injected every four months: a multicenter phase 3 trial. EClinicalMedicine 2022; 44:101273. [PMID: 35128365 PMCID: PMC8804165 DOI: 10.1016/j.eclinm.2022.101273] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/24/2021] [Accepted: 01/06/2022] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Sayana Press® is a 3-monthly contraceptive injection approved by regulatory agencies in more than 40 countries worldwide. Existing effectiveness and pharmacokinetics (PK) data suggest that high contraceptive efficacy may be maintained if the reinjection interval of Sayana Press is extended from 3 to 4 months. METHODS We conducted a phase 3 trial at three sites in the Dominican Republic, Brazil, and Chile from September 2017 through April 2020. We enrolled 750 women at risk of pregnancy who agreed to use Sayana Press off-label every 4 months (3 treatment cycles) for 12 months. The effectiveness cohort included 710 participants randomized equally to receive injections in the abdomen or thigh. Forty additional participants received injections in the back of the upper arm for comparative PK analyses. The primary outcome was pregnancy, defined by a positive urine pregnancy test confirmed by ultrasound and/or serum human chorionic gonadotropin. Secondary outcomes included PK, safety, and acceptability. Laboratory and trial Sponsor staff were blind to injection site. This study is registered with ClinicalTrials.gov, number NCT03154125. FINDINGS There were no pregnancies during follow-up; the Pearl Index during 629.3 woman-years (WY) of follow-up in the primary effectiveness analysis was 0.00 (95% CI 0.00, 0.59). Pharmacokinetic profiles differed by injection site, with higher geometric mean (GM) medroxyprogesterone acetate concentrations for the abdomen than the thigh and arm. At month 8, significantly higher GM concentrations were observed in the abdomen and the thigh as compared to the arm, as well as at month 12 in the abdomen as compared to the arm. Injection site reactions were reported by 10.7% of participants. INTERPRETATION Both pregnancy and PK results confirm that Sayana Press is a highly effective contraceptive method when administered every 4 months. These findings may inform modification of the dosing schedule, or duration of the grace period for reinjection, or both, to reduce overall drug exposure while maintaining contraceptive efficacy. FUNDING This work is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID), provided to FHI 360 through Cooperative Agreement AID-OAA-A-15-00,045, and a grant from the Gates Foundation. The contents are the responsibility of FHI 360 and do not necessarily reflect the views of USAID, the United States Government, or the Gates Foundation, nor does any mention of trade names, commercial products, or organizations imply endorsement by FHI 360, USAID, the United States Government, or the Gates Foundation.
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Affiliation(s)
- Jennifer Deese
- Women's Global Health Imperative, Global Public Health Impact Center, RTI International, 3040 East Cornwalis Road, Research Triangle Park, NC 27709, United States
- Corresponding author.
| | | | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Sao Paulo, Brazil
| | - Abril Salinas
- Instituto Chileno de Medicina Reproductiva, Universidad de Chile, Chile
| | | | - Nelio Veiga
- Department of Obstetrics and Gynaecology, University of Campinas Faculty of Medical Sciences, Campinas, Sao Paulo, Brazil
| | - Rachael Fuchs
- Biostatistics and Data Sciences, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Ashley Miller
- Science Facilitation, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Doug Taylor
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Vera Halpern
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
| | - Laneta Dorflinger
- Product Development and Introduction, FHI 360, 359 Blackwell Street, Durham, NC 27701, United States
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4
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Halpern V, Fuchs R, Brache V, Bahamondes L, Miranda MJ, Lendvay A, Cochón L, Taylor D, Dorflinger LJ. Suppression of ovulation and pharmacokinetics following subcutaneous administration of various doses of Depo-Provera®: a randomized trial. Contracept X 2021; 3:100070. [PMID: 34746745 PMCID: PMC8551587 DOI: 10.1016/j.conx.2021.100070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES To identify the lowest dose of Depo-Provera that, when administered off-label subcutaneously, suppressed ovulation and had a pharmacokinetic profile consistent with a 4-month contraceptive effect. STUDY DESIGN We conducted a randomized, multicenter, parallel-group study to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of medroxyprogesterone acetate (MPA) after subcutaneous injection of three different doses of Depo-Provera. We randomized sixty women between 18 and 40 years of age at low risk of pregnancy with confirmed ovulation and body mass index of 18 to 35 kg/m2 to receive a single injection of 45, 75 or 105 mg of Depo-Provera, or a single injection of Depo-subQ provera 104 as a reference drug (15 women per group) and followed them for 7.5 months. We evaluated suppression of ovulation as the primary outcome, and MPA concentrations, pharmacokinetic