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Coleman JS, Diniz CP, Fuchs EJ, Marzinke MA, Aung W, Bakshi RP, Farzadegan H, Bream JH, Nilles TL, Hudson S, Bumpus NN, Schwartz GJ, Rosenblum MA, Rooney JF, Hendrix CW. Interaction of Depot Medroxyprogesterone Acetate and Tenofovir Disoproxil Fumarate/Emtricitabine on Peripheral Blood Mononuclear Cells and Cervical Tissue Susceptibility to HIV Infection and Pharmacokinetics. J Acquir Immune Defic Syndr 2023; 92:89-96. [PMID: 36305827 PMCID: PMC9742287 DOI: 10.1097/qai.0000000000003113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/19/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Depot medroxyprogesterone acetate (DMPA) is a widely used contraceptive method. HIV pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate (F/TDF) is highly effective in reducing HIV acquisition in women. We sought to determine the impact of DMPA on F/TDF pharmacokinetics and pharmacodynamics. METHODS Twelve healthy premenopausal cisgender women were enrolled and each completed 4 sequential conditions: (1) baseline, (2) steady-state F/TDF alone, (3) steady-state F/TDF + DMPA, and (4) DMPA alone. Assessments included clinical, pharmacokinetic, viral infectivity (ex vivo challenge of peripheral blood mononuclear cells by X4- and R5-tropic green fluorescent protein pseudoviruses and cervical tissue by HIV BaL ), endocrine, immune cell phenotyping, and renal function. RESULTS Compared with baseline, F/TDF (± DMPA) significantly decreased both %R5- and X4-infected CD4 T cells and F/TDF + DMPA decreased cervical explant p24 (all P < 0.05). The %R5- and X4-infected CD4 T cells were higher during DMPA alone than during F/TDF periods and lower than baseline (not statistically significant). Cervical explant p24 fell between baseline and F/TDF values (not statistically significant). There were neither statistically significant differences in F/TDF pharmacokinetics, including total or renal clearance of either antiviral drug, nor changes in glomerular filtration rate with the addition of DMPA. There were few immune cell phenotypic differences across conditions. CONCLUSIONS F/TDF decreased HIV infection in both challenge assays, whereas DMPA alone did not enhance HIV infection in either challenge assay. DMPA did not alter F/TDF pharmacokinetics or renal function.
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Affiliation(s)
- Jenell S Coleman
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Clarissa P Diniz
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edward J Fuchs
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark A Marzinke
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wutyi Aung
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rahul P Bakshi
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Homayoon Farzadegan
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jay H Bream
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Tricia L Nilles
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Sherry Hudson
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Namandjé N Bumpus
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacology and Molecular Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - George J Schwartz
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Michael A Rosenblum
- Department of Biostatistics, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and
| | | | - Craig W Hendrix
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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Assessing the Potential Impact of Hormonal-Based Contraceptives on HIV Transmission Dynamics Among Heterosexuals. Bull Math Biol 2017; 79:738-771. [PMID: 28258539 DOI: 10.1007/s11538-017-0252-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
Abstract
HIV susceptibility linked to hormonal contraception (HC) has been studied before, but with mixed results. Reports from some of the recent findings have prompted the World Health Organisation to encourage women who use HC to concurrently use condoms in order to prevent HIV infection in the light of possible increased HIV risk of infection associated with hormone-based contraceptives. A two-sex HIV model classifying women into three risk groups consisting of individuals who use condoms, natural methods, and hormone-based contraceptives is formulated and analysed to assess the possible effects of various birth control strategies on the transmission dynamics of the disease. Our model results showed that women who use HC could be key drivers of the epidemic and that their increased infectivity may be critical in driving the epidemic. Women who use hormone-based contraceptives potentially act as a core group from which men get infected and in turn transmit the disease to other population groups. We fitted the model to HIV prevalence data for Zimbabwe reported by UNAIDS and Zimbabwe Ministry of Health and Child Care and used the model fit to project HIV prevalence. Predictions using HIV data for Zimbabwe suggest that a hypothesised increase in susceptibility and infectivity of two-, three-, and fourfold would result in a 25, 50, and 100% increase in baseline HIV prevalence projection, respectively, thus suggesting possible increased disease burden even in countries reporting plausible HIV prevalence declines. Although a possible causal relationship between HIV susceptibility and HC use remains subject of continuing scientific probe, its inclusion as part of birth control strategy has been shown in this study, to possibly increase HIV transmission. If proven, HC use may potentially explain the inordinate spread of HIV within the sub-Saharan Africa region and therefore compel for urgent assessment with a view to reorienting birth control methods in use in settings with generalised epidemics.
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Center KE, Gunn JKL, Asaolu IO, Gibson SJ, Ehiri JE. Contraceptive Use and Uptake of HIV-Testing among Sub-Saharan African Women. PLoS One 2016; 11:e0154213. [PMID: 27111915 PMCID: PMC4844155 DOI: 10.1371/journal.pone.0154213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/11/2016] [Indexed: 11/19/2022] Open
Abstract
Despite improved availability of simple, relatively inexpensive, and highly effective antiretroviral treatment for HIV/AIDS, the disease remains a major public health challenge for women in sub-Saharan Africa (SSA). Given the numerous barriers in access to care for women in this region, every health issue that brings them into contact with the health system should be optimized as an opportunity to integrate HIV/AIDS prevention. Because most non-condom forms of modern contraception require a clinical appointment for use, contraception appointments could provide a confidential opportunity for access to HIV counseling, testing, and referral to care. This study sought to investigate the relationship between contraceptive methods and HIV testing among women in SSA. Data from the Demographic and Health Survey from four African countries-Congo, Mozambique, Nigeria, and Uganda-was used to examine whether modern (e.g., pills, condom) or traditional (e.g., periodic abstinence, withdrawal) forms of contraception were associated with uptake of HIV testing. Data for the current analyses were restricted to 35,748 women with complete information on the variables of interest. Chi-square tests and logistic regression models were used to assess the relationship between uptake of HIV testing and respondents' baseline characteristics and contraceptive methods. In the total sample and in Mozambique, women who used modern forms of contraception were more likely to be tested for HIV compared to those who did not use contraception. This positive association was not demonstrated in Congo, Nigeria, or Uganda. That many women who access modern contraception are not tested for HIV in high HIV burden areas highlights a missed opportunity to deliver an important intervention to promote maternal and child health. Given the increasing popularity of hormonal contraception methods in low-income countries, there is an urgent need to integrate HIV counseling, testing, and treatment into family planning programs. Women on hormonal contraceptives should be encouraged to continue to use condoms for HIV-prevention.
