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Time to focus on improving the contraceptive method mix in high HIV prevalence settings and let go of unanswerable questions

  • Heidi E. Jones
    Correspondence
    Corresponding author. CUNY School of Public Health and Hunter College Epidemiology & Biostatistics, 2180 Third Avenue, New York, NY 10035 Tel.: +212 396 7750; fax: +34 952 131568.
    Affiliations
    City University of New York (CUNY) School of Public Health, Hunter College
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      The evidence on the impact of depot medroxyprogesterone acetate (DMPA), a progestin-only injectable form of contraception, on increased HIV-1 acquisition is mixed [
      • Polis C.B.
      • Curtis K.M.
      Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence.
      ]. A meta-analysis of observational data from 18 studies of over 38,000 women with 1887 incident HIV infections, adjusted for region, age, partner status, time-varying number of sexual partners and time-varying condom use, suggests that the use of DMPA increases the risk of HIV-1 acquisition by 1.5 times [95% confidence interval (CI), 1.2–1.8] compared to women not using hormonal contraceptive methods [
      • Morrison C.S.
      • Chen P.L.
      ]. Further, a recent, planned secondary analysis of 3163 women from an HIV prevention trial in Uganda, South Africa and Zimbabwe (the VOICE study) found that DMPA users had 1.4 times (95% CI 1.0–2.0) the hazard of HIV acquisition compared to users of norethistoerone enanthate (NET-EN) injectable contraception [
      • Noguchi L.
      • Richardson B.
      • Chirenje Z.
      • Ramjee G.
      • Nair G.
      • Palanee T.
      • et al.
      Injectable contraception and HIV acquisition in the VOICE study (MTN-003).
      ]. In this study, HIV incidence among DMPA users was 8.0 per 100 woman–years compared to 5.4 per 100 woman–years among NET-EN users, resulting in 2.6 additional cases of HIV per 100 woman–years for DMPA users compared to NET-EN users [
      • Noguchi L.
      • Richardson B.
      • Chirenje Z.
      • Ramjee G.
      • Nair G.
      • Palanee T.
      • et al.
      Injectable contraception and HIV acquisition in the VOICE study (MTN-003).
      ]. Thus, while the findings are mixed, our best estimates are that DMPA use increases HIV acquisition modestly.
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