parameters, safety, and local tolerability as secondary outcomes. RESULTS Five women ovulated within four months of treatment initiation (three in the 45 mg group and two in the 75 mg group). MPA levels associated with ovulation were in general low, largely ≤ 0.2 ng/mL (the presumed contraceptive threshold). No women in either the 105 mg group or the Depo-subQ provera 104 group ovulated within four months. The PK parameters including Cmax, C119, and AUC0-119 for these 2 groups were similar but not equivalent. CONCLUSION A dose of 105 mg of Depo-Provera injected subcutaneously was the lowest tested dose that consistently suppressed ovulation and maintained serum MPA levels consistent with contraceptive effect for at least 4 months. The PK and PD results for the 105 mg dose were similar to Depo-subQ provera 104 over this period.
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Affiliation(s)
| | | | - Vivian Brache
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
| | - Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medicine, University of Campinas (UNICAMP) Campinas, Brazil
| | | | | | - Leila Cochón
- Profamilia, Biomedical Research Department, Santo Domingo, Dominican Republic
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Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther 2021; 222:107789. [PMID: 33316287 PMCID: PMC8122039 DOI: 10.1016/j.pharmthera.2020.107789] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Many different forms of hormonal contraception are used by millions of women worldwide. These contraceptives differ in the dose and type of synthetic progestogenic compound (progestin) used, as well as the route of administration and whether or not they contain estrogenic compounds. There is an increasing awareness that different forms of contraception and different progestins have different side-effect profiles, in particular their cardiovascular effects, effects on reproductive cancers and susceptibility to infectious diseases. There is a need to develop new methods to suit different needs and with minimal risks, especially in under-resourced areas. This requires a better understanding of the pharmacokinetics, metabolism, serum and tissue concentrations of progestins used in contraception as well as the biological activities of progestins and their metabolites via steroid receptors. Here we review the current knowledge on these topics and identify the research gaps. We show that there is a paucity of research on most of these topics for most progestins. We find that major impediments to clear conclusions on these topics include a lack of standardized methodologies, comparisons between non-parallel clinical studies and variability of data on serum concentrations between and within studies. The latter is most likely due, at least in part, to differences in intrinsic characteristics of participants. The review highlights the importance of insight on these topics in order to provide the best contraceptive options to women with minimal risks.
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Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Renate Louw-du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Pharmacokinetic and Pharmacodynamic Impacts of Depot Medroxyprogesterone Acetate Use on HIV Pre-exposure Prophylaxis in Women. J Acquir Immune Defic Syndr 2020; 85:182-188. [PMID: 32568766 DOI: 10.1097/qai.0000000000002421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Depot medroxyprogesterone acetate (DMPA) is a commonly used contraceptive in areas where use of tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis (PrEP) is increasing. OBJECTIVES We aimed to investigate the impact of DMPA on PrEP drug pharmacokinetics and pharmacodynamics in women using PrEP before and after DMPA administration. METHODS In this pilot study, 12 HIV-negative women ages 18-45 underwent biological sample collection at 3 time points: before study drug, after 2 weeks of daily PrEP use alone, and after 2 weeks of daily PrEP and concomitant DMPA use. We measured drug and drug metabolites in plasma, peripheral blood mononuclear cells, cervicovaginal fluid, cervical tissue, and rectal fluid after each 2-week course of PrEP. We measured HIV replication ex vivo in genital tissue biopsies and innate anti-HIV activity in cervicovaginal fluid before PrEP and after both courses. We compared drug concentrations after PrEP alone to after PrEP and DMPA in the same participant using Wilcoxon signed-rank tests. We used mixed effects linear regression models to compare pharmacodynamic measures for each participant at predrug baseline, after PrEP alone, and after PrEP and DMPA. RESULTS We found no significant differences in PrEP drug and drug metabolite concentrations in any compartment during concomitant DMPA use compared with use of PrEP alone, except for a reduction in emtricitabine concentration in cervical tissue. We found no difference in HIV replication in cervical tissue or anti-HIV activity in cervicovaginal fluid during concomitant DMPA and PrEP use compared with during PrEP use alone. CONCLUSIONS Concomitant use of DMPA does not clinically alter pharmacokinetics or pharmacodynamics of PrEP in women. These data support the safety of DMPA use in women using PrEP.
