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Avenant C, Singata-Madliki M, Bick AJ, Africander D, Balakrishna Y, Storbeck KH, Moliki JM, Dlamini S, Skosana S, Smit J, Beksinska M, Beesham I, Seocharan I, Batting J, Hofmeyr GJ, Hapgood JP. The injectable contraceptives depot medroxyprogesterone acetate and norethisterone enanthate substantially and differentially decrease testosterone and sex hormone binding globulin levels: A secondary study from the WHICH randomized clinical trial. PLoS One 2024; 19:e0307736. [PMID: 39178280 PMCID: PMC11343371 DOI: 10.1371/journal.pone.0307736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/09/2024] [Indexed: 08/25/2024] Open
Abstract
HIV acquisition risk with norethisterone (NET) enanthate (NET-EN) is reportedly less than for depo-medroxyprogesterone acetate intramuscular (DMPA-IM). We investigated the effects of these progestin-only injectable contraceptives on serum testosterone and sex hormone binding globulin (SHBG) levels, since these may play a role in sexual behavior and HIV acquisition. The open-label WHICH clinical trial, conducted at two sites in South Africa from 2018-2019, randomized HIV-negative women aged 18-40 years to 150 mg DMPA-IM 12-weekly (n = 262) or 200 mg NET-EN 8-weekly (n = 259). We measured testosterone by UHPLC-MS/MS and SHBG by immunoassay in matched pairs of serum samples collected at baseline (D0) and at peak serum progestin levels at 25 weeks post initiation (25W) (n = 214-218 pairs). Both contraceptives substantially decreased, from D0 to 25W, the total testosterone [DMPA-IM D0 0.560, 25W 0.423 nmol/L, -24.3% (p < 0.0001); NET-EN D0 0.551, 25W 0.253 nmol/L, -54.1%, (p < 0.0001)], SHBG [DMPA-IM D0 45.0, 25W 32.7 nmol/L, -29.8% (p < 0.0001); NET-EN D0 50.2, 25W 17.6 nmol/L, -65.1% (p < 0.0001)], and calculated free testosterone levels [DMPA-IM D0 6.87, 25W 5.38 pmol/L, -17.2% (p = 0.0371); NET-EN D0 6.00, 25W 3.70, -40.0% (p < 0.0001)]. After adjusting for change from D0, the total testosterone, SHBG and calculated free testosterone levels were significantly higher for DMPA-IM than NET-EN (64.9%, p < 0.0001; 101.2%, p < 0.0001; and 38.0%, p = 0.0120, respectively). The substantial and differential decrease in testosterone and SHBG levels does not explain our previous finding of no detected decrease in risky sexual behavior or sexual function for DMPA-IM or NET-EN users from D0 to 25W. Medroxyprogesterone (MPA) and NET are androgenic and are both present in molar excess over testosterone and SHBG concentrations at 25W. Any within or between contraceptive group androgenic effects on behavior in the brain are likely dominated by the androgenic activities of MPA and NET and not by the decreased endogenous testosterone levels. The clinical trial was registered with the Pan African Clinical Trials Registry (PACTR 202009758229976).
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Affiliation(s)
- Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Alexis J. Bick
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Johnson M. Moliki
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sigcinile Dlamini
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Salndave Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Jenni Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ivana Beesham
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - George J. Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
- Walter Sisulu University, East London, South Africa
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
| | - 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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Singata-Madliki M, Smit J, Beksinska M, Balakrishna Y, Avenant C, Beesham I, Seocharan I, Batting J, Hapgood JP, Hofmeyr GJ. Effects of injectable contraception with depot medroxyprogesterone acetate or norethisterone enanthate on estradiol levels and menstrual, psychological and behavioral measures relevant to HIV risk: The WHICH randomized trial. PLoS One 2024; 19:e0295764. [PMID: 38530848 DOI: 10.1371/journal.pone.0295764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/14/2023] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Observational data suggest lower HIV risk with norethisterone enanthate (NET-EN) than with depo-medroxyprogesterone acetate intramuscular (DMPA-IM) injectable contraceptives. If confirmed, a switch between these similar injectable methods would be programmatically feasible and could impact the trajectory of the HIV epidemic. We aimed in this paper to investigate the effects of DMPA-IM and NET-EN on estradiol levels, measures of depression and sexual activity and menstrual effects, relevant to HIV risk; and to ascertain whether these measures are associated with estradiol levels. METHODS This open-label trial conducted at two sites in South Africa from 5 November 2018 to 30 November 2019, randomized HIV-negative women aged 18-40 to DMPA-IM 150 mg intramuscular 12-weekly (n = 262) or NET-EN 200 mg intramuscular 8-weekly (n = 259). Data were collected on hormonal, behavioral and menstrual effects at baseline and at 25 weeks (25W). RESULTS At 25W, median 17β estradiol levels were substantially lower than at baseline (p<0.001) for both methods: 76.5 pmol/L (interquartile range (IQR) 54.1 to 104.2) in the DMPA-IM group (n = 222), and 69.8 pmol/L (IQR: 55.1 to 89.3) in the NET-EN group (n = 225), with no statistical difference between the two methods (p = 0.450). Compared with DMPA-IM, NET-EN users reported significantly less amenorrhoea, fewer sexual acts, fewer users reporting at least one act of unprotected sex, more condom use with steady partner, more days with urge for sexual intercourse, more days feeling partner does not love her, and more days feeling sad for no reason. We did not find a clear association between estradiol levels and sexual behavior, depression and menstrual effects. Behavioral outcomes suggest less sexual exposure with NET-EN than DMPA-IM. The strength of this evidence is high due to the randomized study design and the consistency of results across the outcomes measured. CONCLUSIONS Estradiol levels were reduced to postmenopausal levels by both methods. Secondary outcomes suggesting less sexual exposure with NET-EN are consistent with reported observational evidence of less HIV risk with NET-EN. A randomized trial powered for HIV acquisition is feasible and needed to answer this important question. TRIAL REGISTRATION PACTR 202009758229976.
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Affiliation(s)
- Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Jenni Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Ivana Beesham
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - 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
| | - G Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, East London, South Africa
- Walter Sisulu University, East London, South Africa
- Department of Obstetrics and Gynecology, University of Botswana, Gabarone, Botswana
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Avenant C, Bick AJ, Skosana SB, Dlamini S, Balakrishna Y, Moliki JM, Singata-Madliki M, Hofmeyr GJ, Smit J, Beksinska M, Beesham I, Seocharan I, Batting J, Chen PL, Storbeck KH, Africander D, Hapgood JP. Misreporting contraceptive use and the association of peak study progestin levels with weight and BMI among women randomized to the progestin-only injectable contraceptives DMPA-IM and NET-EN. PLoS One 2023; 18:e0295959. [PMID: 38134043 PMCID: PMC10745193 DOI: 10.1371/journal.pone.0295959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023] Open
Abstract
Progestin-only injectable contraceptives, mainly depo-medroxyprogesterone acetate intramuscular (DMPA-IM), are the most widely used contraceptive methods in sub-Saharan Africa. Insufficient robust data on their relative side-effects and serum concentrations limit understanding of reported outcomes in contraception trials. The WHICH clinical trial randomized HIV-negative women to DMPA-IM (n = 262) or norethisterone enanthate (NET-EN) (n = 259) at two South African sites between 2018-2019. We measured serum concentrations of study and non-study progestins at initiation (D0) and peak serum levels, one week after the 24-week injection [25 weeks (25W)], (n = 435) and investigated associations between study progestin levels, and BMI and weight of participants. Peak median serum concentrations were 6.59 (IQR 4.80; 8.70) nM for medroxyprogesterone (MPA) (n = 161) and 13.6 (IQR 9.01; 19.0) nM for norethisterone (NET) (n = 155). MPA was the most commonly quantifiable non-study progestin at D0 in both arms (54%) and at 25W in the NET-EN arm (27%), followed by NET at D0 in both arms (29%) and at 25W in the DMPA-IM arm (19%). Levonorgestrel was quantifiable in both arms [D0 (6.9%); 25W (3.4%)], while other progestins were quantifiable in ≤ 14 participants. Significant negative time-varying associations were detected between MPA and NET concentrations and weight and BMI in both contraceptive arms and a significant increase was detected for peak serum progestin concentrations for normal weight versus obese women. Contraceptive-related reported outcomes are likely confounded by MPA, more so than NET, with reported DMPA-IM effects likely underestimated, at sites where DMPA-IM is widely used, due to misreporting of contraceptive use before and during trials, and 'tail' effects of DMPA-IM use more than six months before trial enrolment. Peak serum levels of MPA and NET are negatively associated with BMI and weight, suggesting another source of variability between trial outcomes and a potential increase in side-effects for normal weight versus overweight and obese women. Trail registration: The clinical trial was registered with the Pan African Clinical Trials Registry (PACTR 202009758229976).
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Affiliation(s)
- Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Alexis J. Bick
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Salndave B. Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sigcinile Dlamini
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Johnson Mosoko Moliki
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - G. Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
- Walter Sisulu University, East London, South Africa
- Department of Obstetrics and Gynecology, University of Botswana, Gabarone, Botswana
| | - Jenni Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ivana Beesham
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Pai-Lien Chen
- Family Health International (FHI) 360, Durham, North Carolina, United States of America
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - 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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Patel MV, Rodriguez-Garcia M, Shen Z, Wira CR. Medroxyprogesterone acetate inhibits wound closure of human endometrial epithelial cells and stromal fibroblasts in vitro. Sci Rep 2021; 11:23246. [PMID: 34853394 PMCID: PMC8636475 DOI: 10.1038/s41598-021-02681-6] [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: 06/11/2021] [Accepted: 11/15/2021] [Indexed: 01/13/2023] Open
Abstract
Mucosal integrity in the endometrium is essential for immune protection. Since breaches or injury to the epithelial barrier exposes underlying tissue and is hypothesized to increase infection risk, we determined whether endogenous progesterone or three exogenous progestins (medroxyprogesterone acetate (MPA), norethindrone (NET), and levonorgestrel (LNG)) used by women as contraceptives interfere with wound closure of endometrial epithelial cells and fibroblasts in vitro. Progesterone and LNG had no inhibitory effect on wound closure by either epithelial cells or fibroblasts. MPA significantly impaired wound closure in both cell types and delayed the reestablishment of transepithelial resistance by epithelial cells. In contrast to MPA, NET selectively decreased wound closure by stromal fibroblasts but not epithelial cells. Following epithelial injury, MPA but not LNG or NET, blocked the injury-induced upregulation of HBD2, a broad-spectrum antimicrobial implicated in wound healing, but had no effect on the secretion of RANTES, CCL20 and SDF-1α. This study demonstrates that, unlike progesterone and LNG, MPA and NET may interfere with wound closure following injury in the endometrium, potentially conferring a higher risk of pathogen transmission. Our findings highlight the importance of evaluating progestins for their impact on wound repair at mucosal surfaces.
