Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2022 Nov 30;75(11):2000-2011.
doi: 10.1093/cid/ciac284.

Initiating Intramuscular Depot Medroxyprogesterone Acetate Increases Frequencies of Th17-like Human Immunodeficiency Virus Target Cells in the Genital Tract of Women in South Africa: A Randomized Trial

Rubina Bunjun  1 , Tanko F Ramla  1   2 , Shameem Z Jaumdally  1 , Laura Noël-Romas  3   4 , Hossaena Ayele  3 , Bryan P Brown  5 , Hoyam Gamieldien  1 , Rushil Harryparsad  1 , Smritee Dabee  1 , Gonasagrie Nair  6 , Maricianah Onono  7 , Thesla Palanee-Phillips  8   9 , Catilin W Scoville  9 , Kate B Heller  9 , Jared M Baeten  9 , Steven E Bosinger  10   11 , Adam Burgener  3   4   12 , Jo-Ann S Passmore  1   13 , Heather Jaspan  1   5   9 , Renee Heffron  9
Affiliations
Randomized Controlled Trial

Initiating Intramuscular Depot Medroxyprogesterone Acetate Increases Frequencies of Th17-like Human Immunodeficiency Virus Target Cells in the Genital Tract of Women in South Africa: A Randomized Trial

Rubina Bunjun et al. Clin Infect Dis. .

Erratum in

Abstract

Background: Cervicovaginal CD4+ T cells are preferential targets for human immunodeficiency virus (HIV) infection and have consequently been used as a proxy measure for HIV susceptibility. The ECHO randomized trial offered a unique opportunity to consider the association between contraceptives and Th17-like cells within a trial designed to evaluate HIV risk. In a mucosal substudy of the ECHO trial, we compared the impact of initiating intramuscular depot medroxyprogesterone acetate (DMPA-IM), copper-IUD, and the levonorgestrel (LNG) implant on cervical T cells.

Methods: Cervical cytobrushes from 58 women enrolled in the ECHO trial were collected at baseline and 1 month after contraceptive initiation. We phenotyped cervical T cells using multiparameter flow cytometry, characterized the vaginal microbiome using 16s sequencing, and determined proteomic signatures associated with Th17-like cells using mass spectrometry.

Results: Unlike the LNG implant or copper-IUD, DMPA-IM was associated with higher frequencies of cervical Th17-like cells within 1 month of initiation (P = .012), including a highly susceptible, activated population co-expressing CD38, CCR5, and α4β7 (P = .003). After 1 month, women using DMPA-IM also had more Th17-like cells than women using the Cu-IUD (P = .0002) or LNG implant (P = .04). Importantly, in women using DMPA-IM, proteomic signatures signifying enhanced mucosal barrier function were associated with the increased abundance of Th17-like cells. We also found that a non-Lactobacillus-dominant microbiome at baseline was associated with more Th17-like cells post-DMPA-IM (P = .03), although this did not influence barrier function.

Conclusions: Our data suggest that DMPA-IM-driven accumulation of HIV-susceptible Th17-like cells might be counteracted by their role in maintaining mucosal barrier integrity.

Clinical trials registration: NCT02550067.

Keywords: HIV risk; Th17 cells; hormonal contraception; mucosal barrier integrity.