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Quispe Calla NE, Vicetti Miguel RD, Fritts L, Miller CJ, Aceves KM, Cherpes TL. Exogenous sex steroids regulate genital epithelial barrier function in female rhesus macaques. Biol Reprod 2020; 103:310-317. [PMID: 32542371 PMCID: PMC7401374 DOI: 10.1093/biolre/ioaa105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/27/2020] [Accepted: 06/11/2020] [Indexed: 12/11/2022] Open
Abstract
There is concern that using depot-medroxyprogesterone acetate (DMPA) for pregnancy prevention heightens HIV susceptibility. While no clinical data establishes causal link between HIV acquisition and use of this injectable progestin, prior work from our laboratory showed that DMPA comparably lowers genital levels of the cell-cell adhesion molecule desmoglein-1 (DSG1) and weakens genital epithelial barrier function in female mice and women. We likewise saw DMPA increase mouse susceptibility to multiple genital pathogens including HIV. Herein, we sought to confirm and extend these findings by comparing genital epithelial barrier function in untreated rhesus macaques (RM) vs. RM treated with DMPA or DMPA and estrogen (E). Compared to controls, genital tissue from RM with pharmacologically relevant serum levels of medroxyprogesterone acetate displayed significantly lower DSG1 levels and greater permeability to low molecular mass molecules. Conversely, DMPA-mediated effects on genital epithelial integrity and function were obviated in RM administered DMPA and E. These data corroborate the diminished genital epithelial barrier function observed in women initiating DMPA and identify RM as a useful preclinical model for defining effects of exogenous sex steroids on genital pathogen susceptibility. As treatment with E averted DMPA-mediated loss of genital epithelial barrier function, our results also imply that contraceptives releasing progestin and E may be less likely to promote transmission of HIV and other sexually transmitted pathogens than progestin-only compounds.
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Affiliation(s)
- Nirk E Quispe Calla
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Linda Fritts
- California National Primate Research Center, University of California, Davis, CA, USA
| | - Christopher J Miller
- California National Primate Research Center, University of California, Davis, CA, USA
- Center for Comparative Medicine, University of California, Davis, CA, USA
| | - Kristen M Aceves
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas L Cherpes
- Department of Comparative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Achilles SL, Meyn LA, Mhlanga FG, Matubu AT, Stoner KA, Beamer MA, Chirenje ZM, Hillier SL. Zim CHIC: A cohort study of immune changes in the female genital tract associated with initiation and use of contraceptives. Am J Reprod Immunol 2020; 84:e13287. [PMID: 32533883 PMCID: PMC7507197 DOI: 10.1111/aji.13287] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/13/2020] [Accepted: 06/05/2020] [Indexed: 12/27/2022] Open
Abstract
Problem Contraceptive hormones are systemically active, potent, and likely to invoke biological responses other than known fertility regulation impacts. We hypothesized that initiation of depot medroxyprogesterone acetate (DMPA) would increase genital HIV‐target‐cells and soluble immune mediators compared with baseline and initiation of other contraceptive methods. Method of Study We collected cervical cytobrushes and cervicovaginal fluid from healthy Zimbabwean women aged 18‐34 to assess immune cell populations, cytokines, and innate anti‐HIV activity at baseline and after 30, 90, and 180 days use of DMPA (n = 38), norethisterone enanthate (n = 41), medroxyprogesterone acetate/estradiol cypionate (n = 36), levonorgestrel implant (n = 43), etonogestrel implant (n = 47), or copper intrauterine device (Cu‐IUD) (n = 45). Cells were quantified by flow cytometry, cytokines were detected by multiplex assays, and innate anti‐HIV activity