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FHI 360 statement on the Heffron et al study and hormonal contraceptives and HIV risk

On October 4, 2011 The Lancet Infectious Diseases published an article by Renee Heffron and a group of researchers at the University of Washington. The study was conducted among nearly 3,800 HIV-serodiscordant couples (in which one partner is HIV positive) from seven African countries.  The data indicate increased risks of HIV acquisition by uninfected women and HIV transmission to uninfected male partners among couples in which the women were using progestin-only injectable contraceptives, compared with women not using hormonal contraceptives (HC).

The analysis included some oral contraceptive users; however, the investigators were unable to draw conclusions based on the small number of HIV infections in this group. The data also do not provide estimates of HIV risk related to other types of HC, such as implants, patches, combination injectables, or the levonorgestrel IUD.

The World Health Organization (WHO) has indicated that it will make no immediate change in contraceptive guidelines. A technical meeting will be held January 2012 to review the guidance in light of this new analysis.

Previous prospective studies have also examined whether injectable contraceptives influence the risk of HIV acquisition. Many of these studies have found no relationship between the use of injectable contraceptives and HIV. However, a smaller number of studies (including two of the largest) found an increased risk of HIV acquisition associated with the use of injectable contraceptives.  All of these studies were observational in design, so are frequently biased by self-selection or some other unexplained variables. In addition, HC users may differ in important ways from non-users.  For example, HC users may have higher coital frequency and lower condom use. Thus, these types of studies are usually not considered conclusive.

Going forward, priority should be given to initiating high-quality research to provide a more definitive answer to this important public health issue.  A randomized controlled trial comparing users of the widely used injectable depot medroxyprogesterone acetate (DMPA) to users of highly effective non-hormonal methods such as copper IUDs and/or highly effective low-dose hormonal methods like the implant or levonorgestrel IUDs is urgently needed. Such a study will take, at a minimum, four to five years to yield results.

Family planning and HIV service providers and educators should continue to counsel women and couples about the importance of family planning and the consistent use of condoms in conjunction with hormonal and non-hormonal contraceptives for the prevention of HIV and other sexually transmitted infections. In addition, strategies to improve accessibility to highly effective, lower-dose hormonal (implants) and non-hormonal (IUDs, sterilization) contraceptive methods should be prioritized.