PubMed Disclaimer

Conflict of interest statement

Potential conflicts of interest. J.-A. S. P. reports the following grants or contracts all paid to the author’s institution and unrelated to this work: Bill and Melinda Gates Foundation (BMGF) Vaginal Microbiome Research Consortium (VMRC) Planning Grant (Principal Investigator [PI]: Dr Jo-Ann Passmore. Co-PI: Dr Leila Mansoor; Co-Investigators: Nigel Garrett, Cheryl Baxter, Sinaye Ngcapu, Lenine Liebenberg, Aida Sivro, Brian Kullin, Anna Happel. US $512 088 for 12 months); European and Developing Countries Clinical Trials Partnership (EDCTP) RIA2020I (3297) for project entitled “GIFT for HIV Prevention” (Passmore, Co-PI: Masson (Burnett Institute, Australia); Co-Investigators: Suzanna Francis and Katharina Kranzer (The London School of Hygiene & Tropical Medicine, UK), Janneke van der Wijgert (University Medical Center, Netherlands), Tania Crucitti (Institute Pasteur Madegascar, Madagascar), David Anderson (Burnet Institute, Australia), Ayako Honda (Sophia University, Japan), Chido Dziva-Chikwari (The Organization for Public Health Interventions and Development, Zimbabwe), Katherine Gill (Desmond Tutu Health Foundation, South Africa) (Euro 3 508 462 for 36 months); BMGF Calestous Juma Scientific Leadership Award for project entitled “VMRC4Africa” (PI: Passmore. US $1 million over 5 years); and Medical Research Council Strategic Health Innovation Partnerships (South Africa), Genital inflammation test for females (GIFT) (PIs: Dr Jo-Ann Passmore and Dr Lindi Masson, ZAR 5 million per year for 4 years). J.-A. S. P. also reports a patent granted in 2022 with no payment made (Method for diagnosing an inflammatory condition in the female genital tract; PCT/IB2014/065740; EP3063542B1); and unpaid participation on a Data Safety Monitoring Board (DSMB) or Advisory Board for a phase 2 placebo-controlled randomized trial of LACTIN-V (Lactobacillus crispatus CTV-05) among women at high risk of HIV acquisition in Durban, South Africa (Chair DSMB; Cohen et al National Institute of Child Health and Human Development [NICHD] grant 1R01HD098978). R. H. reports grants or contracts unrelated to this work and paid to the author’s institution from the NICHD. H. J. reports support for attending meetings and/or travel from World Vaccine Congress. S. E. B. reports grants or contracts unrelated to this work from the National Institutes of Health (NIH R01 HD089831): Effects of Hormonal Contraceptives on Genital Immunity and HIV Susceptibility. B. P. B. reports support for attending meetings and/or travel (NIH R01HD089831). J. M. H. reports grants to institution unrelated to this work from the NIH, USAID, and BMGF; and employment (with stocks and stock options) with Gilead Sciences. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Frequencies of cervical CD4+ T cells in women randomized to the Cu-IUD (n = 23; red), DMPA-IM (n = 20; blue), or LNG implant (n = 15; green) at baseline and 1 month after initiating contraception. Graphs show the differences pre-post contraceptive initiation for the frequencies of cervical (A) CD4+ T cells, (B) CD38+ CD4+ T cells, (C) HLA-DR+ CD4+ T cells, (D) CCR5+ CD4+ T cells, and (E) α4β7+ CD4+ T cells. The horizontal bars indicate the median. Statistical comparisons were performed using the Wilcoxon matched-pairs tests for matched data or the Kruskal-Wallis test with false discovery rate correction for cross-sectional data. Abbreviations: Cu-IUD, copper T intrauterine device; DMPA-IM, intramuscular depot medroxyprogesterone acetate; LNG, 2-rod levonorgestrel.
Figure 2.
Figure 2.
The frequency of activated Th17 HIV target cells in women randomized to the Cu-IUD (n = 23; red), DMPA-IM (n = 20; blue), or LNG implant (n = 15; green). (A) The frequency of Th17-like cells (CCR6+ CCR10–) before and after initiation of contraception. (B) The cross-sectional comparison of Th17 frequency post-contraceptive initiation across study arms. (C) The frequency of CD38+ Th17 cells before and after initiation of contraception. (D) The cross-sectional comparison of CD38+ Th17 frequency post-contraceptive initiation across study arms. (E) The frequency of HLA-DR+ Th17 cells before and after initiation of contraception. (F) The cross-sectional comparison of HLA-DR+ Th17 frequency post-contraceptive initiation across study arms. The horizontal bars indicate the median. (G) Proportions of activated Th17 cells expressing different combinations of CD38 and HLA-DR. Statistical comparisons were performed using the Wilcoxon matched-pairs tests for matched data or the Kruskal-Wallis with false discovery rate correction for cross-sectional comparisons. Abbreviations: Cu-IUD, copper T intrauterine device; DMPA-IM, intramuscular depot medroxyprogesterone acetate; HIV, human immunodeficiency virus; LNG, 2-rod levonorgestrel; Th17, T-helper 17.
Figure 3.
Figure 3.