was assessed by in vitro HIV challenge. Results Compared to baseline, the number of cervical HIV target cells (#CD4 cells P < .04 and #CD11c cells P < .04), the concentration of the inflammatory cytokine IL‐1β (P < .01), and the innate in vitro anti‐HIV activity (P < .001) significantly decreased following DMPA initiation. In Cu‐IUD users, genital HIV target cells increased (#CD4 cells P < .001, #CD4CCR5 cells P = .02, #CD4CD69 cells P < .001, #CD8CD69 P = .01, and #CD11c cells P = .003) at day 30 and resolved by day 180. IFN‐γ (P < .001), IL‐1β (P < .001), IL‐6 (P < .001), IL‐8 (P < .001), IL‐10 (P < .01), and RANTES (P < .001) were also significantly increased at day 30. Minimal alterations were observed following initiation of subdermal implantable contraceptives. Conclusions This head‐to‐head study compared six contraceptives and found increased HIV target cells and cervical inflammation temporally associated with Cu‐IUD initiation. Use of hormonal contraception, including DMPA, did not increase cervical HIV target cells or inflammation. Clinical Trial Number: NCT02038335
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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
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Center for Family Planning Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Felix G Mhlanga
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Science, Harare, Zimbabwe
| | - Allen T Matubu
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Science, Harare, Zimbabwe
| | | | - May A Beamer
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Zvavahera M Chirenje
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Science, 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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9
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Hapgood JP. Is the Injectable Contraceptive Depo-Medroxyprogesterone Acetate (DMPA-IM) Associated with an Increased Risk for HIV Acquisition? The Jury Is Still Out. AIDS Res Hum Retroviruses 2020; 36:357-366. [PMID: 31797677 PMCID: PMC7232639 DOI: 10.1089/aid.2019.0228] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Intramuscular depo-medroxyprogesterone acetate (DMPA-IM) is the most widely used hormonal contraceptive in sub-Saharan Africa. Previous meta-analyses of observational studies found a significant 40%–50% increased risk associated with DMPA-IM use, relative to no contraception or infrequent condom use. This raised substantial concerns, although these studies had important limitations. Consequently, the open-label randomized Evidence for Contraceptive Options and HIV Outcomes trial was conducted, designed primarily to detect a 50% or greater difference in HIV risk between DMPA-IM, the levonorgestrel (LNG) implant, and the copper-intrauterine device. The ECHO study, published in July 2019, concluded that there is no substantial difference in HIV risk among the methods evaluated, and that all three methods are safe and highly effective. In response, the WHO relaxed the Medical Eligibility Criteria for DMPA-IM use among women at high HIV risk in August 2019. However, two of the three comparisons in the ECHO trial could rule out neither a 50% increase nor no change in HIV risk for one contraceptive compared with another. The study had limitations and the results contained considerable uncertainty. They also did not inform on associated HIV risk for any one of the individual methods due to the absence of a control group such as no contraception or only infrequent condom use. The HIV risks associated with LNG implant and copper-IUD relative to no contraception or infrequent condom use are unknown and these cannot be seen as controls, nor did the authors claim them to be. The results will be discussed in the context of their limitations, what they add to the body of work to date on contraception and HIV acquisition, and the implications of the findings and reports thereof for future research and contraceptive choice.