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Affiliation(s)
- Mickey V Patel
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA.
| | | | - Zheng Shen
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
| | - Charles R Wira
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, 03756, USA
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Singata-Madliki M, Lawrie TA, Balakrishna Y, d'Hellencourt FCL, Hofmeyr GJ. Behavioral effects of different contraceptive methods and HIV acquisition: an ancillary study of the ECHO randomized trial. Reprod Health 2021; 18:192. [PMID: 34587971 PMCID: PMC8480042 DOI: 10.1186/s12978-021-01232-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ECHO trial randomised 7829 women to depot medroxyprogesterone acetate (DMPA-IM), the copper intrauterine device (IUD) and the levonorgestrel (LNG) implant (1:1:1) and found no clear difference in HIV incidence between these three groups. We have previously hypothesized that oligo-amenorrhoea induced by DMPA-IM may have a protective effect on HIV acquisition. The aim of this ancillary study was to assess the effects of DMPA-IM, the IUD and the LNG implant on menstrual symptoms and sexual behavior and to correlate these with HIV acquisition. METHODS At the Effective Care Research Unit (ECRU) in South Africa, of 615 women already randomised to DMPA-IM, the copper IUD and the LNG implant (1:1:1) 552 agreed to participate. Participants completed a 28-day symptom and behavior diary following their one-month ECHO trial visit and returning it at their 3-month follow-up visit. HIV acquisition data were retrieved from ECHO trial records. RESULTS Of 552 women enrolled on the ancillary study, 390 (70.6%) completed their daily diary; 130, 133, and 127 received DMPA-IM, IUD, and LNG implant, respectively. Thirty-three (5.9%) of these women acquired HIV. Women on the progestin-only contraceptives were more likely to experience amenorrhoea, as expected, and were less likely to have intra-menstrual coitus than IUD users (p < 0.001 for DMPA-IM vs IUD and p = 0.002 for implant vs IUD). Overall coital frequency was highest and condom usage lowest among DMPA-IM users. Intra-menstrual coitus correlated positively, and duration of menstruation correlated negatively, with HIV acquisition, although these effects were not statistically significant (p = 0.09 and p = 0.079, respectively). CONCLUSIONS Findings support the hypothesis that oligo-amenorrhoea and the associated reduced intra-menstrual coitus may mitigate the potential for an increased biological risk of HIV acquisition with DMPA-IM but more evidence is needed. Study registration number PACTR201706001651380.
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Affiliation(s)
- Mandisa Singata-Madliki
- Effective Care Research Unit, Frere Maternity Hospital, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, P.O. Box 4097, East London, South Africa.
| | - Theresa A Lawrie
- Effective Care Research Unit, Frere Maternity Hospital, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, P.O. Box 4097, East London, South Africa.,Evidence-Based Medicine Consultancy Ltd, Bath, UK
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | | | - G Justus Hofmeyr
- Effective Care Research Unit, Frere Maternity Hospital, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, P.O. Box 4097, East London, South Africa.,Department of Obstetrics and Gynaecology, University of Botswana, Botswana and Walter Sisulu University, East London, South Africa
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Noguchi LM, Marrazzo JM, Richardson B, Hillier SL, Balkus JE, Palanee-Phillips T, Nair G, Panchia R, Piper J, Gomez K, Ramjee G, Chirenje ZM. Prevalence and Incidence of Sexually Transmitted Infection in Injectable Progestin Contraception Users in South Africa. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3. [PMID: 35669097 PMCID: PMC9165437 DOI: 10.3389/frph.2021.668685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction: Whether intramuscular depot medroxyprogesterone acetate (DMPA-IM) and norethisterone enanthate (NET-EN) have a differential impact on the incidence of sexually transmitted infection (STI) remains unclear. In the Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial, HIV-1 acquisition was higher for DMPA-IM users vs. NET-EN users. We compared DMPA-IM and NET-EN users with regard to chlamydia, gonorrhea, trichomoniasis, syphilis, and herpes simplex virus type 2 (HSV-2) infection.Materials and Methods: Prospective data were analyzed from VOICE, a randomized trial of HIV-1 chemoprophylaxis. Participants were evaluated annually and as indicated for chlamydia, gonorrhea, trichomoniasis, and syphilis. Stored specimens were tested for HSV-2. Proportional hazards models compared the risk of STI between DMPA-IM and NET-EN users.Results: Among 2,911 injectable contraception users in South Africa, 1,800 (61.8%) used DMPA-IM and 1,111 used NET-EN (38.2%). DMPA-IM and NET-EN users did not differ in baseline chlamydia: 15.1 vs. 14.3%, p = 0.54; gonorrhea: 3.4 vs. 3.7%, p = 0.70; trichomoniasis: 5.7 vs.5.0%, p = 0.40; or syphilis: 1.5 vs. 0.7%, p = 0.08; but differed for baseline HSV-2: (51.3 vs. 38.6%, p < 0.001). Four hundred forty-eight incident chlamydia, 103 gonorrhea, 150 trichomonas, 17 syphilis, and 48 HSV-2 infections were detected over 2,742, 2,742, 2,783, 2,945, and 756 person-years (py), respectively (chlamydia 16.3/100 py; gonorrhea 3.8/100 py; trichomoniasis 5.4/100 py; syphilis 0.6/100 py; HSV-2 6.4/100 py). Comparing DMPA-IM with NET-EN users, no difference was noted in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV-2 infections, including when adjusted for confounders [chlamydia (aHR 1.03, 95% CI 0.85–1.25), gonorrhea (aHR 0.88, 95% CI 0.60–1.31), trichomoniasis (aHR 1.07, 95% CI 0.74–1.54), syphilis (aHR 0.41, 95% CI 0.15–1.10), and HSV-2 (aHR 0.83, 95% CI 0.45–1.54, p = 0.56)].Discussion: Among South African participants enrolled in VOICE, DMPA-IM and NET-EN users differed in prevalence of HSV-2 at baseline but did not differ in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV-2 infection. Differential HIV-1 acquisition, previously demonstrated in this cohort, does not appear to be explained by differential STI acquisition. However, the high incidence of multiple STIs reinforces the need to accelerate access to comprehensive sexual and reproductive health services.
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Affiliation(s)
- Lisa M. Noguchi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- *Correspondence: Lisa M. Noguchi
| | - Jeanne M. Marrazzo
- Division of Infectious Diseases, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Barbara Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Sharon L. Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh and the Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Jennifer E. Balkus
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
| | - Thesla Palanee-Phillips
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Jeanna Piper
- Division of AIDS, NIAID, U.S. National Institutes of Health, Bethesda, MD, United States
| | | | - Gita Ramjee
- South African Medical Research Council, Durban, South Africa
| | - Z. Mike Chirenje
- University of Zimbabwe Clinical Trials Research Centre, Department of Obstetrics and Gynaecology, Harare, Zimbabwe
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7
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Molatlhegi RP, Ngcobo S, Liebenberg LJP, Ngcapu S, Mabhula A, Leslie A, Mchunu N, Zondi MM, Adamson JH, Govender K, Samsunder N, Karim SSA, Karim QA, Passmore JAS, Sivro A, McKinnon LR. Genital and systemic immune effects of the injectable, contraceptive norethisterone enanthate (NET-EN), in South African women. Am J Reprod Immunol 2021; 86:e13411. [PMID: 33641222 DOI: 10.1111/aji.13411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/25/2022] Open
Abstract
PROBLEM Injectable hormonal contraceptives (IHC) have been associated with altered mucosal and systemic milieu which might increase HIV risk, but most studies have focused on DMPA and not NET-EN, despite the growing popularity and lower HIV risk associated with the latter in observational studies. METHOD OF STUDY We used high-performance liquid chromatography in combination with tandem triple quadrupole mass spectrometry (HPLC-LC-MS/MS) to measure steroid hormones in plasma samples of CAPRISA004 study participants. Concentrations of 48 cytokines were measured in the cervicovaginal lavage (CVL) and plasma, and their expression was compared between participants with detectable NET-EN (n = 201) versus non-detectable IHC (n = 90). Each log10 cytokine concentration was tested as an outcome in linear-mixed models, with NET-EN detection as the main explanatory variable. Multivariable models were adjusted for potential confounders. RESULTS In bivariate analysis, detectable NET-EN was associated with reduced cervicovaginal M-CSF (P = 0.008), GM-CSF (P = 0.025) and G-CSF (P = 0.039), and elevated levels MIF (P = 0.008), IL-18 (P = 0.011), RANTES (P = 0.005) and IL-1Rα (P < 0.001). Lower G-CSF (P = 0.011) and elevated IL-1Rα (P = 0.008) remained significant in adjusted models. Multivariable analyses of plasma samples obtained from NET-EN-detectable women showed a significant increase in IP-10 (P = 0.026) and reductions in TNF-β (P = 0.037), RANTES (P = 0.009), and M-CSF (P < 0.001). While similar growth factor reduction in CVL was noted for both DMPA and NET-EN, similar trends were not observed for endogenous progesterone. CONCLUSIONS Detectable NET-EN was associated with reduced growth factors in the plasma and genital tract; particularly G-CSF and M-CSF. Our results suggest that while NET-EN is not inflammatory, it may have important immunological effects.