The expression of HIV receptors CCR5 and α4β7 on Th17 target cells in women randomized to the Cu-IUD (n = 23; red), DMPA-IM (n = 20; blue), or LNG implant (n = 15; green). (A) The frequency of CCR5+ Th17 before and after initiation of contraception. (B) The cross-sectional comparison of CCR5+ Th17 frequency post-contraceptive initiation across study arms. (C) The MFI of CCR5 on Th17 cells before and after initiation of contraception. (D) The cross-sectional comparison of CCR5 MFI post-contraceptive initiation across study arms. (E) The frequency of α4β7+ Th17 cells before and after initiation of contraception. (F) The cross-sectional comparison of α4β7+ Th17 frequency post-contraceptive initiation across study arms. (G) The MFI of α4β7 on Th17 cells before and after initiation of contraception. (H) The cross-sectional comparison of α4β7 MFI post-contraceptive initiation across study arms. Th17 cells were defined as CD4+ CCR6+ CCR10−. The horizontal bars indicate the median. Statistical comparisons were performed using the Wilcoxon matched-pairs tests for matched data or the Kruskal-Wallis with false discovery rate correction for cross-sectional comparisons. Abbreviations: Cu-IUD, copper T intrauterine device; DMPA-IM, intramuscular depot medroxyprogesterone acetate; LNG, 2-rod levonorgestrel; MRI, median fluorescent intensity; Th17, T-helper 17.
Figure 4.
Figure 4.
Changes in the co-expression of HIV target cell markers on Th17 cells from women randomized to the Cu-IUD (n = 23; red), DMPA-IM (n = 20; blue), or LNG implant (n = 15; green). The cross-sectional comparison of Th17 populations expressing CD38, HLA-DR, α4β7, and CCR5 in different combinations: (A) before and after the start of contraception and (B) between study arms post-contraceptive initiation with the 5 most abundant populations (medians >5% for at least 1 contraceptive arm at either time point). The dashed line indicates the 5% cutoff. Th17 cells were defined as CD4+ CCR6+ CCR10−. Statistical comparisons were performed using the Wilcoxon matched-pairs tests for matched data or the Kruskal-Wallis with false discovery rate correction for cross-sectional comparisons. Abbreviations: Cu-IUD, copper T intrauterine device; DMPA-IM, intramuscular depot medroxyprogesterone acetate; HIV, human immunodeficiency virus; LNG, 2-rod levonorgestrel; Th17, T-helper 17.
Figure 5.
Figure 5.
The effect of the vaginal microbiome at baseline on the abundance of Th17-like cells in women randomized to the Cu-IUD (n = 17; red), DMPA-IM (n = 17; blue), or LNG implant (n = 13; green). (A) Relative abundance of the different vaginal bacterial species in each participant at baseline, where data were available (n = 47). The CSTs are shown above the panel. The color of the dots at the bottom of the panel indicates which contraceptive arm the participant was randomized to (red for CU-IUD, blue for DMPA-IM, and green for LNG implant). (B) Th17 cell frequency before and after initiation of contraception in women with a Lactobacillus-dominant (CSTs III-A or I-B; n = 15) or non–Lactobacillus-dominant microbiome (CSTs IV-A, IV-B, or IV-D; n = 32). Statistical comparisons were performed using the Wilcoxon matched-pairs tests. (C) The cross-sectional comparison of Th17 frequency post-contraceptive initiation across study arms in women with a Lactobacillus-dominant or non–Lactobacillus-dominant microbiome. Statistical comparisons were performed using Kruskal–Wallis with false discovery rate correction. (D) Linear associations between women with Lactobacillus-dominant microbiomes at baseline (pre) and at month 1 post–DMPA-IM (post) and Th17-like cell abundance post–DMPA-IM initiation. The associations are shown as a β-coefficient with error bars representing the 95% confidence interval. Abbreviations: CST, community state type; Cu-IUD, copper T intrauterine device; DMPA-IM, intramuscular depot medroxyprogesterone acetate; HIV, human immunodeficiency virus; LNG, 2-rod levonorgestrel; Th17, T-helper 17.
Figure 6.
Figure 6.
Proteome signatures associated with Th17 cell levels in women randomized to DMPA-IM. Cervicovaginal samples taken at baseline and post–DMPA-IM initiation (n = 20) were analyzed by label-free mass spectrometry. Longitudinal differences in Th17-like cells and proteins were correlated using Pearson’s R test, which found 13.7% of proteins to be significantly correlated (P = .05). (A) Pathway annotation using IPA and DAVID bioinformatics identified 5 unique biological pathways increased and 6 decreased with the increase in Th17-like cells. (B) Hierarchical clustering showing the associations between the increase in Th17 cells and corresponding increase in mucosal barrier integrity proteins. Abbreviations: DMPA-IM, intramuscular depot medroxyprogesterone acetate; Th17, T-helper 17.
See this image and copyright information in PMC

References

    1. ECHO . HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 2019; 394:303–13. - PMC - PubMed
    1. Polis CB, Curtis KM, Hannaford PC, et al. . An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016; 30:2665–83. - PMC - PubMed
    1. Hapgood JP, Kaushic C, Hel Z. Hormonal contraception and HIV-1 acquisition: biological mechanisms. Endocr Rev 2018; 39:36–78. - PMC - PubMed
    1. Heffron R, Achilles SL, Dorflinger LJ, et al. . Pharmacokinetic, biologic and epidemiologic differences in MPA- and NET-based progestin-only injectable contraceptives relative to the potential impact on HIV acquisition in women. Contraception 2019; 99:199–204. - PMC - PubMed
    1. Mwatelah R, McKinnon LR, Baxter C, Abdool Karim Q, Abdool Karim SS. Mechanisms of sexually transmitted infection-induced inflammation in women: implications for HIV risk. J Int AIDS Soc 2019; 22:e25346. - PMC - PubMed

Publication types

Associated data