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Affiliation(s)
- Janet P. Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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10
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Tomasicchio M, Davids M, Pooran A, Theron G, Smith L, Semple L, Meldau R, Hapgood JP, Dheda K. The Injectable Contraceptive Medroxyprogesterone Acetate Attenuates Mycobacterium tuberculosis-Specific Host Immunity Through the Glucocorticoid Receptor. J Infect Dis 2020; 219:1329-1337. [PMID: 30452655 PMCID: PMC6452311 DOI: 10.1093/infdis/jiy657] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 11/12/2018] [Indexed: 01/28/2023] Open
Abstract
Background The effects of the widely used progestin-only injectable contraceptives, medroxyprogesterone acetate (MPA) and norethisterone acetate (NET-A), on host susceptibility to Mycobacterium tuberculosis (Mtb) are unknown. Methods We recruited human immunodeficiency virus–uninfected females, not taking any contraceptives, from Cape Town, South Africa, to evaluate the effect of MPA, NET-A, and dexamethasone on Mtb containment in monocyte-derived macrophages co-incubated with purified protein derivative (PPD)–driven peripheral blood–derived effector cells. Results MPA (P < .005) and dexamethasone (P < .01), but not NET-A, significantly attenuated Mtb containment in Mtb-infected macrophages co-cultured with PPD-driven effector cells at physiologically relevant concentrations and in a dose-dependent manner. Antagonizing the glucocorticoid receptor with mifepristone (RU486) abrogated the reduction in Mtb containment. In PPD-stimulated peripheral blood mononuclear cells, MPA and dexamethasone, but not NET-A, upregulated (median [interquartile range]) regulatory T cells (5.3% [3.1%–18.2%]; P < .05), reduced CD4+ T-cell interferon-γ (21% [0.5%–28%]; P < .05) and granzyme B production (12.6% [7%–13.5%]; P < .05), and reduced CD8+ perforin activity (2.2% [0.1%–7%]; P < .05). RU486 reversed regulatory T-cell up-regulation and the inhibitory effect on Th1 and granzyme/perforin-related pathways. Conclusions MPA, but not NET-A, subverts mycobacterial containment in vitro and downregulates pathways associated with protective CD8+- and CD4+-related host immunity via the glucocorticoid receptor. These data potentially inform the selection and use of injectable contraceptives in tuberculosis-endemic countries.
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Affiliation(s)
- Michele Tomasicchio
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Malika Davids
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Anil Pooran
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Grant Theron
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town.,Department of Science and Technology, National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Health Sciences, Stellenbosch University
| | - Liezel Smith
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Lynn Semple
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Richard Meldau
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town
| | - Janet Patricia Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, South Africa.,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town.,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, South Africa.,Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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11
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Quispe Calla NE, Vicetti Miguel RD, Aceves KM, Torres A, Cherpes TL. Depot-medroxyprogesterone acetate reduces genital cell-cell adhesion molecule expression and increases genital herpes simplex virus type 2 infection susceptibility in a dose-dependent fashion. Contraception 2019; 100:397-401. [PMID: 31302121 DOI: 10.1016/j.contraception.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Analyzing ectocervical biopsy tissue from women before and after they initiated use of depot-medroxyprogesterone acetate (DMPA), we previously reported this progestin reduces levels of the cell-cell adhesion molecule (CCAM) desmoglein-1 and increases genital mucosal permeability. We likewise saw treating mice with 1.0 mg of DMPA reduced vaginal CCAM expression and increased genital pathogen susceptibility. Herein, we used dose-response studies to delimit DMPA doses and serum MPA levels in mice associated with impaired genital mucosal barrier function and enhanced susceptibility to low-dose herpes simplex virus type 2 (HSV-2) infection. STUDY DESIGN We compared genital CCAM expression, genital mucosal permeability, and susceptibility to genital inoculation with 103 plaque-forming units of HSV-2 among mice in estrus vs. after treatment with 0.01 mg, 0.1 mg, 0.3 mg, or 1.0 mg of DMPA. RESULTS Compared to mice in estrus, DMPA treatment in a dose-dependent fashion significantly reduced desmoglein 1α (Dsg1a) and desmocollin-1 (Dsc1) gene expression, reduced DSG1 protein levels, and increased genital mucosal permeability to a low molecular weight molecule. While no mice infected with HSV-2 in estrus died, we respectively saw 50% and 100% mortality in mice administered 0.1 mg or 0.3 mg of DMPA. At time of infection, mean serum MPA levels in mice administered the 0.1 mg or 0.3 mg doses were 3.8 nM and 13.0 nM respectively (values comparable to trough and peak MPA serum levels in women using DMPA). CONCLUSIONS Mice with pharmacologically relevant serum MPA concentrations display significant changes in genital CCAM expression, genital mucosal barrier function, and HSV-2 susceptibility.
