Genital Abnormalities, Hormonal Contraception, and Human Immunodeficiency Virus Transmission Risk in Rwandan Serodifferent Couples

BACKGROUND

We explored the role of genital abnormalities and hormonal contraception in human immunodeficiency virus (HIV) transmission among heterosexual serodifferent couples in Rwanda.

METHODS

From 2002 to 2011, HIV-serodifferent couples who were not using antiretroviral treatment were followed up, and sociodemographic and clinical data were collected, family planning provided, and HIV-negative partners retested. Couples were assessed for genital ulcers; nonulcerative genital sexually transmitted infection (STIs), including gonorrhea, chlamydia, and trichomoniasis; and non-STI vaginal infections, including bacterial vaginosis and candida. Multivariable models evaluated associations between covariates and HIV transmission genetically linked to the index partner.

RESULTS

Among 877 couples in which the man was HIV positive, 37 linked transmissions occurred. Factors associated with women's HIV acquisition included genital ulceration in the female partner (adjusted hazard ratio, 14.1) and nonulcerative STI in the male partner (8.6). Among 955 couples in which the woman was HIV positive, 46 linked transmissions occurred. Factors associated with HIV acquisition in men included nonulcerative STI in the female partner (adjusted hazard ratio, 4.4), non-STI vaginal dysbiosis (7.1), and genital ulceration in the male partner (2.6). Hormonal contraception use was not associated with HIV transmission or acquisition.

CONCLUSIONS

Our findings underscore the need for integrating HIV services with care for genital abnormalities. Barriers (eg, cost of training, demand creation, advocacy, and client education; provider time; and clinic space) to joint HIV/STI testing need to be considered and addressed.

Update on Novel Hormonal and Nonhormonal Male Contraceptive Development

BACKGROUND

The advent of new methods of male contraception would increase contraceptive options for men and women and advance male contraceptive agency. Pharmaceutical R&D for male contraception has been dormant since the 1990s. The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) has supported a contraceptive development program since 1969 and supports most ongoing hormonal male contraceptive development. Nonhormonal methods are in earlier stages of development.

CONTENT

Several hormonal male contraceptive agents have entered clinical trials. Novel single agent products being evaluated include dimethandrolone undecanoate, 11β-methyl-nortestosterone dodecylcarbonate, and 7α-methyl-19-nortestosterone. A contraceptive efficacy trial of Nestorone®/testosterone gel is underway. Potential nonhormonal methods are at preclinical stages of development. Many nonhormonal male contraceptive targets that affect sperm production, sperm function, or sperm transport have been identified.

SUMMARY

NICHD supports development of reversible male contraceptive agents. Other organizations such as the World Health Organization, the Population Council, and the Male Contraception Initiative are pursuing male contraceptive development, but industry involvement remains limited.

Initiating Hormonal Contraception

Most patients can safely begin using hormonal contraception at any point in their menstrual cycle. An evidence-based, flexible, patient-centered approach to initiating contraception promotes health and enhances patients' reproductive autonomy. A recent Papanicolaou test is not necessary before prescribing hormonal contraception. Most patients can begin using progestin-only contraceptives immediately after childbirth. Patients can begin any appropriate contraceptive method immediately after an abortion or early pregnancy loss, except for an intrauterine device following septic abortion. Delaying contraception to wait for the next menses or for an appointment creates unnecessary barriers for patients. Clinicians can facilitate the use of hormonal contraception by providing anticipatory guidance about common side effects (e.g., spotting, other menstrual cycle changes), giving comprehensive information about available contraceptive choices, honoring patients' preferences, and eliminating office-related barriers. Prescribing or dispensing a one-year supply of contraceptives lowers costs and improves adherence. Counseling via telemedicine or a patient portal eliminates unnecessary office visits.

Assessing safety in hormonal male contraception: a critical appraisal of adverse events reported in a male contraceptive trial

INTRODUCTION

There is unmet need for male contraceptive options, but a recent injectable combination male contraceptive trial was terminated early due to adverse events (AEs).

METHODS

We examined the frequency of reported AEs by male research participants compared with AEs reported in prescribing information of approved female hormonal contraceptive methods. Published data from trials of the top five most-used female hormonal contraceptives, supplemented by contemporary contraceptive research, were compared with the frequency of AEs reported in a male injectable hormonal contraceptive trial.

RESULTS

We observed similar frequencies of AEs reported by users of male contraceptives compared with those reported by female users. Among quantitatively comparable AEs, compared with men, women reported experiencing higher frequencies of headaches, pelvic pain, and weight gain and similar frequencies of decreased libido. Compared with women, men reported experiencing higher frequencies of acne and mood changes. Men discontinued participation due to AEs at a lower frequency than women.

CONCLUSIONS

Female hormonal methods generally have similar frequencies of AEs to those reported in a recent male hormonal contraceptive trial, and male users had lower rates of discontinuation due to AEs. There were fewer serious AEs of the male contraceptive than reported in contemporary female trials which resulted in FDA licensure. This suggests there may be implicit bias in the scientific community regarding the level of acceptable risk for users of male contraceptive methods.

Hormonal contraception and HIV acquisition among women: an updated systematic review

OBJECTIVE

To update a 2016 systematic review on hormonal contraception use and HIV acquisition.

