Evidence observed in an updated systematic review published in AIDS suggests that use of depot medroxyprogesterone acetate (DMPA) contraception may be associated with an increased risk of HIV acquisition in women.
Chelsea B. Polis, PhD, from the Guttmacher Institute in New York and the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health, and colleagues identified studies published between January 15, 2014, and January 15, 2016, that compared users of a specific hormonal contraception with either nonusers of hormonal contraception or with users a different type of contraception.
The authors note that the possible association “is critically important for women’s health, particularly in sub-Saharan Africa, where high rates of HIV coincide with high use of injectable contraception. Many regions with high HIV prevalence also have high rates of unmet need for contraception, unintended pregnancy, and maternal mortality and morbidity, underlying the imperative for access to effective contraception.”
The researchers added newly identified studies to those used in a previous review that included evidence prior to January 2014. They assessed study quality and conducted a meta-analysis to compare use of DMPA with non-use of hormonal contraception. The investigators identified 5 new reports and focused on 9 additional reports from the previous review that were considered “informative but with important limitations.”
The data did not suggest that there is an association between HIV acquisition and the use of oral contraceptive pills, injectable norethisterone enanthate, or levonorgestrel implants.
Twelve studies in the meta-analysis assessed DMPA or nondisaggregated injectables compared with non-use of hormonal contraception, and 4 or 5 studies, depending on the statistical model considered, showed statistically significant increased risks of HIV acquisition. Hazard ratios (HR) ranged from 1.45 to 2.04 in Cox models. Among 4 newly included studies, 2 reported a statistically significant HIV risk (adjusted HRs, 1.45 and 1.69).
The researchers concluded that if the association between DMPA and HIV risk is causal, the data suggest an increase in risk of hazard ratios 1.5 or less. They note that more discussion is needed to evaluate study quality with the current evidence.
“An important next step is for WHO [World Health Organization] to determine whether these concerns warrant a reconsideration of global guidance for DMPA,” they wrote. “Modeling studies can be useful in understanding net health impacts of various policy responses in different epidemiological contexts, including the risk of HIV, maternal mortality and morbidity, and access to alternative contraception and HIV prevention methods.”
- Polis CB, Curtis KM, Hannaford PC, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS. 2016;30:2665-2683. 2016; doi: 10.1097/QAD.0000000000001228.