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Affiliation(s)
- Nirk E Quispe Calla
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA.
| | - Rodolfo D Vicetti Miguel
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA.
| | - Kristen M Aceves
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA
| | - Angelo Torres
- Midwestern University College of Veterinary Medicine, Glendale, AZ, USA
| | - Thomas L Cherpes
- Department of Comparative Medicine, Stanford University School of Medicine. Stanford, California, USA
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12
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Schatzkin E, Afolabi K, Adedeji O, Kongnyuy E, Shen J, Liu J. Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.13010.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.
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13
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Heffron R, Stalter R, Pyra M, Nanda K, Erikson DW, Hladik F, Blue SW, Davis NL, Mugo N, Kourtis AP, Lingappa JR, Baeten JM. HIV risk associated with serum medroxyprogesterone acetate levels among women in East and southern Africa. AIDS 2019; 33:735-744. [PMID: 30585845 PMCID: PMC6399047 DOI: 10.1097/qad.0000000000002123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Some observational studies have found increased HIV risk associated with self-reported use of injectable depot medroxyprogesterone acetate. Testing blood samples for medroxyprogesterone acetate (MPA), the progestin in depot medroxyprogesterone acetate, permits validation of self-reported data, and exploration of whether potential HIV risk is correlated with MPA levels, which are highest soon after injection. METHODS We conducted a case-control study testing archived serum from women who participated in three longitudinal studies of HIV prevention in East and southern Africa. Case samples, from women who acquired HIV, were from visits that occurred at or immediately prior to the first evidence of HIV infection. Secondary analyses restricted to case samples collected within 15 and 30 days of the estimated date of HIV infection. Matched control samples were from women who remained HIV uninfected. We used multivariable conditional logistic regression to compare exogenous hormone levels, quantified through mass spectrometry, among cases and controls. RESULTS When restricted to cases with samples collected within 15 days or less of estimated date of HIV infection, MPA detection was more frequent among women who acquired HIV (adjusted odds ratio = 2.75, 95% confidence interval 1.22-6.19). In this subset, the increase in HIV risk was only among samples with MPA detected at a low level of 0.02-0.50 ng/ml: 36.7% of cases and 9.4% of controls, adjusted odds ratio = 6.03, 95% confidence interval 2.50-14.54. CONCLUSION Detection of MPA at low levels close to the estimated time of HIV acquisition was significantly more frequent among women who acquired HIV. Studies are needed that explore biological mechanisms elicited by any MPA level and HIV risk.