METHODS

We searched Pubmed and Embase between 15 January 2016 and 26 June 2019 for longitudinal studies comparing incident HIV infection among women using a hormonal contraceptive method and either non-users or users of another specific hormonal contraceptive method. We extracted information from newly identified studies, assessed study quality, and updated forest plots and meta-analyses.

RESULTS

In addition to 31 previously included studies, five more were identified; three provided higher quality evidence. A randomised clinical trial (RCT) found no statistically significant differences in HIV risk among users of intramuscular depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel implant (LNG implant) or the copper intrauterine device (Cu-IUD). An observational study found no statistically significant differences in HIV risk among women using DMPA, norethisterone enanthate (NET-EN), implants (type not specified) or Cu-IUD. Updated results from a previously included observational study continued to find a statistically significant increased HIV risk with oral contraceptives and DMPA compared with no contraceptive use, and found no association between LNG implant and HIV risk.

CONCLUSIONS

High-quality RCT data comparing use of DMPA, LNG implant and Cu-IUD does not support previous concerns from observational studies that DMPA-IM use increases the risk of HIV acquisition. Use of other hormonal contraceptive methods (oral contraceptives, NET-EN and implants) is not associated with an increased risk of HIV acquisition.

Hormonal Contraception and Bone Health in Adolescents

Hormonal contraception is prescribed commonly to adolescents for myriad indications from pregnancy prevention to treatment for acne, hirsutism or dysmenorrhea. Although use of these hormones generally has no effect or benefits bone health in mature premenopausal women, the same may not be true for adolescents. The teen years are a critical period for acquiring peak bone strength. Sex hormones, growth hormone, and insulin-like growth factors (IGFs) interact to modulate the changes in bone size, geometry, mineral content, and microarchitecture that determine skeletal strength. Combined oral contraceptives (COCs) and intramuscular depo medroxyprogesterone (DMPA) can compromise the expected gains in adolescence by altering estrogen and IGF concentrations. Use of these medications has been associated with slower accrual of bone mineral density (BMD) and increased fracture risk in some studies. Far less is known about the skeletal effects of the newer long acting reversible contraceptives (LARCs). This review takes a critical look at the gaps in current knowledge of the skeletal effects of COCs, DMPA, and LARCs and underscores the need for additional research.

Pharmacist self-perception of readiness to prescribe hormonal contraception and additional training needs

INTRODUCTION

Our objectives were to describe pharmacist perceptions of training and preparation to prescribe hormonal contraception (HC), identify training gaps, and elicit preferred training methods.

METHODS

In this cross-sectional survey, pharmacists in the United States (US) completed an online 29-item survey. Descriptive statistics were used to analyze responses.

RESULTS

Of 823 participating pharmacists, 58% felt they received adequate training to prescribe HC. Prescribing any medications within the last five years or completion of residency training were significantly associated with more participants feeling adequately trained. Of those who indicated HC was not covered in their pharmacy school curriculum, most (78%) felt they were either not adequately trained or unsure. Only 36% were aware of the Centers for Disease Control and Prevention US Medical Eligibility Criteria for Contraceptive Use (CDC MEC). Residency-trained pharmacists were statistically more likely to have used the CDC MEC and feel comfortable prescribing for adolescents. Most participants desired more training about switching between products (80%) and patient specific product selection (72%). Preferred methods for additional training were basic (<four hours) live trainings, on-demand webinars, and online self-study programs.

CONCLUSIONS

As pharmacist scope of practice expands to include prescribing HC, many opportunities remain to ensure pharmacists feel adequately trained to provide this service. Pharmacy educators and training programs should incorporate the findings of this study into their curricula, experiential opportunities, and continuing education offerings. Additional studies are needed on the effectiveness of various training formats and programs.

Potential user interest in new long-acting contraceptives: Results from a mixed methods study in Burkina Faso and Uganda

Method-related concerns represent an important cause of contraceptive non-use and discontinuation. User preferences must be incorporated into the design of new contraceptive technologies to ensure product success and improve family planning outcomes. We assessed preferences among potential users in Burkina Faso and Uganda for six contraceptive methods currently under development or ready for introduction: a new copper intra-uterine device (IUD), a levonorgestrel intra-uterine system, a new single-rod implant, a biodegradable implant, a longer-acting injectable, and a method of non-surgical permanent contraception. Questions were added to nationally-representative PMA2020 household surveys that asked 2,743 and 2,403 women in Burkina Faso and Uganda, respectively, their interest in using each new method. We assessed factors associated with interest through multivariable logistic regression models. We conducted qualitative interviews and focus groups with 398 women, 78 men, and 52 family planning providers and key informants to explore perceived advantages and disadvantages of the methods. Respondents expressed interest in using all new methods, with greatest interest in the longer-acting injectable (77% in Burkina Faso, 61% in Uganda), followed by a new single-rod implant. Least interest was expressed in a new copper IUD (26% Burkina Faso, 15% in Uganda). In both countries, women with less education had higher odds of interest in a longer-acting injectable. Interest in most new methods was associated with desiring a method lasting longer than one year and acceptance of lack of menstrual bleeding as a contraceptive side effect. Perceived advantages and disadvantages were similar between countries, including concerns about menstrual side effects and fear of the biodegradable nature of the biodegradable implant. Potential users, their partners, and providers are interested in new longer-acting methods, however, familiar forms including the injectable and implant may be the most immediately acceptable. A biodegradable implant will require clear counseling messages to allay potential fears.