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Vicetti Miguel RD, Quispe Calla NE, Cherpes TL. HIV, progestins, genital epithelial barrier function, and the burden of objectivity†. Biol Reprod 2020; 103:318-322. [PMID: 32561906 PMCID: PMC7401028 DOI: 10.1093/biolre/ioaa078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 02/04/2023] Open
Abstract
Contributions from a diverse set of scientific disciplines will be needed to help individuals make fully informed decisions regarding contraceptive choices least likely to promote HIV susceptibility. This commentary recaps contrasting interpretations of results from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial, a study that compared HIV risk in women using the progestin-only injectable contraceptive depot medroxyprogesterone acetate (DMPA) vs. two other contraceptive choices. It also summarizes results from basic and translational research that establish biological plausibility for earlier clinical studies that identified enhanced HIV susceptibility in women using DMPA.
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Affiliation(s)
| | - Nirk E Quispe Calla
- 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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Quispe Calla NE, Vicetti Miguel RD, Torres AR, Trout W, Gabriel JM, Hatfield AM, Aceves KM, Kwiek JJ, Kaur B, Cherpes TL. Norethisterone Enanthate Increases Mouse Susceptibility to Genital Infection with Herpes Simplex Virus Type 2 and HIV Type 1. Immunohorizons 2020; 4:72-81. [PMID: 32047094 PMCID: PMC7172028 DOI: 10.4049/immunohorizons.1900077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/21/2020] [Indexed: 12/17/2022] Open
Abstract
Norethisterone enanthate (NET-EN) and depot-medroxyprogesterone acetate (DMPA) are two forms of injectable progestin used for contraception. Whereas clinical research indicates that women using DMPA are more susceptible to HIV and other genital pathogens, causal relationships have not been determined. Providing an underlying mechanism for this connection, however, is recent work that showed DMPA weakens genital mucosal barrier function in mice and humans and respectively promotes susceptibility of wild-type and humanized mice to genital infection with HSV type 2 and HIV type 1. However, analogous effects of NET-EN treatment on antivirus immunity and host susceptibility to genital infection are much less explored. In this study, we show that compared with mice in estrus, treatment of mice with DMPA or NET-EN significantly decreased genital levels of the cell-cell adhesion molecule desmoglein-1 and increased genital mucosal permeability. These effects, however, were more pronounced in DMPA- versus NET-EN-treated mice. Likewise, we detected comparable mortality rates in DMPA- and NET-EN-treated wild-type and humanized mice after intravaginal infection with HSV type 2 or cell-associated HIV type 1, respectively, but NET-EN treatment was associated with slower onset of HSV-induced genital pathology and lower burden of systemic HIV disease. These findings reveal DMPA and NET-EN treatment of mice significantly reduces genital desmoglein-1 levels and increases genital mucosal permeability and susceptibility to genital pathogens while also implying that NET-EN generates less compromise of genital mucosal barrier function than DMPA.
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Affiliation(s)
- Nirk E Quispe Calla
- Department of Comparative Medicine, Stanford University, Stanford, CA 94305;
| | | | - Angelo R Torres
- Midwestern University College of Veterinary Medicine, Glendale, AZ 85308
| | - Wayne Trout
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH 43210
| | - Janelle M Gabriel
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH 43210
| | - Alissa M Hatfield
- Department of Comparative Medicine, Stanford University, Stanford, CA 94305
| | - Kristen M Aceves
- Department of Comparative Medicine, Stanford University, Stanford, CA 94305
| | - Jesse J Kwiek
- Department of Microbiology, The Ohio State University, Columbus, OH 43210; and
| | - Balveen Kaur
- Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas, Houston, TX 77058
| | - Thomas L Cherpes
- Department of Comparative Medicine, Stanford University, Stanford, CA 94305
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Objective Measurement of Inaccurate Condom Use Reporting Among Women Using Depot Medroxyprogesterone Acetate for Contraception. AIDS Behav 2017; 21:2173-2179. [PMID: 27699594 DOI: 10.1007/s10461-016-1563-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Observational analyses have suggested that women using the injectable contraceptive depot medroxyprogesterone acetate (DMPA) may have heightened risk of acquiring HIV. However, those analyses were potentially confounded by sexual behavior, with possible differential condom use and reporting by women using DMPA versus no contraception. In a cross-sectional study, we measured the presence of a biomarker of recent condomless sex (Y chromosomal [Yc] DNA) in vaginal swabs from HIV-uninfected African women who had an HIV-infected partner and reported 100 % condom use. Half of the samples tested were from women reporting DMPA and half were from women using no contraception. Among 428 specimens tested (213 from DMPA users and 215 from women using no contraception), 32.0 % had Yc DNA detected, with a mean of 193 copies/10,000 human cells (range 0.1-8201). The frequency of detection did not differ by contraceptive use: 34.2 % of DMPA users versus 29.8 % of women using no contraception, adjusted odds ratio 1.3 (95 % confidence interval 0.9-2.0). These results suggest that inaccurate reporting of condom use by DMPA users may not account for the heightened risk of HIV acquisition among DMPA users in some observational studies.