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Affiliation(s)
| | | | - Maria Pyra
- University of Washington, Seattle, Washington
| | - Kavita Nanda
- Global Health, Population and Nutrition, FHI360, Durham, North Carolina
| | - David W Erikson
- Endocrine Technologies Core, Oregon National Primate Research Center, Hillsboro, Oregon
| | - Florian Hladik
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Steven W Blue
- Endocrine Technologies Core, Oregon National Primate Research Center, Hillsboro, Oregon
| | - Nicole L Davis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nelly Mugo
- University of Washington, Seattle, Washington
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Athena P Kourtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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14
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The contraceptive medroxyprogesterone acetate, unlike norethisterone, directly increases R5 HIV-1 infection in human cervical explant tissue at physiologically relevant concentrations. Sci Rep 2019; 9:4334. [PMID: 30867477 PMCID: PMC6416361 DOI: 10.1038/s41598-019-40756-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
The intramuscular progestin-only injectable contraceptive, depo-medroxyprogesterone acetate (DMPA-IM), is more widely used in Sub-Saharan Africa than another injectable contraceptive, norethisterone enanthate (NET-EN). Epidemiological data show a significant 1.4-fold increased risk of HIV-1 acquisition for DMPA-IM usage, while no such association is shown from limited data for NET-EN. We show that MPA, unlike NET, significantly increases R5-tropic but not X4-tropic HIV-1 replication ex vivo in human endocervical and ectocervical explant tissue from pre-menopausal donors, at physiologically relevant doses. Results support a mechanism whereby MPA, unlike NET, acts via the glucocorticoid receptor (GR) to increase HIV-1 replication in cervical tissue by increasing the relative frequency of CD4+ T cells and activated monocytes. We show that MPA, unlike NET, increases mRNA expression of the CD4 HIV-1 receptor and CCR5 but not CXCR4 chemokine receptors, via the GR. However, increased density of CD4 on CD3+ cells was not observed with MPA by flow cytometry of digested tissue. Results suggest that DMPA-IM may increase HIV-1 acquisition in vivo at least in part via direct effects on cervical tissue to increase founder R5-tropic HIV-1 replication. Our findings support differential biological mechanisms and disaggregation of DMPA-IM and NET-EN regarding HIV-1 acquisition risk category for use in high risk areas.
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15
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Heffron R, Achilles SL, Dorflinger LJ, Hapgood JP, Kiarie J, Polis CB, Steyn PS. Pharmacokinetic, biologic and epidemiologic differences in MPA- and NET-based progestin-only injectable contraceptives relative to the potential impact on HIV acquisition in women. Contraception 2018; 99:199-204. [PMID: 30576636 PMCID: PMC6467541 DOI: 10.1016/j.contraception.2018.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/25/2018] [Accepted: 12/05/2018] [Indexed: 11/13/2022]
Abstract
Access to safe and effective contraceptive choices is a reproductive right and contributes tremendously to improvements in maternal and child health. Progestin-only injectables, particularly intramuscularly injected depot medroxyprogesterone acetate (DMPA-IM), have received increased attention given findings suggesting a potential association with increased HIV risk. For women at high risk of HIV, the World Health Organization's Medical eligibility criteria for contraceptive use currently aggregate recommendations for all progestin-only injectables, including DMPA-IM, subcutaneously injected DMPA (DMPA-SC) and intramuscularly injected norethindrone/ norethisterone enanthate (NET-EN), except in the case of some drug interactions. We considered whether published data indicate differences or similarities between these injectables relevant to risk of acquiring HIV. In vitro data confirm different biological activities of these distinct progestins, including that MPA, and not NET, binds and activates the glucocorticoid receptor resulting in different biological effects relevant to immune function. Limited clinical data suggest changes in immunologic activity following DMPA-IM and NET-EN initiation, but interstudy variation and study design differences diminish ability to determine clinical relevance and the degree to which DMPA-IM and NET-EN could act differentially. The highest-quality epidemiologic studies suggest a potential 40% increase in HIV incidence in users of DMPA-IM relative to women not using hormonal contraception but no significant increase in risk in users of NET-EN. In our opinion, most of the available biologic activity and epidemiologic data indicate that DMPA and NET-EN are likely to act differently, and data remain too limited to evaluate differences between DMPA-IM and DMPA-SC.
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Affiliation(s)
- Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA, USA; Department of Epidemiology, University of Washington, 325 Ninth Avenue Box 359927, Seattle, WA, USA.
| | - 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.
| | | | - Janet P Hapgood
- Department of Molecular and Cell Biology, Faculty of Science, University of Cape Town, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Private Bag X3, Rondebosch, 7701, Cape Town, South Africa.
| | - James Kiarie
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland.
| | - Chelsea B Polis
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, Manhattan, New York, 10038, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St., Baltimore, MD 21205, USA.
| | - Petrus S Steyn
- Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland.