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Affiliation(s)
- Refilwe P Molatlhegi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Samkelisiwe Ngcobo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Lenine J P Liebenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Amanda Mabhula
- African Health Research Institute (AHRI), Durban, South Africa
| | - Alasdair Leslie
- African Health Research Institute (AHRI), Durban, South Africa
| | - Nobuhle Mchunu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Biostatistics Unit, South African Medical Research Council (SAMRC), Durban, South Africa.,School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Mthobisi M Zondi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - John H Adamson
- African Health Research Institute (AHRI), Durban, South Africa
| | - Katya Govender
- African Health Research Institute (AHRI), Durban, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Epidemiology, Columbia University, New York City, New York, USA
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Epidemiology, Columbia University, New York City, New York, USA
| | - Jo-Ann S Passmore
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa.,Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lyle R McKinnon
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
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8
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Balle C, Konstantinus IN, Jaumdally SZ, Havyarimana E, Lennard K, Esra R, Barnabas SL, Happel AU, Moodie Z, Gill K, Pidwell T, Karaoz U, Brodie E, Maseko V, Gamieldien H, Bosinger SE, Myer L, Bekker LG, Passmore JAS, Jaspan HB. Hormonal contraception alters vaginal microbiota and cytokines in South African adolescents in a randomized trial. Nat Commun 2020; 11:5578. [PMID: 33149114 PMCID: PMC7643181 DOI: 10.1038/s41467-020-19382-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Young women in sub-Saharan Africa are disproportionally affected by HIV infection and unintended pregnancies. However, hormonal contraceptive (HC) use may influence HIV risk through changes in genital tract microbiota and inflammatory cytokines. To investigate this, 130 HIV negative adolescent females aged 15-19 years were enrolled into a substudy of UChoose, an open-label randomized crossover study (NCT02404038), comparing acceptability and contraceptive product preference as a proxy for HIV prevention delivery methods. Participants were randomized to injectable norethisterone enanthate (Net-En), combined oral contraceptives (COC) or etonorgesterol/ethinyl estradiol combined contraceptive vaginal ring (CCVR) for 16 weeks, then crossed over to another HC for 16 weeks. Cervicovaginal samples were collected at baseline, crossover and exit for characterization of the microbiota and measurement of cytokine levels; primary endpoints were cervical T cell activation, vaginal microbial diversity and cytokine concentrations. Adolescents randomized to COCs had lower vaginal microbial diversity and relative abundance of HIV risk-associated taxa compared to Net-En or CCVR. Cervicovaginal inflammatory cytokine concentrations were significantly higher in adolescents randomized to CCVR compared to COC and Net-En. This suggests that COC use may induce an optimal vaginal ecosystem by decreasing bacterial diversity and inflammatory taxa, while CCVR use is associated with genital inflammation.
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Affiliation(s)
- Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Iyaloo N Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shameem Z Jaumdally
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Enock Havyarimana
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Katie Lennard
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Rachel Esra
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaun L Barnabas
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zoe Moodie
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Tanya Pidwell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ulas Karaoz
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA
| | - Eoin Brodie
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA.,University of California, Berkeley, CA, USA
| | - Venessa Maseko
- National Institute for Communicable Diseases, Sandringham, Johannesburg, South Africa
| | - Hoyam Gamieldien
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven E Bosinger
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine; Division of Microbiology and Immunology, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Landon Myer
- Division of Epidemiology, Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Cape Town, South Africa
| | - Heather B Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. .,Seattle Children's Research Institute, Seattle, WA, USA. .,University of Washington Department of Pediatrics and Global Health, Seattle, WA, USA.
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9
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Brady M, Rodger A, Asboe D, Cambiano V, Clutterbuck D, Desai M, Field N, Harbottle J, Jamal Z, McCormack S, Palfreeman A, Portman M, Quinn K, Tenant-Flowers M, Wilkins E, Young I. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med 2020; 20 Suppl 2:s2-s80. [PMID: 30869189 DOI: 10.1111/hiv.12718] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Michael Brady
- Consultant in Sexual Health and HIV, King's College Hospital, London
| | - Alison Rodger
- Reader and Honorary Consultant Infectious Diseases and HIV, University College London
| | - David Asboe
- Consultant HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London
| | - Valentina Cambiano
- Lecturer in Infectious Disease Modelling and Biostatistics, University College London
| | | | - Monica Desai
- Consultant Epidemiologist, Public Health England
| | - Nigel Field
- Senior Lecturer, Consultant Clinical Epidemiologist, University College London
| | | | | | - Sheena McCormack
- Professor of Clinical Epidemiology, MRC Clinical Trials Unit at University College London
| | - Adrian Palfreeman
- Consultant HIV and Sexual Health, University Hospitals of Leicester NHS Trust
| | - Mags Portman
- Consultant HIV and Sexual Health, Mortimer Market Centre, London
| | - Killian Quinn
- Consultant HIV and Sexual Health, King's College Hospital, London
| | | | - Ed Wilkins
- Consultant in Infectious Diseases, North Manchester General Hospital
| | - Ingrid Young
- Chancellor's Fellow, Usher Institute, University of Edinburgh
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10
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Plasma concentration of injectable contraceptive correlates with reduced cervicovaginal growth factor expression in South African women. Mucosal Immunol 2020; 13:449-459. [PMID: 31896762 DOI: 10.1038/s41385-019-0249-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/10/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023]
Abstract
Long-acting injectable contraceptives have been associated with mucosal immune changes and increased HIV acquisition, but studies have often been hampered by the inaccuracy of self-reported data, unknown timing of injection, and interactions with mucosal transmission co-factors. We used mass spectrometry to quantify the plasma concentrations of injectable contraceptives in women from the CAPRISA004 study (n = 664), with parallel quantification of 48 cytokines and >500 host proteins in cervicovaginal lavage. Higher DMPA levels were associated with reduced CVL concentrations of GCSF, MCSF, IL-16, CTACK, LIF, IL-1α, and SCGF-β in adjusted linear mixed models. Dose-dependent relationships between DMPA concentration and genital cytokines were frequently observed. Unsupervised clustering of host proteins by DMPA concentration suggest that women with low DMPA had increases in proteins associated with mucosal fluid function, growth factors, and keratinization. Although DMPA was not broadly pro-inflammatory, DMPA was associated with increased IP-10 in HSV-2 seropositive and older women. DMPA-cytokine associations frequently differed by vaginal microbiome; in non-Lactobacillus-dominant women, DMPA was associated with elevated IL-8, MCP-1, and IP-10 concentrations. These data confirm a direct, concentration-dependant effect of DMPA on functionally important immune factors within the vaginal compartment. The biological effects of DMPA may vary depending on age, HSV-2 status, and vaginal microbiome composition.
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11
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Matubu A, Hillier SL, Meyn LA, Stoner KA, Mhlanga F, Mbizvo M, Maramba A, Chirenje ZM, Achilles SL. Depot medroxyprogesterone acetate and norethisterone enanthate differentially impact T-cell responses and expression of immunosuppressive markers. Am J Reprod Immunol 2019; 83:e13210. [PMID: 31729087 DOI: 10.1111/aji.13210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/07/2019] [Accepted: 10/22/2019] [Indexed: 11/28/2022] Open
Abstract
PROBLEM Injectable contraceptive use may impact immune cell responsiveness and susceptibility to infection. We measured responsiveness of T-cells from women before and after initiating depot medroxyprogesterone acetate (DMPA) or norethisterone enanthate (Net-En). METHOD OF STUDY Peripheral blood mononuclear cells collected from women aged 18-34 years prior to, at steady state, and nadir concentrations after initiating DMPA (n = 30) or Net-En (n = 36) and from women initiating copper intrauterine device (CU-IUD; n = 32) were stimulated with phorbol myristate acetate and analyzed using flow cytometry. We evaluated percentage change in T-cells expressing programmed cell death-1 (PD-1) and cytotoxic T-lymphocyte associated protein-4 (CTLA-4). RESULTS Compared to baseline, there were decreased numbers of CD4+CTLA4+ (P < .001) and CD8+CTLA4+ (P < .01) T-cells following ex vivo stimulation challenge at steady state DMPA concentrations and no differences at nadir concentrations (P = .781 and P = .463, respectively). In Net-En users, no differences in CD4+CTLA4+ T-cells at steady state (P = .087) and nadir concentrations (P = .217) were observed. DMPA users had fewer CD4+PD-1+ (P < .001) and CD8+PD-1+ (P < .001) T-cells at nadir concentrations. Number of CD4+PD-1+ and CD8+PD-1+ T-cells decreased at steady state concentration (P = .002 and P = .001, respectively) and at nadir concentrations after Net-En initiation (P < .001 and P < .001). In CU-IUD users, there were no changes in number of CD4+CTLA4+ (P = .426) and CD8+CTLA4+ (P = .169) and no changes in CD4+PD-1+ (P = .083) and CD8+PD-1+ (P = .936) compared to baseline. CONCLUSION Activation of T-cells in response to ex vivo stimulation is suppressed at steady state DMPA concentration and resolves at nadir concentration, suggesting DMPA immunosuppressive effects may be transient.