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Calla NEQ, Miguel RDV, Boyaka PN, Hall-Stoodley L, Kaur B, Trout W, Pavelko SD, Cherpes TL. Medroxyprogesterone acetate and levonorgestrel increase genital mucosal permeability and enhance susceptibility to genital herpes simplex virus type 2 infection. Mucosal Immunol 2016; 9:1571-1583. [PMID: 27007679 PMCID: PMC5035233 DOI: 10.1038/mi.2016.22] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/19/2016] [Indexed: 02/07/2023]
Abstract
Depot-medroxyprogesterone acetate (DMPA) is a hormonal contraceptive especially popular in areas with high prevalence of HIV and other sexually transmitted infections (STI). Although observational studies identify DMPA as an important STI risk factor, mechanisms underlying this connection are undefined. Levonorgestrel (LNG) is another progestin used for hormonal contraception, but its effect on STI susceptibility is much less explored. Using a mouse model of genital herpes simplex virus type 2 (HSV-2) infection, we herein found that DMPA and LNG similarly reduced genital expression of the desmosomal cadherin desmoglein-1α (DSG1α), enhanced access of inflammatory cells to genital tissue by increasing mucosal epithelial permeability, and increased susceptibility to viral infection. Additional studies with uninfected mice revealed that DMPA-mediated increases in mucosal permeability promoted tissue inflammation by facilitating endogenous vaginal microbiota invasion. Conversely, concomitant treatment of mice with DMPA and intravaginal estrogen restored mucosal barrier function and prevented HSV-2 infection. Evaluating ectocervical biopsy tissue from women before and 1 month after initiating DMPA remarkably revealed that inflammation and barrier protection were altered by treatment identically to changes seen in progestin-treated mice. Together, our work reveals DMPA and LNG diminish the genital mucosal barrier; a first-line defense against all STI, but may offer foundation for new contraceptive strategies less compromising of barrier protection.
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Affiliation(s)
- Nirk E Quispe Calla
- Department of Microbial infection & Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA,Corresponding authors: Thomas L. Cherpes, DVM, MD, Biomedical Research Tower, Room 712, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.1897 Fax: 614.292.9616. Rodolfo D. Vicetti Miguel, MD, Biomedical Research Tower, Room 731, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616. Nirk E. Quispe Calla, MD, Biomedical Research Tower, Room 740,460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616
| | - Rodolfo D Vicetti Miguel
- Department of Microbial infection & Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA,Corresponding authors: Thomas L. Cherpes, DVM, MD, Biomedical Research Tower, Room 712, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.1897 Fax: 614.292.9616. Rodolfo D. Vicetti Miguel, MD, Biomedical Research Tower, Room 731, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616. Nirk E. Quispe Calla, MD, Biomedical Research Tower, Room 740,460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616
| | - Prosper N Boyaka
- Department of Veterinary Biosciences, The Ohio State University College of Veterinary Medicine, Columbus, Ohio, USA
| | - Luanne Hall-Stoodley
- Department of Microbial infection & Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Balveen Kaur
- Department of Neurological Surgery, James Comprehensive Cancer Center, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Wayne Trout
- Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stephen D Pavelko
- Department of Microbial infection & Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Thomas L Cherpes
- Department of Microbial infection & Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA,Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA,Corresponding authors: Thomas L. Cherpes, DVM, MD, Biomedical Research Tower, Room 712, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.1897 Fax: 614.292.9616. Rodolfo D. Vicetti Miguel, MD, Biomedical Research Tower, Room 731, 460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616. Nirk E. Quispe Calla, MD, Biomedical Research Tower, Room 740,460 West 12th Ave., Columbus, OH 43210, USA, Telephone: 614.688.2165 Fax: 614.292.9616
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Association between injectable progestin-only contraceptives and HIV acquisition and HIV target cell frequency in the female genital tract in South African women: a prospective cohort study. THE LANCET. INFECTIOUS DISEASES 2015; 16:441-8. [PMID: 26723758 DOI: 10.1016/s1473-3099(15)00429-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/22/2015] [Accepted: 10/29/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of injectable progestin-only contraceptives has been associated with increased risk of HIV acquisition in observational studies, but the biological mechanisms of this risk remain poorly understood. We aimed to assess the effects of progestins on HIV acquisition risk and the immune environment in the female genital tract. METHODS In this prospective cohort, we enrolled HIV-negative South African women aged 18-23 years who were not pregnant and were living in Umlazi, South Africa from the Females Rising through Education, Support, and Health (FRESH) study. We tested for HIV-1 twice per week to monitor incident infection. Every 3 months, we collected demographic and behavioural data in addition to blood and cervical samples. The study objective was to characterise host immune determinants of HIV acquisition risk, including those associated with injectable progestin-only contraceptive use. Hazard ratios (HRs) were estimated using Cox proportional hazards methods. FINDINGS Between Nov 19, 2012, and May 31, 2015, we characterised 432 HIV-uninfected South African women from the FRESH study. In this cohort, 152 women used injectable progestin-only contraceptives, 43 used other forms of contraception, and 222 women used no method of long-term contraception. Women using injectable progestin-only contraceptives were at substantially higher risk of acquiring HIV (12·06 per 100 person-years, 95% CI 6·41-20·63) than women using no long-term contraception (3·71 per 100 person-years, 1·36-8·07; adjusted hazard ratio [aHR] 2·93, 95% CI 1·09-7·868, p=0·0326). HIV-negative injectable progestin-only contraceptive users had 3·92 times the frequency of cervical HIV target cells (CCR5+ CD4 T cells) compared with women using no long-term contraceptive (p=0·0241). Women using no long-term contraceptive in the luteal phase of the menstrual cycle also had a 3·25 times higher frequency of cervical target cells compared with those in the follicular phase (p=0·0488), suggesting that a naturally high progestin state had similar immunological effects to injectable progestin-only contraceptives. INTERPRETATION Injectable progestin-only contraceptive use and high endogenous progesterone are both associated with increased frequency of activated HIV targets cells at the cervix, the site of initial HIV entry in most women, providing a possible biological mechanism underlying increased HIV acquisition in women with high progestin exposure. FUNDING The Bill and Melinda Gates Foundation and the National Institute of Allergy and Infectious Diseases.
