Hormonal contraception and HIV disease progression: a multicountry cohort analysis of the MTCT-Plus Initiative

Abstract

Objective: HIV-infected women need access to safe and effective contraception. Recent animal and human data suggest that hormonal contraception may accelerate HIV disease progression.

Methods: We compared the incidence of HIV disease progression among antiretroviral therapy-naive women with and without exposure to hormonal contraception at 13 sites in Africa and Asia. Disease progression was defined as becoming eligible for antiretroviral therapy or death.

Results: Between 1 August 2002 and 31 December 2007, the MTCT-Plus programs enrolled 7846 women. In total, 4109 (52%) women met eligibility criteria for this analysis and contributed 5911 person-years of follow-up (median follow-up, 379 days; interquartile range, 121-833). At baseline, 3064 (75%) women reported using either no contraception or a nonhormonal method, whereas 823 (20%) reported using implants/injectables and 222 (5%) reported using oral contraceptive pills. The disease progression outcome was met by 944 (29%) women (rate, 18.3/100 woman-years). Neither implants/injectables (adjusted hazard ratio 1.0, 95% confidence interval 0.8-1.1) nor oral contraceptive pills (adjusted hazard ratio 0.8, 95% confidence interval 0.6-1.1) were associated with disease progression. Treating contraceptive method as a time-varying exposure did not change this negative finding.

Conclusion: This multicountry cohort analysis provides some reassurance that hormonal contraception is not associated with HIV disease progression. Further research is needed to address the contraceptive needs of HIV-infected women.

Figure 1

Potential effects of hormonal contraception on the pathogenesis of HIV infection. Arrows pointing down indicate decreases in immune response, arrows pointing up indicate increases in immune response, and question marks indicate unknown effects. The boxed sections denote processes in which hormonal effects may be significant. E, estrogens (effects of E on immune responses are shown in blue); IDO, indolamine 2,3-deoxygenase; P, progesterone (effects of P on immune response are shown in red).