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16
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Hernandez JH, Akilimali P, Glover A, Emel R, Mwembo A, Bertrand J. Task-shifting the provision of DMPA-SC in the DR Congo: Perspectives from two different groups of providers. Contraception 2018; 98:449-453. [PMID: 30031000 PMCID: PMC6197837 DOI: 10.1016/j.contraception.2018.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/02/2018] [Accepted: 07/04/2018] [Indexed: 11/14/2022]
Abstract
Objectives To document the experience of three groups of Family Planning service providers participating in task-shifting for the provision of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC) at the community level in the DRC. Study design This article compares results from interviews with DMPA-SC providers in two separate pilot studies: 1) 53 medical and nursing school students teaching women how to self-inject (2016–2017); and 2) 34 lay community health workers providing DMPA-SC in rural areas of Lualaba (2017). All providers gave information on socio-demographic characteristics, recruitment,) training, supervision, experience and satisfaction with the provision of DMPA-SC. The paper examines variations in responses from the different provider cadres. Results Despite substantive variations in provider profiles in terms of age, educational and marital status, reported levels of satisfaction with offering DMPA-SC in the community were consistently high. Over 90% of all providers declared being comfortable or very comfortable interacting with FP clients, and more than three quarters of them were very comfortable performing an injection. Over 90% of Lualaba providers and over 80% of student providers gave correct responses to DMPA-SC protocol questions regarding referral of clients to facilities and side-effects management. The vast majority declared being (very) satisfied with their experience providing DMPA-SC. Conclusions Providers with and without a clinical background, when properly trained and supervised, can provide DMPA-SC at the community level in both urban and rural settings of the DRC. Support strategies from the Family Planning environment (continuous contraceptive supplies and adequate referral system to fixed facilities) are key to engaging community health workers and sustainably leveraging task-shifting opportunities. Implication statement This study provides additional evidence on the acceptability and feasibility of task-shifting in relation to DMCP-SC and supports further scale-up efforts.
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Affiliation(s)
- Julie H Hernandez
- Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA.
| | - Pierre Akilimali
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Annie Glover
- Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
| | - Rebecca Emel
- Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
| | - Albert Mwembo
- École de Santé Publique de Lubumbashi, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo
| | - Jane Bertrand
- Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, Suite 1900, New Orleans, LA 70112, USA
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17
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Medroxyprogesterone acetate, unlike norethisterone, increases HIV-1 replication in human peripheral blood mononuclear cells and an indicator cell line, via mechanisms involving the glucocorticoid receptor, increased CD4/CD8 ratios and CCR5 levels. PLoS One 2018; 13:e0196043. [PMID: 29698514 PMCID: PMC5919616 DOI: 10.1371/journal.pone.0196043] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/05/2018] [Indexed: 01/11/2023] Open
Abstract
High usage of progestin-only injectable contraceptives, which include the intramuscular injectables depo-medroxyprogesterone acetate (DMPA-IM, Depo-Provera) and norethisterone (NET) enanthate (NET-EN or Nur-Isterate), correlates worldwide with areas of high HIV-1 prevalence. Epidemiological data show a significant association between usage of DMPA-IM and increased HIV-1 acquisition but no such association from limited data for NET-EN. Whether MPA and NET have similar effects on HIV-1 acquisition and pathogenesis, and the relationship between these effects and the dose of MPA, are critical issues for women's health and access to suitable and safe contraceptives. We show for the first time that MPA, unlike NET, significantly increases HIV-1 replication in peripheral blood mononuclear cells (PBMCs) and a cervical cell line model. The results provide novel evidence for a biological mechanism whereby MPA, acting via the glucocorticoid receptor (GR), increases HIV-1 replication by at least in part increasing expression of the CCR5 HIV-1 coreceptor on target T-lymphocytes. MPA, unlike NET, also increases activation of T-cells and increases the CD4/CD8 ratio, suggesting that multiple mechanisms are involved in the MPA response. Our data offer strong support for different biological mechanisms for MPA versus NET, due to their differential GR activity. The dose-dependence of the MPA response suggests that significant effects are observed within the range of peak serum levels of progestins in DMPA-IM but not NET-EN users. Dose-response results further suggest that effects of contraceptives containing MPA on HIV-1 acquisition and disease progression may be critically dependent on dose, time after injection and intrinsic factors that affect serum concentrations in women.
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