Abstract
Objective
To determine the impact of hormonal contraceptive methods on risk of HIV acquisition
among HIV-negative women cohabiting with HIV-positive male partners.
Study design
From 1994–2012, HIV discordant couples recruited from a couples' voluntary HIV counseling
and testing center in Lusaka, Zambia were followed longitudinally. HIV-negative partners
were tested quarterly. This analysis is restricted to couples in which the man was
HIV-positive and the woman was HIV-negative at enrollment and the man was not on antiretroviral
treatment. Multivariate Cox models evaluated associations between time-varying contraceptive
methods and HIV acquisition among women. Sensitivity analyses explored exposure misclassification
and time-varying confounder mediation.
Results
Among 1393 couples, 252 incident infections occurred in women over 2842 couple-years
(8.9 infections per 100 couple-years; 95% CI, 7.8–10.0). Multivariate Cox models indicated
that neither injectable [adjusted hazard ratio (aHR)=1.2; 95% CI, 0.8–1.7], oral contraceptive
pill (OCP, aHR=1.3; 95% CI, 0.9–1.8), or implant (aHR=1.1; 95% CI, 0.5–2.2) use was
significantly associated with HIV acquisition relative to non-hormonal contraception
controlling for woman's age, literacy and time-varying measures of genital ulceration/inflammation.
This remained true when only looking at the subset of infections acquired from the
spouse (82% of infections) and additionally controlling for baseline HIV viral load
of the male partner, pregnancy status, and time-varying measures of sperm on a vaginal
swab wet prep and self-reported unprotected sex. OCP and injectable users reported
more unprotected sex (p<.001), and OCP users were more likely to have sperm on vaginal
swab (p=.1) than nonhormonal method users.
Conclusions
We found no association between hormonal contraception and HIV acquisition risk in
women. Condom use and reinforced condom counseling should always be recommended for
HIV discordant couples. HIV testing of sex partners together is critical to establish
HIV risk, ascertain couple fertility intentions and counsel appropriately.
Implications
These findings add to a controversial literature and uniquely address several common
design and analytic challenges faced by previous studies. After controlling for confounders,
we found no association between hormonal contraception and HIV acquisition risk in
women. We support promoting condoms for HIV prevention and increasing the contraceptive
method mix to decrease unintended pregnancy.
Keywords
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Article info
Publication history
Published online: February 20, 2015
Accepted:
February 10,
2015
Received in revised form:
February 9,
2015
Received:
October 24,
2014
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
