Hormonal Contraception and Risk of Cardiometabolic Disease in Women with HIV

Abstract

Objective: We sought to determine the association of hormonal contraception (HC) and cardiometabolic outcomes among women with human immunodeficiency virus (HIV). Methods: We included women with HIV aged 18-45 years in clinical care in the Southeastern United States between 1998 and 2018. Oral and injectable HC use was captured from medication records. Our outcomes included incident cardiovascular/thrombotic disease (CVD) (atherosclerosis, hypertension, cerebrovascular disease, thrombosis, and heart failure) and incident metabolic disorders (diabetes, dyslipidemia, obesity, and non-alcoholic steatohepatitis). We excluded women with prevalent conditions. We used multivariable marginal structural models to examine time-varying current and cumulative HC use and cardiometabolic outcomes in separate analyses, adjusting for age, race, smoking, time-varying comorbidities, CD4 cell count, HIV RNA, and antiretroviral use. Women with HC exposure were compared with women without HC exposure. Results: Among the 710 women included, 201 women (28%) used HC. CVD analyses included 603 women without prevalent CVD and 93 incident events; metabolic analyses included 365 women without prevalent metabolic disease and 150 incident events. Current and cumulative oral HC use was associated with increased odds of CVD, though this was not statistically significant (adjusted odds ratio [aOR] = 2.08, [95% confidence interval (CI): 0.80-5.43] and aOR = 1.24 [95% CI: 0.96-1.60] per year of use, respectively). Oral HC was not associated with risk of incident metabolic disorders. Depot medroxyprogesterone acetate (DMPA) was not associated with risk of incident CVD. Current and cumulative DMPA use was significantly associated with decreased odds of incident metabolic disorders (aOR = 0.48 [95% CI: 0.23, 1.00] and aOR = 0.65 [95% CI: 0.42-1.00] per year of use, respectively). Conclusion: Our results suggest that cardiovascular risk should be considered when selecting contraception for women with HIV.

Keywords: HIV; cardiometabolic disease; contraception; women.

FIG. 1.

aORs for time-varying current (a) and cumulative (b) HC use and incident CVD events (n = 117 events). ^aMultivariable marginal structural model comparing oral contraception and DMPA use to no hormonal contraception use. Model directly adjusted for race, age at first non-pregnant visit, smoking status, CD4 cell count at first non-pregnant visit, and prevalent metabolic disorder; analyses also adjusted for these variables as well as time-varying CD4 cell count, HIV RNA, ART, and incident metabolic disorders through the use of inverse-probability weights. ^bMarginal structural logistic regression model comparing any hormonal contraception use to no hormonal contraception use. Model directly adjusted for race, age at first non-pregnant visit, smoking status, CD4 cell count at first non-pregnant visit, and prevalent metabolic disorder; analyses also adjusted for these variables as well as time-varying CD4 cell count, HIV RNA, ART, and incident metabolic disorders through the use of inverse-probability weights. aOR, adjusted odds ratio; CI, confidence interval; CVD, cardiovascular/thrombotic disease; DMPA, depot-medroxyprogesterone acetate; HC, hormonal contraception.

FIG. 2.

aORs for time-varying current (a) and cumulative (b) HC use and incident metabolic events (n = 172 events). ^aMultivariable marginal structural model comparing oral contraception and DMPA use with no hormonal contraception use. Model directly adjusted for race, age at first non-pregnant visit, smoking status, CD4 cell count at first non-pregnant visit, and prevalent cardiovascular disorder; analyses also adjusted for these variables as well as time-varying CD4 cell count, HIV RNA, ART, and incident cardiovascular disorders through the use of inverse-probability weights. ^bMarginal structural logistic regression model comparing any hormonal contraception use with no hormonal contraception use. Model directly adjusted for race, age at first non-pregnant visit, smoking status, CD4 cell count at first non-pregnant visit, and prevalent cardiovascular disorder; analyses also adjusted for these variables as well as time-varying CD4 cell count, HIV RNA, ART, and incident cardiovascular disorders through the use of inverse-probability weights.