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Affiliation(s)
- Allen Matubu
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Sharon L Hillier
- Department of Obstetrics, Gynaecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Leslie A Meyn
- Department of Obstetrics, Gynaecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Felix Mhlanga
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Mike Mbizvo
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Aaron Maramba
- Department of Medical Laboratory Sciences, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Zvavahera M Chirenje
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Sharon L Achilles
- Department of Obstetrics, Gynaecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Magee-Womens Research Institute, Pittsburgh, PA, USA
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12
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Risk of HIV-1 acquisition among South African women using a variety of contraceptive methods in a prospective study. AIDS 2019; 33:1619-1622. [PMID: 31306167 DOI: 10.1097/qad.0000000000002260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Observational studies have associated use of intramuscular injectable depot medroxyprogesterone acetate (DMPA-IM) with increased risk of HIV-1 acquisition, but limited data are available to assess HIV-1 risk for alternate contraceptive methods. METHODS Within a randomized trial of the dapivirine vaginal ring for HIV-1 prevention, we assessed HIV-1 incidence by contraceptive method. We limited analyses to participants from South African sites and to women who used DMPA-IM, the alternative injectable norethisterone enanthate, implants, or copper intrauterine devices (IUDs). Contraceptive method was assessed as a time-dependent exposure and multivariate models adjusted for trial randomization arm, age, sexual behaviour, and incident sexually transmitted infections. RESULTS A total of 95 incident HIV-1 infections were observed: incidence 5.8 (DMPA-IM, n = 52), 6.2 (norethisterone enanthate, n = 28), 1.9 (implant, n = 3), and 4.5 (IUD, n = 12) cases per 100 woman-years. In multivariable models, there were no statistically significant differences between contraceptive methods in the risk of HIV-1 acquisition. However, compared with the IUD, the three hormonal methods each had point estimates near 1 while the implant had risk that was approximately half that of the IUD. When the three hormonal methods were combined, their relative risk compared with IUD was 0.90 (95% confidence interval 0.45-1.76). CONCLUSION Among women at risk of HIV-1 infections in South Africa, we found no statistically significant differences in HIV-1 incidence by contraceptive method. Implants had the lowest point estimate for HIV-1 incidence, and IUDs had risk comparable with injectable methods in multivariate models. Large, prospective studies are needed to define better the relative HIV-1 risks across different contraceptive methods.
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13
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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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14
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Morhason-Bello IO, Kabakama S, Baisley K, Francis SC, Watson-Jones D. Reported oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa: a systematic review. Reprod Health 2019; 16:48. [PMID: 31060573 PMCID: PMC6501425 DOI: 10.1186/s12978-019-0722-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral and anal sexual behaviours are increasingly reported among adolescents and adults reporting heterosexual sex in peer-reviewed journals in high income countries, but less is known about these behaviours in low and middle-income countries, especially in sub-Saharan Africa. The aim of this systematic review is to describe the prevalence of, and motivations for, oral and anal sex among adolescents and adults reporting heterosexual sex in sub-Saharan Africa. METHODS A systematic review of published articles that reported oral and or anal sex in sub-Saharan Africa was conducted from seven databases up to and including 30th August 2018. RESULTS Of 13,592 articles, 103 met the inclusion criteria. The prevalence of reporting ever practising oral sex among adolescents, university students and a combined population of adolescents/adults ranged from 1.7-26.6%, 5.0-46.4% and 3.0-47.2% respectively. Similarly, prevalences of reported ever practising anal sex ranged from 6.4-12.4% among adolescents, 0.3-46.5% among university students and 4.3-37.8% amongst combined population of adolescents and adults. Higher prevalences of oral and anal sex were reported among populations at high-risk for sexually transmitted infections and HIV and university students and, in most studies, both behaviours were more commonly reported by males than females. Heterosexual oral and anal sexual acts were associated with some high-risk behaviours such as inconsistent condom use and multiple sexual partners. CONCLUSION Reported oral and anal sex between men and women are prevalent behaviours in sub-Saharan Africa. Health professionals and policy makers should be aware of these behaviours and their potential associated health risks.
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Affiliation(s)
- Imran O. Morhason-Bello
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT UK
- Obstetrics and Gynaecology Department, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Severin Kabakama
- Mwanza Intervention Trials Unit, National Institute for Medical Research, PO Box 11936, Mwanza, Tanzania
| | - Kathy Baisley
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Suzanna C. Francis
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Deborah Watson-Jones
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT UK
- Mwanza Intervention Trials Unit, National Institute for Medical Research, PO Box 11936, Mwanza, Tanzania
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15
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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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16
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Caplan MR, Landovitz RJ, Palanee-Phillips T, Nair G, Mhlanga F, Balkus JE, Riddler SA, Gorbach PM. Complex decisions: correlates of injectable contraceptive discontinuation following HIV-1 seroconversion in an HIV prevention trial. AIDS Care 2019; 31:746-753. [PMID: 30759997 DOI: 10.1080/09540121.2019.1580345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Contraceptive adherence during acute and recent HIV-1 infection is important to maternal and child health given the elevated risk of vertical HIV-1 transmission and additional complications of pregnancy. Injectable contraception (IC) is the most common non-barrier modern contraception method used in sub-Saharan Africa (SSA). Adherence to IC after HIV-1 seroconversion is not well understood. We examined factors associated with IC discontinuation among women in SSA diagnosed with HIV-1 infection while participating in a clinical trial of biomedical HIV-1 prevention. After diagnosis with HIV-1 infection in the VOICE trial, 255 women from South Africa, Uganda, and Zimbabwe enrolled in a longitudinal observational study (MTN-015). Contraceptive method was assessed at MTN-015 baseline and at 3, 12, and 24 months post-seroconversion. Correlates of IC discontinuation were examined by Cox proportional hazard modeling. IC use was reported at baseline by 78% of women enrolled (198/255), of which 92% (182/198) completed at least one follow-up visit. Two-thirds of women (66%, 121/182) continued on IC during the follow-up period (median 24 months). Lower rates of IC discontinuation were observed in women who reported having had at least one child (HR 0.39, 95% CI 0.20-0.82) or earning a personal income (HR 0.51, 95% CI 0.30-0.87) at baseline. These findings suggest that many women with HIV-1 infection face complex decision-making regarding family planning in the years that follow seroconversion and highlight that some women may discontinue IC use despite on-site provision of family planning services. Understanding the broader context of family planning choices in recently seroconverted women may be key to more effective linkages between family planning services and HIV-1 testing and care.
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Affiliation(s)
- Margaret R Caplan
- a Los Angeles Biomedical Research Institute , Harbor-UCLA Medical Center , Torrance.,b David Geffen School of Medicine , University of California , Los Angeles
| | | | - Thesla Palanee-Phillips
- c Wits Reproductive Health and HIV Institute , University of the Witwatersrand , Johannesburg , South Africa
| | - Gonasagrie Nair
- d Desmond Tutu HIV Centre , University of Cape Town , Cape Town , South Africa
| | - Felix Mhlanga
- e University of Zimbabwe-University of California, San Francisco , Collaborative Research Programme , Harare , Zimbabwe
| | | | | | - Pamina M Gorbach
- b David Geffen School of Medicine , University of California , Los Angeles.,h Department of Epidemiology , Fielding School of Public Health, University of California , Los Angeles
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17
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Kiweewa FM, Brown E, Mishra A, Nair G, Palanee‐Phillips T, Mgodi N, Nakabiito C, Chakhtoura N, Hillier SL, Baeten JM. Acquisition of Sexually Transmitted Infections among Women Using a Variety of Contraceptive Options: A prospective Study among High-risk African Women. J Int AIDS Soc 2019; 22:e25257. [PMID: 30816632 PMCID: PMC6393855 DOI: 10.1002/jia2.25257] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/04/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION In many African settings, women concurrently face substantial risk of human immunodeficiency virus type 1 (HIV-1) infection, sexually transmitted infections (STIs) and unintended pregnancies. Few studies have evaluated STI risk among users of hormonal implants and copper intrauterine devices (IUDs) although these long-acting reversible contraceptive methods are being promoted widely because of their benefits. Within a prospective study of women at risk for HIV-1, we compared the risk of acquisition of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis among women using different contraceptive methods. METHODS MTN-020/ASPIRE was a randomized trial of the dapivirine vaginal ring for HIV-1 prevention among 2629 women aged 18 to 45 years from Malawi, South Africa, Uganda and Zimbabwe, of whom 2264 used copper IUDs or progestin-based injectables or implants during follow-up. Screening for the above STIs occurred semi-annually. RESULTS Over 3440 person-years of follow-up, 408 cases of C. trachomatis (incidence 11.86/100 person-years), 196 of N. gonorrhoeae (5.70/100 person-years) and 213 cases of T. vaginalis (6.19/100 person-years) were detected. C. trachomatis and N. gonorrhoeae incidence were not significantly different across contraceptive methods. T. vaginalis incidence was significantly higher for copper IUD users compared to depot medroxyprogesterone acetate (DMPA), implant and norethisterone enanthate users. CONCLUSION Among African women at high HIV-1 risk, STIs were common. Risk of cervical infections did not differ across contraceptive methods. Significantly higher rates of T. vaginalis were observed among progestin-based methods compared to copper IUD users. Overall, these findings call for more intensive routine screening for STIs, and they support current World Health Organization guidance that women should have a wide range of contraceptive options.
