DMPA and HIV: do we need a trial?

      Whether hormonal contraceptive use increases the risk of HIV acquisition is still a much debated question. In countries that endure the double challenges of high HIV prevalence and high maternal mortality, the need for safe contraceptives is enormous, yet the meaning of “safe” becomes impossible to parse because of competing risks. Effective contraceptive use in these settings clearly and dramatically reduces maternal mortality. If women — or clinicians or health systems — avoid some contraceptives due to fear of HIV, will overall maternal deaths increase or decrease? The answer may vary by country and population subgroup, and thus general advice for public health policy is paralyzed. Thus far, our understanding of the increased risks comes from observational studies and secondary outcomes from trials designed to answer other questions. The quandary is whether DMPA users (and perhaps NET-EN users) have an increased risk of HIV acquisition and, if increased, by how much. If an increased risk were certain, what should we do? How might the magnitude of this risk drive public policy in different settings? Will the answer be the same across settings that have different HIV prevalence, different maternal mortality and different contraceptive method mix? Jain's calculations, previously published in this journal, suggest that, under most assumptions (based on current assessment of risk), the withdrawal of DMPA is unwarranted [
      • Jain A.K.
      Hormonal contraception and HIV acquisition risk: implications for individual users and public policies.
      • Jain A.K.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Contraception
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jain A.K.
        Hormonal contraception and HIV acquisition risk: implications for individual users and public policies.
        Contraception. 2012; 86: 645-652
        • Jain A.K.
        Contraception. 2013; 88: 195
        • Polis C.B.
        • Phillips S.J.
        • Curtis K.M.
        • Westreich D.J.
        • Steyn P.S.
        • Raymond E.
        • et al.
        Hormonal contraceptive methods and risk of HIV acquisition in women: a systematic review of epidemiological evidence.
        Contraception. 2014; 90: 360-391
        • World Health Organization
        Hormonal contraceptive methods for women at high risk of HIV and living with HIV: 2014 guidance statement.
        (Available at)
        • Rees H.
        The ECHO Consortium. DMPA and HIV: why we need a trial.
        Contraception. 2014; 90: 354-356
        • Jones H.S.
        Time to focus on improving the contraceptive method mix and let go of unanswerable questions.
        Contraception. 2014; 90: 357-359
        • Blanchard K.
        • Chipato T.
        • Ramjee G.
        • Nhemachena T.
        • Harper C.C.
        • The Provider Study Writing Committee
        Clinicians' perceptions and provision of hormonal contraceptives for HIV positive and at-risk women in Southern Africa: an original research article.
        Contraception. 2014; 90: 392-399