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Mugo NR, Stalter RM, Heffron R, Rees H, Scoville CW, Morrison C, Kourtis AP, Bukusi E, Beksinska M, Philip NM, Beesham I, Deese J, Edward V, Donnell D, Baeten JM. Incidence of Herpes Simplex Virus Type 2 Infection Among African Women Using Depot Medroxyprogesterone Acetate, a Copper Intrauterine Device, or a Levonorgestrel Implant for Contraception: A Nested Randomized Trial. Clin Infect Dis 2021; 75:586-595. [PMID: 34910143 PMCID: PMC9464069 DOI: 10.1093/cid/ciab1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Globally, women have higher herpes simplex virus type 2 (HSV-2) prevalence than men; data from observational studies suggest a possible association of HSV-2 acquisition with use of intramuscular depot medroxyprogesterone acetate (DMPA-IM). METHODS Within a randomized trial of the effect of 3 contraceptive methods-DMPA-IM, a copper intrauterine device (IUD), and a levonorgestrel (LNG) implant-on human immunodeficiency virus (HIV) acquisition, we assessed HSV-2 acquisition. HSV-2 and HIV seronegative women, aged 16-35 years, and seeking effective contraception were followed for 12-18 months at 12 sites in Eswatini, Kenya, South Africa, and Zambia from 2015 to 2018. HSV-2 serologic testing was done at enrollment and final study visits. Intention-to-treat analysis using Poisson regression with robust standard errors compared HSV-2 incidence by contraceptive method. RESULTS At baseline, 4062 randomized women were HSV-2 seronegative, of whom 3898 (96.0%) had a conclusive HSV-2 result at their final study visit. Of these, 614 (15.8%) acquired HSV-2, at an incidence of 12.4/100 person-years (p-y): 10.9/100 p-y among women assigned DMPA-IM, 13.7/100 p-y the copper IUD, and 12.7/100 p-y the LNG implant. Incidence rate ratios (IRR) for HSV-2 acquisition were 0.80 (95% confidence interval [CI], .65-.97) for DMPA-IM compared with copper IUD, 0.86 (95% CI, .71-1.05) for DMPA-IM compared with LNG implant, and 1.08 (95% CI, .89-1.30) for copper IUD compared with LNG implant. HSV-2 acquisition risk was significantly increased among women who also acquired HIV during follow-up (IRR 3.55; 95% CI, 2.78-4.48). CONCLUSIONS In a randomized trial, we found no association between HSV-2 acquisition and use of 3 contraceptive methods. TRIAL REGISTRATION ClinicalTrials.gov number NCT02550067.
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Affiliation(s)
- Nelly R Mugo
- Correspondence: N. R. Mugo, Kenya Medical Research Institute (KEMRI), Center for Clinical Research & Department of Global Health, University of Washington, 325 Ninth Ave, Seattle, WA ()
| | - Randy M Stalter
- Department of Global Health, Seattle, Washington, USA,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Renee Heffron
- Department of Global Health, Seattle, Washington, USA,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Helen Rees
- University of the Witwatersrand, Wits Reproductive Health and HIV Institute (Wits RHI), Johannesburg, South Africa
| | | | - Charles Morrison
- Behavioral, Epidemiologic and Clinical Sciences, FHI 360, Durham, North Carolina, USA
| | - Athena P Kourtis
- Division of HIV Prevention, National Center for HIV, Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth Bukusi
- Center for Clinical Research & Center for Microbiology Kenya Medical Research Institute (KEMRI), Kenya,Department of Global Health, Seattle, Washington, USA
| | - Mags Beksinska
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Neena M Philip
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Ivana Beesham
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Jen Deese
- Present affiliation: Women’s Global Health Imperative, Global Public Health Impact Center, RTI International, Research Triangle Park, North Carolina, USA
| | - Vinodh Edward
- The Aurum Institute, Johannesburg, South Africa,School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Deborah Donnell
- Vaccine and Infectious Disease Division, Fred Hutchinson, Seattle, Washington, USA
| | - Jared M Baeten
- Present affiliation: Gilead Sciences, Foster City, California, USA
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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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The Effect of Hormonal Contraception and Menstrual Cycle Timing on Genital Herpes Simplex Virus-2 Shedding and Lesions. Sex Transm Dis 2020; 46:58-62. [PMID: 30148758 DOI: 10.1097/olq.