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Affiliation(s)
- Flavia Matovu Kiweewa
- Makerere University ‐ Johns Hopkins University Research CollaborationKampalaUganda
- Makerere University School of Public HealthKampalaUganda
| | - Elizabeth Brown
- Fred Hutchinson Cancer Research CenterSeattleWAUSA
- University of WashingtonSeattleWAUSA
| | | | | | - Thesla Palanee‐Phillips
- Wits Reproductive Health and HIV InstituteUniversity of the WitwatersrandJohannesburgRepublic of South Africa
| | - Nyaradzo Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research CentreHarareZimbabwe
| | - Clemensia Nakabiito
- Makerere University ‐ Johns Hopkins University Research CollaborationKampalaUganda
| | - Nahida Chakhtoura
- National Institute of Child Health and Human Development/National Institute of HealthBethesdaMDUSA
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18
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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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19
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Zalenskaya IA, Chandra N, Yousefieh N, Fang X, Adedipe OE, Jackson SS, Anderson SM, Mauck CK, Schwartz JL, Thurman AR, Doncel GF. Use of contraceptive depot medroxyprogesterone acetate is associated with impaired cervicovaginal mucosal integrity. J Clin Invest 2018; 128:4622-4638. [PMID: 30222141 DOI: 10.1172/jci120583] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Injectable depot medroxyprogesterone acetate (DMPA) is one of the most popular contraception methods in areas of high HIV seroprevalence. Evidence is accumulating that use of DMPA might be associated with an increased risk of HIV-1 acquisition by women; however, mechanisms of this association are not completely understood. The goal of this study was to gain insight into mechanisms underlying the possible link between use of DMPA and risk of HIV-1 acquisition, exploring transcription profiling of ectocervical tissues. METHODS Healthy women received either DMPA (n = 31) or combined oral contraceptive (COC), which has not been linked to an increased risk of HIV acquisition (n = 32). We conducted a comparative microarray-based whole-genome transcriptome profiling of human ectocervical tissues before and after 6 weeks of hormonal contraception use. RESULTS The analysis identified that expression of 235 and 76 genes was significantly altered after DMPA and COC use, respectively. The most striking effect of DMPA, but not COC, was significantly altered expression (mostly downregulation) of many genes strategically involved in the maintenance of mucosal barrier function; the alterations, as indicated by Ingenuity Pathway Analysis (IPA), were most likely due to the DMPA-induced estrogen deficiency. Furthermore, IPA predicted that transcriptome alterations related to ectocervical immune responses were in general compatible with an immunosuppressive effect of DMPA, but, in some women, also with an inflammatory-like response. CONCLUSION Our results suggest that impairment of cervicovaginal mucosal integrity in response to DMPA administration is an important mechanism contributing to the potential increased risk of HIV-1 acquisition in DMPA users. TRIAL REGISTRATION ClinicalTrials.gov NCT01421368. FUNDING This study was supported by the United States Agency for International Development (USAID) under Cooperative Agreement GPO-A-00-08-00005-00.
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Affiliation(s)
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | | | | | | | - Jill L Schwartz
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, USA
| | | | - Gustavo F Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, USA.,CONRAD, Eastern Virginia Medical School, Arlington, Virginia, USA
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20
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Bosinger SE, Tharp GK, Patel NB, Zhao C, Payne TL, Dietz Ostergaard S, Butler K, Ellis S, Johnson RL, Kersh EN, McNicholl JM, Vishwanathan SA. Progestin-based contraception regimens modulate expression of putative HIV risk factors in the vaginal epithelium of pig-tailed Macaques. Am J Reprod Immunol 2018; 80:e13029. [PMID: 30076667 DOI: 10.1111/aji.13029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 12/30/2022] Open
Abstract
PROBLEM In women, the use of progestin-based contraception may increase the risk of vaginal HIV acquisition. We previously showed in macaques that there is a significantly higher simian-human immunodeficiency virus (SHIV) acquisition rate in the luteal phase of the menstrual cycle, which presents a naturally high-progesterone state, and this may be attributable to altered expression of innate immune factors. We hypothesized that progestin-based contraception, especially depot medroxyprogesterone acetate (DMPA), would, in a similar way, affect mucosal immune factors that influence HIV acquisition risk. METHOD OF STUDY We used a pig-tailed macaque model to evaluate the effects of two progestin-based contraceptives, DMPA, and levonorgestrel (LNG)/ethinyl estradiol (EE)-based combined oral contraceptives (COCs), on innate mucosal factors. We compared the vaginal epithelial thickness data from previous studies and used cytokine profiling and microarray analysis to evaluate contraception-induced molecular changes in the vagina. RESULTS The administration of DMPA caused a reduction in the thickness of the vaginal epithelium relative to that of the follicular or luteal phase. DMPA also induced a significant increase in vaginal levels of the anti-inflammatory cytokine IL-10. Both DMPA- and LNG-based contraception induced a signature of gene expression similar to that of the luteal phase, only more exacerbated, including widespread downregulation of antiviral genes. CONCLUSION The use of progestin-based contraception might engender a milieu that poses an increased risk of HIV acquisition as compared to both the luteal and follicular phases of the menstrual cycle.
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Affiliation(s)
- Steven E Bosinger
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia.,Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Georgia
| | - Gregory K Tharp
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Georgia
| | - Nirav B Patel
- Division of Microbiology and Immunology, Yerkes National Primate Research Center, Emory University, Atlanta, Georgia
| | | | | | | | - Katherine Butler
- Office of the Associate Director for Laboratory Science and Safety, CDC, Atlanta, Georgia
| | | | | | - Ellen N Kersh
- Division of Sexually Transmitted Disease Prevention, CDC, Atlanta, Georgia
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21
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Oliver VO, Otieno G, Gvetadze R, Desai MA, Makanga M, Akelo V, Gust DA, Nyagol B, McLellan-Lemal E. High prevalence of sexually transmitted infections among women screened for a contraceptive intravaginal ring study, Kisumu, Kenya, 2014. Int J STD AIDS 2018; 29:1390-1399. [PMID: 30071799 DOI: 10.1177/0956462418782810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assessed prevalence and correlates of bacterial vaginosis (BV) and sexually transmitted infections (STIs) including herpes simplex virus type 2 (HSV-2), gonorrhoea (GC), syphilis (SYP), Chlamydia (CT) and HIV among Kenyan women aged 18–34 years who were screened for a contraceptive intravaginal ring study. Women provided demographic, behavioural and medical information, and underwent medical evaluation, including a pelvic exam. We computed crude and adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using log-binomial regression. Of 463 women screened, 457 provided laboratory specimens and were included in the analysis. The median age was 25 years, interquartile range (21–28), and 68.5% had completed primary or lower education. Overall, 72.2% tested positive for any STI or BV. Point prevalence was 55.6, 38.5, 3.9, 2.0, 4.6, and 14.7% for HSV-2, BV, GC, SYP, CT, and HIV, respectively. Co-infection with HSV-2, BV, and HIV occurred in 28 (6.1%) participants. Having ≥1 STI/BV was associated with younger age at first sex (≤13 versus 17–19 years, aPR=1.27, 95% CI 1.07–1.51), history of exchange sex (aPR = 2.05, 95% CI 1.07–3.92), sexual intercourse in the past seven days (aPR = 1.17, 95% CI 1.01–1.36), and older age (30–34 versus 18–24 years, aPR = 1.26, 95% CI 1.06–1.48). STI/BV diagnosis was less likely for women reporting one lifetime sexual partner compared to women with ≥4 lifetime sexual partners (aPR = 0.70, 95% CI 0.54–0.92). Combination prevention approaches (biomedical, behavioural, social, and structural) tailored to women with diverse risk profiles may help mitigate STI/BV prevalence in this setting.
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Affiliation(s)
- Vincent O Oliver
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - George Otieno
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Roman Gvetadze
- US Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | - Mitesh A Desai
- US Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | - Mumbi Makanga
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Victor Akelo
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Deborah A Gust
- US Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
| | - Beatrice Nyagol
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eleanor McLellan-Lemal
- US Centers for Disease Control and Prevention, Office of Infectious Diseases, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention, Atlanta, GA, USA
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22
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Hofmeyr GJ, Morrison CS, Baeten JM, Chipato T, Donnell D, Gichangi P, Mugo N, Nanda K, Rees H, Steyn P, Taylor D. Rationale and design of a multi-center, open-label, randomised clinical trial comparing HIV incidence and contraceptive benefits in women using three commonly-used contraceptive methods (the ECHO study). Gates Open Res 2018; 1:17. [PMID: 29355224 PMCID: PMC5771152 DOI: 10.12688/gatesopenres.12775.2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/20/2022] Open
Abstract
Background:In vitro, animal, biological and observational clinical studies suggest that some hormonal methods, particularly depot medroxyprogesterone acetate - DMPA, may increase women's risk of HIV acquisition. DMPA is the most common contraceptive used in many countries worst affected by the HIV epidemic. To provide robust evidence for contraceptive decision-making among women, clinicians and planners, we are conducting the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study in four countries with high HIV incidence and DMPA use: Kenya, South Africa, Swaziland, and Zambia (Clinical Trials.gov identifier NCT02550067). Study design: We randomized HIV negative, sexually active women 16-35 years old requesting effective contraception and agreeing to participate to either DMPA, the copper T 380A intrauterine device or levonorgestrel implant. Participants attend a contraception support visit after 1 month and quarterly visits thereafter for up to 18 months. Participants receive a standard HIV prevention package and contraceptive side-effect management at each visit. The primary outcome is HIV seroconversion. Secondary outcomes include pregnancy, serious adverse events and method discontinuation. The sample size of 7800 women provides 80% power to detect a 50% relative increase in HIV risk between any of the three method pairs, assuming 250 incident infections per comparison. Ethical considerations: Several WHO consultations have concluded that current evidence on HIV risk associated with DMPA is inconclusive and that a randomized trial is needed to guide policy, counselling and choice. Previous studies suggest that women without a specific contraceptive preference are willing to accept randomization to different contraceptive methods. Stringent performance standards are monitored by an independent data and safety monitoring board approximately every 6 months. The study has been conducted with extensive stakeholder engagement. Conclusions: The ECHO study is designed to provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between three effective contraceptive methods.