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Quispe Calla NE, Ghonime MG, Cherpes TL, Vicetti Miguel RD. Medroxyprogesterone acetate impairs human dendritic cell activation and function. Hum Reprod 2015; 30:1169-77. [PMID: 25740884 PMCID: PMC4481667 DOI: 10.1093/humrep/dev035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/02/2015] [Accepted: 02/04/2015] [Indexed: 01/01/2023] Open
Abstract
STUDY QUESTION Does medroxyprogesterone acetate (MPA) impair human dendritic cell (DC) activation and function? SUMMARY ANSWER In vitro MPA treatment suppressed expression of CD40 and CD80 by human primary DCs responding to Toll-like receptor 3 (TLR3) agonist stimulation (i.e. DC activation). Moreover, this MPA-mediated decrease in CD40 expression impaired DC capacity to stimulate T cell proliferation (i.e. DC function). WHAT IS KNOWN ALREADY MPA is the active molecule in Depo-Provera(®) (DMPA), a commonly used injectable hormonal contraceptive (HC). Although DMPA treatment of mice prior to viral mucosal tissue infection impaired the capacity of DCs to up-regulate CD40 and CD80 and prime virus-specific T cell proliferation, neither DC activation marker expression nor the ability of DCs to promote T cell proliferation were affected by in vitro progesterone treatment of human DCs generated from peripheral blood monocytes. STUDY DESIGN, SIZE, DURATION This cross-sectional study examined MPA-mediated effects on the activation and function of human primary untouched peripheral blood DCs. PARTICIPANTS/MATERIALS, SETTING, METHODS Human DCs isolated from peripheral blood mononuclear cells by negative immunomagnetic selection were incubated for 24 h with various concentrations of MPA. After an additional 24 h incubation with the TLR3 agonist polyinosinic:polycytidylic acid (poly I:C), flow cytometry was used to evaluate DC phenotype (i.e. expression of CD40, CD80, CD86, and HLA-DR). In separate experiments, primary untouched human DCs were sequentially MPA-treated, poly I:C-activated, and incubated for 7 days with fluorescently labeled naïve allogeneic T cells. Flow cytometry was then used to quantify allogeneic T cell proliferation. MAIN RESULTS AND THE ROLE OF CHANCE Several pharmacologically relevant concentrations of MPA dramatically reduced CD40 and CD80 expression in human primary DCs responding to the immunostimulant poly I:C. In addition, MPA-treated DCs displayed a reduced capacity to promote allogeneic CD4(+) and CD8(+) T cell proliferation. In other DC: T cell co-cultures, the addition of antibody blocking the CD40-CD154 (CD40L) interaction mirrored the decreased T cell proliferation produced by MPA treatment, while addition of recombinant soluble CD154 restored the capacity of MPA-treated DCs to induce T cell proliferation to levels produced by non-MPA-treated controls. LIMITATIONS, REASON FOR CAUTION While our results newly reveal that pharmacologically relevant MPA concentrations suppress human DC function in vitro, additional research is needed to learn if DMPA similarly inhibits DC maturation and function in the human female genital tract. WIDER IMPLICATIONS OF THE FINDINGS Identification of a mechanism by which MPA impairs human DC activation and function increases the biological plausibility for the relationships currently suspected between DMPA use and enhanced susceptibility to genital tract infection. STUDY FUNDING/COMPETING INTERESTS Funding provided by the NIH (grant R01HD072663) and The Ohio State University College of Medicine. The authors have no conflicts of interest to declare.
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Affiliation(s)
- N E Quispe Calla
- Departments of Microbial Infection & Immunity and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - M G Ghonime
- Departments of Microbial Infection & Immunity and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - T L Cherpes
- Departments of Microbial Infection & Immunity and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - R D Vicetti Miguel
- Departments of Microbial Infection & Immunity and Obstetrics & Gynecology, The Ohio State University College of Medicine, Columbus, OH 43210, USA
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