Associations of hormonal contraceptive use with measures of HIV disease progression and antiretroviral therapy effectiveness

Abstract

Objective To examine the associations between hormonal contraceptive use and measures of HIV disease progression and antiretroviral treatment (ART) effectiveness. Study design A prospective cohort study of women with prevalent HIV infection in St. Petersburg, Russia, was conducted. After contraceptive counseling, participants chose to use combined oral contraceptives (COCs), depot-medroxyprogesterone acetate (DMPA), a copper intrauterine device (IUD) or male condoms for pregnancy prevention. Among participants not using ART at enrollment, we used multivariate Cox regression to assess the association between current (time-varying) contraceptive use and disease progression, measured by the primary composite outcome of CD4 decline to <350 cells/mm3, ART initiation or death. Among participants using ART at enrollment, we used linear mixed models to estimate the predicted mean CD4 change at select time points by contraceptive method. Results During a total of 5233 months follow-up among participants not using ART with enrollment CD4 ≥ 350 cells/mm3 (n=315), 97 experienced disease progression. Neither current use of COCs [adjusted hazard ratio (aHR) 0.91, 95% confidence interval (CI) 0.56–1.48] nor DMPA (aHR 1.28, 95% CI 0.71–2.31) was associated with a statistically significant increased risk for disease progression compared with use of nonhormonal methods (IUD or condoms). Among participants using ART at enrollment (n=77), we found no statistically significant differences in the predicted mean changes in CD4 cell count comparing current use of COCs (p=.1) or DMPA (p=.3) with nonhormonal methods. Conclusion Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection. Implications Hormonal contraceptive use was not significantly associated with measures of HIV disease progression or ART effectiveness among women with prevalent HIV infection.

Drug interactions between hormonal contraceptives and antiretrovirals

“…Eight reports evaluated the effects of hormonal contraceptive use on the effectiveness of NNRTI-containing or protease inhibitor-containing cART, and found no effects on death, CD4 + cell count, or plasma viral load with concurrent use of DMPA, levonorgestrel implants, or oral contraceptives [14,43–49]. Use of DMPA also did not affect the efficacy of PrEP [50].…”

Global implementation of PrEP as part of combination HIV prevention - Unsolved challenges

“…No evidence currently exists to suggest that PrEP interacts with commonly used feminizing hormone regimens, and evidence from studies of antiretroviral interactions with hormonal contraceptives has been reassuring [57]. However, there…”

“…As an example, we can consider a representative net expenditure level of $20 billion for the continent over the next 15 years (from 2016 to 2030) and examine what role PrEP plays in scale-up of the optimal prevention at this total expenditure. The $20 billion figure is obtained by assuming that current levels of HIV funding [51] will be maintained annually in the near future [21], the prevention share in HIV spending will approach 25% [57], and 90% of this prevention share will be directed to scaling up current methods (rather than to research and development of new methods). As this avoids assumptions about future domestic growth in the modelled countries and also likely declines in HIV funding by international donors, we can consider $20 billion to represent a moderate spending level for the intervention period.…”

“…Training of health providers both to provide PrEP and transform judgmental and stigmatizing behaviours is important. In many parts of the world, misconceptions among health providers about the effectiveness and side effects of PrEP, as well as the likelihood it will induce drug resistance have slowed uptake [57]. National policies need to include minimum standards for training and quality assurance for PrEP implementation, as well as addressing supply chain issues which secure drug availability [58].…”

“…Australia released NSW state and then national guidance for PrEP prescribers in 2014 to 2015 [33,56]. Australian guidance differs from current clinical guidelines in the United States [56,57], South Africa [58] and the European Union [59] in its approach to determining eligibility for PrEP. In the current environment with limited access to TDF/FTC, the guidelines target daily PrEP to those at high and ongoing risk of HIV infection, which in the Australian context is mainly MSM [56].…”