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Affiliation(s)
- G. Justus Hofmeyr
- Effective Care Research Unit, Universities of Witwatersrand and Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | | | - Jared M. Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Peter Gichangi
- University of Nairobi, Nairobi, Kenya
- Ghent University, Ghent, Belgium
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kavita Nanda
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Douglas Taylor
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
| | - ECHO Trial Team
- Effective Care Research Unit, Universities of Witwatersrand and Fort Hare, Eastern Cape Department of Health, East London, South Africa
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Nairobi, Nairobi, Kenya
- Ghent University, Ghent, Belgium
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- World Health Organization, Geneva, Switzerland
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23
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Sexually Transmitted Infections and Human Immunodeficiency Virus: Are We Applying the Lessons Learned? Sex Transm Dis 2018; 44:141-142. [PMID: 28178110 DOI: 10.1097/olq.0000000000000588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Hapgood JP, Kaushic C, Hel Z. Hormonal Contraception and HIV-1 Acquisition: Biological Mechanisms. Endocr Rev 2018; 39:36-78. [PMID: 29309550 PMCID: PMC5807094 DOI: 10.1210/er.2017-00103] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/27/2017] [Indexed: 12/12/2022]
Abstract
Access to effective affordable contraception is critical for individual and public health. A wide range of hormonal contraceptives (HCs), which differ in composition, concentration of the progestin component, frequency of dosage, and method of administration, is currently available globally. However, the options are rather limited in settings with restricted economic resources that frequently overlap with areas of high HIV-1 prevalence. The predominant contraceptive used in sub-Saharan Africa is the progestin-only three-monthly injectable depot medroxyprogesterone acetate. Determination of whether HCs affect HIV-1 acquisition has been hampered by behavioral differences potentially confounding clinical observational data. Meta-analysis of these studies shows a significant association between depot medroxyprogesterone acetate use and increased risk of HIV-1 acquisition, raising important concerns. No association was found for combined oral contraceptives containing levonorgestrel, nor for the two-monthly injectable contraceptive norethisterone enanthate, although data for norethisterone enanthate are limited. Susceptibility to HIV-1 and other sexually transmitted infections may, however, be dependent on the type of progestin present in the formulation. Several underlying biological mechanisms that may mediate the effect of HCs on HIV-1 and other sexually transmitted infection acquisition have been identified in clinical, animal, and ex vivo studies. A substantial gap exists in the translation of basic research into clinical practice and public health policy. To bridge this gap, we review the current knowledge of underlying mechanisms and biological effects of commonly used progestins. The review sheds light on issues critical for an informed choice of progestins for the identification of safe, effective, acceptable, and affordable contraceptive methods.
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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
| | - Charu Kaushic
- Department of Pathology and Molecular Medicine, McMaster University, Ontario, Canada.,McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Zdenek Hel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama.,Center for AIDS Research, University of Alabama at Birmingham, Birmingham, Alabama
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25
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Hofmeyr GJ, Morrison CS, Baeten JM, Chipato T, Donnell D, Gichangi P, Mugo N, Nanda K, Rees H, Steyn P, Taylor D. Rationale and design of a multi-center, open-label, randomised clinical trial comparing HIV incidence and contraceptive benefits in women using three commonly-used contraceptive methods (the ECHO study). Gates Open Res 2017; 1:17. [PMID: 29355224 PMCID: PMC5771152 DOI: 10.12688/gatesopenres.12775.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In vitro, animal, biological and observational clinical studies suggest that some hormonal methods, particularly depot medroxyprogesterone acetate - DMPA, may increase women's risk of HIV acquisition. DMPA is the most common contraceptive used in many countries worst affected by the HIV epidemic. To provide robust evidence for contraceptive decision-making among women, clinicians and planners, we are conducting the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study in four countries with high HIV incidence and DMPA use: Kenya, South Africa, Swaziland, and Zambia (Clinical Trials.gov identifier NCT02550067). STUDY DESIGN We randomized HIV negative, sexually active women 16-35 years old requesting effective contraception and agreeing to participate to either DMPA, the copper T 380A intrauterine device or levonorgestrel implant. Participants attend a contraception support visit after 1 month and quarterly visits thereafter for 12 to 18 months. Participants receive a standard HIV prevention package and contraceptive side-effect management at each visit. The primary outcome is HIV seroconversion. Secondary outcomes include pregnancy, serious adverse events and method discontinuation. The sample size of 7800 women provides 80% power to detect a 50% difference in HIV risk between any of the three method pairs, assuming 250 incident infections per comparison. Ethical considerations: Several WHO consultations have concluded that current evidence on HIV risk associated with DMPA is inconclusive and that a randomized trial is needed to guide policy, counselling and choice. Previous studies suggest that women without a specific contraceptive preference are willing to accept randomization to different contraceptive methods. Stringent performance standards are monitored by an independent data and safety monitoring board approximately every 6 months. The study has been conducted with extensive stakeholder engagement. CONCLUSIONS The ECHO study is designed to provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between three effective contraceptive methods.
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Affiliation(s)
- G. Justus Hofmeyr
- Effective Care Research Unit, Universities of Witwatersrand and Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | | | - Jared M. Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Tsungai Chipato
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Peter Gichangi
- University of Nairobi, Nairobi, Kenya
- Ghent University, Ghent, Belgium
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kavita Nanda
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Douglas Taylor
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
| | - ECHO Trial Team
- Effective Care Research Unit, Universities of Witwatersrand and Fort Hare, Eastern Cape Department of Health, East London, South Africa
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Nairobi, Nairobi, Kenya
- Ghent University, Ghent, Belgium
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- World Health Organization, Geneva, Switzerland
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26
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Abstract
The HIV pandemic has disproportionately impacted sub-Saharan Africa and Southern Africa in particular. The concurrent presence of overlapping epidemic drivers likely underpins how and why the HIV epidemic is so explosive in this region, with implications for understanding approaches to reduce transmission. In this review, we discuss the relative contribution and interaction between epidemic drivers in the Southern African context, including factors both distally and proximally associated with the likelihood and degree of exposure to HIV and factors that increase the probability of transmission when exposure occurs. In particular, we focus on young women as a key population in need of HIV prevention and highlight factors that increase their risk on several levels.
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Affiliation(s)
- Lyle R McKinnon
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Nelson R Mandela School of Medicine, 719 Umbilo Road, Private Bag X7, Congella, Durban, 4013, South Africa. .,Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Nelson R Mandela School of Medicine, 719 Umbilo Road, Private Bag X7, Congella, Durban, 4013, South Africa.,Department of Epidemiology, Columbia University, New York, USA
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27
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A Depot Medroxyprogesterone Acetate Dose That Models Human Use and Its Effect on Vaginal SHIV Acquisition Risk. J Acquir Immune Defic Syndr 2017; 72:363-71. [PMID: 27355414 DOI: 10.1097/qai.0000000000000975] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Hormonal contraception with depot medroxyprogesterone acetate (DMPA) may increase HIV acquisition risk, but observational human studies are inconclusive, and animal models can help investigate this risk. In this study, we test the impact of a low DMPA dose, designed to resemble human contraceptive use, on Simian-Human Immunodeficiency Virus (SHIV) acquisition risk in pigtail macaques (Macaca nemestrina). METHODS Macaques metabolize DMPA faster than humans. We previously identified a per-weight DMPA dose and administration frequency that achieves long-lasting suppression of ovulation in macaques. Eight macaques were given 1.5-mg/kg DMPA monthly, whereas 11 were untreated controls. For comparison, women receive 150 mg (approximately 2 mg/kg) every 3 months. We exposed monkeys to 20 suboptimal SHIV challenges, designed to slowly infect half of controls and allow increased infection in the DMPA group. RESULTS It took a median 5.5 viral challenges to infect DMPA-treated macaques and 9 challenges for controls (P = 0.27; exact conditional logistic regression). The exact odds ratio was 2.2 (CI: 0.6 to 8.3). Ovulation was suppressed, and the vaginal epithelium was thinned after DMPA treatment in all animals (mean, 30 and 219 mm in DMPA-treated and control macaques, respectively, P = 0.03, t test using the Satterthwaite degrees-of-freedom approximation). CONCLUSIONS SHIV infections in DMPA-treated macaques were 2.2 times those of controls, but this was not statistically significant. The result is remarkably similar to studies of human DMPA use, which have shown HIV risk increases of a similar magnitude and of variable significance. Taken together with previous studies of higher DMPA doses in macaques, the results suggest a dose-dependent effect of DMPA on Simian Immunodeficiency Virus (SIV) or SHIV acquisition.
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Bassis CM, Allsworth JE, Wahl HN, Sack DE, Young VB, Bell JD. Effects of intrauterine contraception on the vaginal microbiota. Contraception 2017. [PMID: 28624570 DOI: 10.1016/j.contraception.2017.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES There have been conflicting reports of altered vaginal microbiota and infection susceptibility associated with contraception use. The objectives of this study were to determine if intrauterine contraception altered the vaginal microbiota and to compare the effects of a copper intrauterine device (Cu-IUD) and a levonorgestrel intrauterine system (LNG-IUS) on the vaginal microbiota. STUDY DESIGN DNA was isolated from the vaginal swab samples of 76 women using Cu-IUD (n=36) or LNG-IUS (n=40) collected prior to insertion of intrauterine contraception (baseline) and at 6 months. A third swab from approximately 12 months following insertion was available for 69 (Cu-IUD, n=33; LNG-IUS, n=36) of these women. The V4 region of the bacterial 16S rRNA-encoding gene was amplified from the vaginal swab DNA and sequenced. The 16S rRNA gene sequences were processed and analyzed using the software package mothur to compare the structure and dynamics of the vaginal bacterial communities. RESULTS The vaginal microbiota from individuals in this study clustered into 3 major vaginal bacterial community types: one dominated by Lactobacillus iners, one dominated by Lactobacillus crispatus and one community type that was not dominated by a single Lactobacillus species. Changes in the vaginal bacterial community composition were not associated with the use of Cu-IUD or LNG-IUS. Additionally, we did not observe a clear difference in vaginal microbiota stability with Cu-IUD versus LNG-IUS use. CONCLUSIONS Although the vaginal microbiota can be highly dynamic, alterations in the community associated with the use of intrauterine contraception (Cu-IUD or LNG-IUS) were not detected over 12 months. IMPLICATIONS We found no evidence that intrauterine contraception (Cu-IUD or LNG-IUS) altered the vaginal microbiota composition. Therefore, the use of intrauterine contraception is unlikely to shift the composition of the vaginal microbiota such that infection susceptibility is altered.