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effect of female sex hormones on herpes simplex virus (HSV)-2 shedding and lesion frequency is poorly understood. Previous studies suggest that hormonal contraception may increase the frequency of HSV-2 shedding. METHODS We studied HSV-2 seropositive women who performed daily genital swabbing for HSV DNA and completed diaries for genital lesions and menses. We used Poisson mixed effects models to determine if HSV detection varied throughout the menstrual cycle, or in response to hormonal contraception. We used the Wilcoxon signed-rank test and rank-sum test to determine if lesion frequency differed by cycle phase or hormonal contraceptive use. RESULTS In 189 women aged 19 to 46 years who collected swabs on 10,715 days and were not using hormonal contraception, HSV-2 DNA was detected on 20.9% of days in the follicular phase and 17.8% of days in the luteal phase (rate ratio, 1.19; 95% confidence interval, 1.03-1.37, P = 0.02). Genital lesions did not differ in the follicular versus luteal phase (12.8% vs. 10.7%, P = 0.07). In analyses of hormonal contraception, including 244 women, HSV-2 DNA was detected on 19.0% of days for women not using hormonal contraception and 18.3% of days for those using hormonal contraception (P = 0.50). Lesions were present on 11.1% of days for women not using hormonal contraception, and 8.7% of days for those using hormonal contraception (P = 0.66). CONCLUSIONS In women with genital HSV-2 infection who are not using hormonal contraception, the follicular phase of the cycle may be associated with a higher frequency of HSV-2 shedding compared to the luteal phase. Lesion frequency is similar during the 2 menstrual phases. Hormonal contraception use was not observed to affect genital HSV-2 DNA detection or lesions.
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Deese J, Pradhan S, Goetz H, Morrison C. Contraceptive use and the risk of sexually transmitted infection: systematic review and current perspectives. Open Access J Contracept 2018; 9:91-112. [PMID: 30519127 PMCID: PMC6239113 DOI: 10.2147/oajc.s135439] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose Evidence on the association between contraceptive use and risk of sexually transmitted infections (STIs) and bacterial vaginosis (BV) is lacking, with few prospective studies. We systematically reviewed the last 10 years' evidence on the association between contraception and STI/BV, building on the most recent systematic reviews published in 2006 and 2009. Methods We searched the MEDLINE and POPLINE databases for peer-reviewed articles p ublished between January 1, 2008 and January 31, 2018 reporting prospective studies that assessed the association between contraceptive use and incident STI and/or incident or recurrent BV. Results We identified 33 articles that evaluated combined oral contraceptives (COC), depot medroxyprogesterone acetate (DMPA), the copper intrauterine device (Cu-IUD), the levonorgestrel intrauterine system (LNG-IUS) and other methods. The strength of the evidence for many specific contraceptive method/STI associations is limited by few prospective studies with comparably defined exposures and outcomes. Available data suggest no association of COCs and Neisseria gonorrhoeae, Trichomonas vaginalis, HSV-2 or syphilis, and mixed evidence on the association with HPV, Chlamydia trachomatis, and BV. For DMPA, none of the studies identified found an association with N. gonorrhoeae or syphilis, and data on C. trachomatis, T. vaginalis, HPV and BV were mixed. Two large studies showed a highly clinically significant increased risk of HSV-2 infection with DMPA use. Data on the effect of Cu-IUD and the LNG-IUS on the acquisition of C. trachomatis, N. gonorrhoeae and T. vaginalis are sparse, and data on HPV and BV are mixed. Conclusion Few data are available from prospective studies, including randomized trials, to draw strong conclusions about the relationships between contraceptive methods and specific STIs. The overall evidence on the association between contraceptive use and STI/BV risk is limited by the lack of any randomized trials, few published prospective studies designed to analyze these associations, wide variability in exposure definitions and comparator groups, potential for confounding due to inaccurate sexual behavior data, differential confounder adjustment and differences in study populations and sizes. Despite these limitations, new evidence is supportive of a significantly increased risk of HSV-2 infection among DMPA users which warrants additional research to better understand this association.
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Affiliation(s)
- Jennifer Deese
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Subarna Pradhan
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Hannah Goetz
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Charles Morrison
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
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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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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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