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A recent article by Heffron and colleagues published in Lancet Infectious Diseases suggests that hormonal contraception may increase the risk of HIV acquisition among men and women two-fold.1 Given the potential impact of these findings, it is worth considering the study and available evidence carefully as well as the organizational responses from the World Health Organization (WHO), United States Agency for International Development (USAID), and other key organizations such as the Guttmacher Institute.
The original study was designed to assess the effectiveness of acyclovir and other antiretroviral medications in preventing HIV infections, and the study involved more than 3,000 participants in 14 sites in sub-Saharan Africa. The Heffron article cited comes from a secondary analysis of data from the original study. The study was not prospectively designed to assess the effect of hormonal contraception on HIV risk. Accordingly, the study is limited by potential bias and confounding variables; reliance on self-reporting and limited data on adherence with contraceptive use (hormonal and condoms); and potential variability across study sites, which was not assessed. In addition, the overall number of women using hormonal contraception in the study was low; only 197 (11%) of 3,790 women reported continued use during the follow-up period. Only ten new HIV infections were observed among users of injectable depot-medroxyprogesterone acetate (DMPA or Depo-Provera®), and three new HIV infections were observed among users of oral contraceptives. So, although the corrected odds ratio is significant—women in the study were 1.93 times more likely to HIV seroconvert with hormonal contraceptive use than without—the confidence interval was wide and the p-value, which is a measure of power of the study, was 0.03. These are statistically significant results but based on the sample size would need verification before any change in practice or policy is warranted.
Given such limitations, it is important not to let these recent findings overshadow the proven and substantial benefits of contraceptives on preventing unwanted pregnancies as well as the deaths and injuries among women and infants and HIV infections in newborns that can accompany these pregnancies. There are mechanisms by which hormonal contraceptive use could, at least theoretically, increase HIV transmission, but previous analyses and systematic reviews of studies have not demonstrated a clear relationship. While the evidence from this secondary analysis should be noted, additional high-quality, large population research designed specifically to examine the relationship between hormonal family planning and HIV acquisition needs to be undertaken.
At this time, there are no recommendations—by either the WHO or USAID—that would support dissuading women from using hormonal contraception given its efficacy in preventing pregnancy or that would support making any programmatic changes based on this evidence. Currently, we would only advise increased emphasis on the importance of counseling people about the importance of dual protection with condoms for couples using hormonal contraception, particularly among sero-discordant couples.
1. Heffron R et.al. October 2011. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infectious Diseases, Early online publication.
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