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Affiliation(s)
- Christine M Bassis
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109.
| | - Jenifer E Allsworth
- Department of Biomedical & Health, University of Missouri - Kansas City School of Medicine, Kansas City, MO 64108; Department of Obstetrics & Gynecology, University of Missouri - Kansas City School of Medicine, Kansas City, MO 64108.
| | - Heather N Wahl
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109.
| | - Daniel E Sack
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109.
| | - Vincent B Young
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109; Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109.
| | - Jason D Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109.
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Owen BN, Elmes J, Silhol R, Dang Q, McGowan I, Shacklett B, Swann EM, van der Straten A, Baggaley RF, Boily MC. How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta-analysis. J Int AIDS Soc 2017; 19:21162. [PMID: 28364565 PMCID: PMC5461120 DOI: 10.7448/ias.20.1.21162] [Citation(s) in RCA: 9] [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: 04/14/2016] [Accepted: 12/15/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa's generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa. METHODS We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI. RESULTS Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4-27.5%], three-month = 20.3% [6.1-34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0-47.4%], recall period not stated = 40.1% [36.2-44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2-40.0% and 0.7-21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts. CONCLUSION Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa's HIV epidemic.
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Affiliation(s)
- Branwen N. Owen
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jocelyn Elmes
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Romain Silhol
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Que Dang
- Vaccine Clinical Research Branch, Division of AIDS, National Institutes of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA
| | - Ian McGowan
- Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, UK
| | - Barbara Shacklett
- Department of Medical Microbiology and Immunology, University of California, Davis, CA, USA
| | - Edith M. Swann
- Vaccine Clinical Research Branch, Division of AIDS, National Institutes of Allergy and Infectious Diseases, US National Institutes of Health, Bethesda, MD, USA
| | | | - Rebecca F. Baggaley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Marie-Claude Boily
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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Crankshaw TL, Smit JA, Beksinska ME. Placing contraception at the centre of the HIV prevention agenda. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 15:157-62. [PMID: 27399045 DOI: 10.2989/16085906.2016.1204330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the past decade, the global response to the HIV epidemic has been unprecedented, and enormous progress has been made. Significant investment in the roll out of antiretroviral treatment (ART) and efforts to increase treatment coverage have greatly reduced the number of AIDS-related deaths worldwide. There are a growing number of promising innovations to expand the HIV prevention mix. However, the reach of these interventions is still very limited in adolescent girls and young women (15-24 years) and the full realisation of the intervention mandates has not yet been achieved. The HIV prevention field has been criticised for the tendency to adopt a narrow focus. The Fast-Track Strategy offers a unique opportunity for the HIV prevention field to broaden its gaze and to begin to identify synergies (and efficiencies) with prevention approaches from other global development priorities, namely sexual and reproductive health and rights (SRHR). This paper applies a SRHR lens to HIV prevention by highlighting the critical relationship between unintended pregnancy and HIV, and seeks to expand on earlier debates that prevention of HIV and prevention of unintended pregnancy are inextricably linked, complementary activities with interrelated and common goals. We call for the prioritisation of prevention of unintended pregnancy amongst two overlapping population groups - girls and young women (15-24 years old) and women living with HIV - as a key tactic to accomplish the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track Strategy and as a way to fully realise existing HIV prevention efforts. We discuss the intersecting pathways between HIV prevention and unintended pregnancy prevention and build a case for contraception to be placed at the centre of the HIV prevention agenda.
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Affiliation(s)
- Tamaryn L Crankshaw
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Jennifer A Smit
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
| | - Mags E Beksinska
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
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Garcia-Minambres A, Eid SG, Mangan NE, Pade C, Lim SS, Matthews AY, de Weerd NA, Hertzog PJ, Mak J. Interferon epsilon promotes HIV restriction at multiple steps of viral replication. Immunol Cell Biol 2017; 95:478-483. [PMID: 28045025 DOI: 10.1038/icb.2016.123] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/11/2016] [Accepted: 12/12/2016] [Indexed: 12/26/2022]
Abstract
Interferon epsilon (IFNɛ) is a type I IFN that is expressed constitutively in the female reproductive tract (FRT), and contributes to protection in models of sexually transmitted infections. Using multiple cell systems, including reporter cell lines and activated peripheral blood lymphocytes (PBLs), we show that recombinant IFNɛ impairs HIV infection at stage(s) post HIV entry and up to the translation of viral proteins. Consistent with this, IFNɛ upregulated a number of host cell restriction factors that block HIV at these stages of the replication cycle. The potency of IFNɛ induction of these HIV restriction factors was comparable to conventional type I IFNs, namely IFNα and IFNβ. IFNɛ also significantly reduced the infectivity of progeny virion particles likely by inducing expression of HIV restriction factors, such as IFITM3, which act at that stage of infection. Thus, our data demonstrate that human IFNɛ suppresses HIV replication at multiple stages of infection.
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Affiliation(s)
- Albert Garcia-Minambres
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,CSIRO Australian Animal Health Laboratory, Geelong, Victoria, Australia
| | - Sahar G Eid
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,CSIRO Australian Animal Health Laboratory, Geelong, Victoria, Australia
| | - Niamh E Mangan
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Corinna Pade
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,CSIRO Australian Animal Health Laboratory, Geelong, Victoria, Australia
| | - San S Lim
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Antony Y Matthews
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Nicole A de Weerd
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Paul J Hertzog
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Johnson Mak
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,CSIRO Australian Animal Health Laboratory, Geelong, Victoria, Australia
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Abstract
The female reproductive tract (FRT) is a major site for human immunodeficiency virus (HIV) infection. There currently exists a poor understanding of how the innate immune system is activated upon HIV transmission and how this activation may affect systemic spread of HIV from the FRT. However, multiple mechanisms for how HIV is sensed have been deciphered using model systems with cell lines and peripheral blood-derived cells. The aim of this review is to summarize recent progress in the field of HIV innate immune sensing and place this in the context of the FRT. Because HIV is somewhat unique as an STD that thrives under inflammatory conditions, the response of cells upon sensing HIV gene products can either promote or limit HIV infection depending on the context. Future studies should include investigations into how FRT-derived primary cells sense and respond to HIV to confirm conclusions drawn from non-mucosal cells. Understanding how cells of the FRT participate in and effect innate immune sensing of HIV will provide a clearer picture of what parameters during the early stages of HIV exposure determine transmission success. Such knowledge could pave the way for novel approaches for preventing HIV acquisition in women.
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An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30:2665-2683. [PMID: 27500670 PMCID: PMC5106090 DOI: 10.1097/qad.0000000000001228] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective and design: Some studies suggest that specific hormonal contraceptive methods [particularly depot medroxyprogesterone acetate (DMPA)] may increase women's HIV acquisition risk. We updated a systematic review to incorporate recent epidemiological data. Methods: We searched for articles published between 15 January 2014 and 15 January 2016 and hand-searched reference lists. We identified longitudinal studies comparing users of a specific hormonal contraceptive method against either nonusers of hormonal contraception or users of another specific hormonal contraceptive method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus non-use of hormonal contraception. Results: We identified 10 new reports of which five were considered ‘unlikely to inform the primary question’. We focus on the other five reports, along with nine from the previous review, which were considered ‘informative but with important limitations’. The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate, and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher quality studies on DMPA (or nondisaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher quality studies of hazard ratio 1.4. Conclusion: Although confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely hazard ratio 1.5 or less. Data for other hormonal contraceptive methods, including norethisterone enanthate, are largely reassuring.
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Hormonal contraceptive use and women's risk of HIV acquisition: priorities emerging from recent data. Curr Opin Obstet Gynecol 2016; 27:487-95. [PMID: 26536211 DOI: 10.1097/gco.0000000000000228] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Understanding whether hormonal contraception increases women's risk of HIV acquisition is a public health priority. This review summarizes recent epidemiologic and biologic data, and considers the implications of new evidence on research and programmatic efforts. RECENT FINDINGS Two secondary analyses of HIV prevention trials demonstrated increased HIV risk among depot medroxyprogesterone acetate (DMPA) users compared with nonhormonal/no method users and norethisterone enanthate (NET-EN) users. A study of women in serodiscordant partnerships found no significant association for DMPA or implants. Two meta-analyses found elevated risks of HIV among DMPA users compared with nonhormonal/no method users, with no association for NET-EN or combined oral contraceptive pills. In-vitro and animal model studies identified plausible biological mechanisms by which progestin exposure could increase risk of HIV, depending on the type and dose of progestin, but such mechanisms have not been definitively observed in humans. SUMMARY Recent epidemiologic and biologic evidence on hormonal contraception and HIV suggests a harmful profile for DMPA but not combined oral contraceptives. In limited data, NET-EN appears safer than DMPA. More research is needed on other progestin-based methods, especially implants and Sayana Press. Future priorities include updating modeling studies with new pooled estimates, continued basic science to understand biological mechanisms, expanding contraceptive choice, and identifying effective ways to promote dual method use.
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Moyo S, Vandormael A, Wilkinson E, Engelbrecht S, Gaseitsiwe S, Kotokwe KP, Musonda R, Tanser F, Essex M, Novitsky V, de Oliveira T. Analysis of Viral Diversity in Relation to the Recency of HIV-1C Infection in Botswana. PLoS One 2016; 11:e0160649. [PMID: 27552218 PMCID: PMC4994946 DOI: 10.1371/journal.pone.0160649] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/23/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cross-sectional, biomarker methods to determine HIV infection recency present a promising and cost-effective alternative to the repeated testing of uninfected individuals. We evaluate a viral-based assay that uses a measure of pairwise distances (PwD) to identify HIV infection recency, and compare its performance with two serologic incidence assays, BED and LAg. In addition, we assess whether combination BED plus PwD or LAg plus PwD screening can improve predictive accuracy by reducing the likelihood of a false-recent result. METHODS The data comes from 854 time-points and 42 participants enrolled in a primary HIV-1C infection study in Botswana. Time points after treatment initiation or with evidence of multiplicity of infection were excluded from the final analysis. PwD was calculated from quasispecies generated using single genome amplification and sequencing. We evaluated the ability of PwD to correctly classify HIV infection recency within <130, <180 and <360 days post-seroconversion using Receiver Operator Characteristics (ROC) methods. Following a secondary PwD screening, we quantified the reduction in the relative false-recency rate (rFRR) of the BED and LAg assays while maintaining a sensitivity of either 75, 80, 85 or 90%. RESULTS The final analytic sample consisted of 758 time-points from 40 participants. The PwD assay was more accurate in classifying infection recency for the 130 and 180-day cut-offs when compared with the recommended LAg and BED thresholds. A higher AUC statistic confirmed the superior predictive performance of the PwD assay for the three cut-offs. When used for combination screening, the PwD assay reduced the rFRR of the LAg assay by 52% and the BED assay by 57.8% while maintaining a 90% sensitivity for the 130 and 180-day cut-offs respectively. CONCLUSION PwD can accurately determine HIV infection recency. A secondary PwD screening reduces misclassification and increases the accuracy of serologic-based assays.
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Affiliation(s)
- Sikhulile Moyo
- Division of Medical Virology, Stellenbosch University, Tygerberg, South Africa
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- * E-mail:
| | - Alain Vandormael
- Wellcome Trust Africa Centre for Health and Population Studies, Dorris Duke Medical Research Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Eduan Wilkinson
- Wellcome Trust Africa Centre for Health and Population Studies, Dorris Duke Medical Research Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Susan Engelbrecht
- Division of Medical Virology, Stellenbosch University, Tygerberg, South Africa
- National Health Laboratory Services (NHLS), Tygerberg Coastal, South Africa
| | - Simani Gaseitsiwe
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | - Rosemary Musonda
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Frank Tanser
- Wellcome Trust Africa Centre for Health and Population Studies, Dorris Duke Medical Research Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Max Essex
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Vladimir Novitsky
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Tulio de Oliveira
- Wellcome Trust Africa Centre for Health and Population Studies, Dorris Duke Medical Research Centre, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection, University College London, London, United Kingdom
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Hormonal Contraceptive Effects on the Vaginal Milieu: Microbiota and Immunity. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0142-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Ramjee G, McCormack S. The role of progestins in HIV acquisition in young women. THE LANCET. INFECTIOUS DISEASES 2015; 16:389-90. [PMID: 26723757 DOI: 10.1016/s1473-3099(15)00476-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 11/11/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Gita Ramjee
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa; Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; Department of Global Health, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
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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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Balkus JE, Brown ER, Hillier SL, Coletti A, Ramjee G, Mgodi N, Makanani B, Reid C, Martinson F, Soto-Torres L, Abdool Karim SS, Chirenje ZM. Oral and injectable contraceptive use and HIV acquisition risk among women in four African countries: a secondary analysis of data from a microbicide trial. Contraception 2015; 93:25-31. [PMID: 26519646 DOI: 10.1016/j.contraception.2015.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/13/2015] [Accepted: 10/16/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the effect of oral and injectable contraceptive use compared to nonhormonal contraceptive use on HIV acquisition among Southern African women enrolled in a microbicide trial. STUDY DESIGN This is a prospective cohort study using data from women enrolled in HIV Prevention Trials Network protocol 035. At each quarterly visit, participants were interviewed about self-reported contraceptive use and sexual behaviors and underwent HIV testing. Cox proportional hazards regression was used to assess the effect of injectable and oral hormonal contraceptive use on HIV acquisition. RESULTS The analysis included 2830 participants, of whom 106 became HIV infected (4.07 per 100 person-years). At baseline, 1546 (51%) participants reported using injectable contraceptives and 595 (21%) reported using oral contraceptives. HIV incidence among injectable, oral and nonhormonal contraceptive method users was 4.72, 2.68 and 3.83 per 100 person-years, respectively. Injectable contraceptive use was associated with a nonstatistically significant increased risk of HIV acquisition [adjusted hazard ratio (aHR)=1.17; 95% confidence interval (CI) 0.70, 1.96], while oral contraceptive use was associated with a nonstatistically significant decreased risk of HIV acquisition (aHR=0.76; 95% CI 0.37,1.55). CONCLUSION In this secondary analysis of randomized trial data, a marginal, but nonstatistically significant, increase in HIV risk among women using injectable hormonal contraceptives was observed. No increased HIV risk was observed among women using oral contraceptives. Our findings support the World Health Organization's recommendation that women at high risk for acquiring HIV, including those using progestogen-only injectable contraception, should be strongly advised to always use condoms and other HIV prevention measures. IMPLICATIONS Among Southern African women participating in an HIV prevention trial, women using injectable hormonal contraceptives had a modest increased risk of HIV acquisition; however, this association was not statistically significant. Continued research on the relationship between widely used hormonal contraceptive methods and HIV acquisition is essential.
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Affiliation(s)
- Jennifer E Balkus
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Elizabeth R Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences and the Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Gita Ramjee
- HIV Prevention Research Unit, South Africa Medical Research Council, Durban, South Africa
| | - Nyaradzo Mgodi
- University of Zimbabwe - University of California San Francisco Research Program, Harare, Zimbabwe
| | - Bonus Makanani
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Cheri Reid
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Francis Martinson
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Salim S Abdool Karim
- Centre for the AIDS Program of Research in South Africa, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Congella, South Africa; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Zvavahera M Chirenje
- University of Zimbabwe - University of California San Francisco Research Program, Harare, Zimbabwe
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40
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Interpretation, communication, and mechanisms of associations between injectable contraception and HIV risk. Lancet HIV 2015; 2:e365-6. [PMID: 26423545 DOI: 10.1016/s2352-3018(15)00154-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/05/2015] [Indexed: 11/22/2022]
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41
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Russell AN, Zheng X, O'Connell CM, Taylor BD, Wiesenfeld HC, Hillier SL, Zhong W, Darville T. Analysis of Factors Driving Incident and Ascending Infection and the Role of Serum Antibody in Chlamydia trachomatis Genital Tract Infection. J Infect Dis 2015; 213:523-31. [PMID: 26347571 DOI: 10.1093/infdis/jiv438] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/27/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis genital tract infection is a major cause of female reproductive morbidity. Risk factors for ascending infection are unknown, and the role for antibody in protection is not well established. METHODS We recruited 225 women from urban outpatient clinics and followed them for a median of 12 months. We performed a cross-sectional analysis of serum anti-chlamydial immunoglobulin G (IgG), behavioral factors, and microbiological factors associated with endometrial infection at enrollment, and a longitudinal analysis of factors associated with incident infection. RESULTS Oral contraceptives (adjusted relative risk [RR], 2.02 [95% confidence interval {CI}, 1.38-2.97]) and gonorrhea (adjusted RR, 1.66 [95% CI, 1.07-2.60]) were associated with endometrial infection. Gonorrhea (adjusted hazard ratio [HR], 3.09 [95% CI, 1.41-6.78]), cervical infection at enrollment (adjusted HR, 2.33 [95% CI, 1.07-5.11]), and exposure to uncircumcised partners (adjusted HR, 2.65 [95% CI, 1.21-5.82]) or infected partners (adjusted HR, 4.99 [95% CI, 2.66-9.39]) significantly increased the risk of incident infection. Seropositivity was associated with a reduced cervical burden (P < .05) but no differences in rates of ascending infection (adjusted RR, 1.24 [95% CI, .71-2.19]) or incident infection (adjusted HR, 0.94 [95% CI, .52-1.69]). CONCLUSIONS Serum anti-chlamydial IgG is not associated with a lowered rate of ascending or repeat infection. Identification of factors associated with ascending infection and increased risk of incident infection provide guidance for targeted screening of women at increased risk for sequelae.
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Affiliation(s)
- Ali N Russell
- Department of Pediatrics, University of North Carolina-Chapel Hill
| | - Xiaojing Zheng
- Department of Pediatrics, University of North Carolina-Chapel Hill
| | | | - Brandie D Taylor
- Department of Epidemiology and Biostatistics, Texas A&M Health Science Center, College Station
| | - Harold C Wiesenfeld
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh and Magee Womens Research Institute, Pennsylvania
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh and Magee Womens Research Institute, Pennsylvania
| | - Wujuan Zhong
- Department of Biostatistics, University of North Carolina-Chapel Hill
| | - Toni Darville
- Department of Pediatrics, University of North Carolina-Chapel Hill
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Hofmeyr GJ, Singata M, Lawrie TA, Temmerman M. Interpretation, communication, and mechanisms of associations between injectable contraception and HIV risk. Lancet HIV 2015; 2:e365. [PMID: 26423546 DOI: 10.1016/s2352-3018(15)00153-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 08/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- G Justus Hofmeyr
- Effective Care Research Unit, East London Hospital Complex, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, South Africa
| | - Mandisa Singata
- Effective Care Research Unit, East London Hospital Complex, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, South Africa
| | - Theresa A Lawrie
- Effective Care Research Unit, East London Hospital Complex, Eastern Cape Department of Health/Universities of the Witwatersrand and Fort Hare, South Africa; Royal United Hospital, Bath, United Kingdom.
| | - Marleen Temmerman
- Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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43
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Jones HE, van de Wijgert JHHM. DMPA use and HIV acquisition: time to switch to NET-EN? Lancet HIV 2015; 2:e263-e264. [PMID: 26423248 DOI: 10.1016/s2352-3018(15)00076-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 04/20/2015] [Indexed: 06/05/2023]
Affiliation(s)
- Heidi E Jones
- City University of New York School of Public Health and Hunter College, New York, NY 10035, USA.
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