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Affiliation(s)
- Katherine E. Center
- Department of Obstetrics and Gynecology, University of Arizona, Tucson, Arizona, United States of America
- Biomedical Research and Education Foundation of Southern Arizona, Tucson, Arizona, United States of America
| | - Jayleen K. L. Gunn
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Ibitola O. Asaolu
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Steven J. Gibson
- University of Arizona Cancer Center, Tucson, Arizona, United States of America
| | - John E. Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
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Ralph LJ, McCoy SI, Shiu K, Padian NS. Hormonal contraceptive use and women's risk of HIV acquisition: a meta-analysis of observational studies. THE LANCET. INFECTIOUS DISEASES 2015; 15:181-9. [PMID: 25578825 PMCID: PMC4526270 DOI: 10.1016/s1473-3099(14)71052-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The evidence from epidemiological research into whether use of hormonal contraception increases women's risk of HIV acquisition is inconsistent. We did a robust meta-analysis of existing data to provide summary estimates by hormonal contraceptive method which can be used to inform contraceptive guidelines, models, and future studies. METHODS We updated a recent systematic review to identify and describe studies that met inclusion criteria. To ensure inclusion of more recent research, we searched PubMed for articles published after December, 2011, using the terms "hormonal contraception", "HIV/acquisition", "injectables", "progestin", and "oral contraceptive pills". We assessed statistical heterogeneity for these studies, and, when appropriate, combined point estimates by hormonal contraception formulation using random-effects models. We assessed publication bias and investigated heterogeneity through subgroup and stratified analyses according to study population and design features. FINDINGS We identified 26 studies, 12 of which met inclusion criteria. There was evidence of an increase in HIV risk in the ten studies of depot medroxyprogesterone acetate (pooled hazard ratio [HR] 1·40, 95% CI 1·16-1·69). This risk was lower in the eight studies done in women in the general population (pooled HR 1·31, 95% CI 1·10-1·57). There was substantial between-study heterogeneity in secondary analyses of trials (n=7, I(2) 51·1%, 95% CI 0-79·3). Although individual study estimates suggested an increased risk, substantial heterogeneity between two studies done in women at high risk of HIV infection (I(2) 54%, 0-88·7) precluded pooling estimates. There was no evidence of an increased HIV risk in ten studies of oral contraceptive pills (pooled HR 1·00, 0·86-1·16) or five studies of norethisterone enanthate (pooled HR 1·10, 0·88-1·37). INTERPRETATION Our findings show a moderate increased risk of HIV acquisition for all women using depot medroxyprogesterone acetate, with a smaller increase in risk for women in the general population. Whether the risks of HIV observed in our study would merit complete withdrawal of depot medroxyprogesterone acetate needs to be balanced against the known benefits of a highly effective contraceptive. FUNDING None.
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Affiliation(s)
- Lauren J Ralph
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
| | - Sandra I McCoy
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Karen Shiu
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Nancy S Padian
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
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Abstract
BACKGROUND Concern about a possible association of hormonal contraception with HIV acquisition has been raised by three types of evidence. Firstly, high-dose progestogen treatment greatly increases HIV acquisition in female non-human primates. Secondly, biological plausibility for a link between hormonal contraception anf HIV acquisition is provided by evidence of a hypo-oestrogenic state induced by progestogen contraception with vaginal mucosal thinning, and evidence of effects on the humoral and cellular immune systems. Thirdly, some but not other large observational studies have found an increase in HIV acquisition among women using hormonal contraception. OBJECTIVES To determine, from the best available evidence, the effect of hormonal contraception on HIV acquisition. SEARCH METHODS We used the Cochrane Fertility Regulation Group trials search strategy. SELECTION CRITERIA Published, unpublished and ongoing trials with random allocation, comparing hormonal with non-hormonal methods, other hormonal methods or no contraception in women at risk of HIV acquisition. DATA COLLECTION AND ANALYSIS Data will be extracted from eligible trials onto a data extraction sheet and analysed using routine Cochrane Collaboration methodology, MAIN RESULTS One ongoing randomised trial was identified, with no data available to date. AUTHORS' CONCLUSIONS There is currently no robust evidence from randomized trials on the possible effect of hormonal contraception on HIV acquisition. High quality trials in this area are needed to inform counselling of individual woman and public health policy.
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Affiliation(s)
- G Justus Hofmeyr
- University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of HealthDepartment of Obstetrics and Gynaecology, East London Hospital ComplexFrere and Cecilia Makiwane HospitalsPrivate Bag X 9047East LondonEastern CapeSouth Africa5200
| | - Mandisa Singata
- University of the Witwatersrand/University of Fort Hare/East London Hospital complexEffective Care Research UnitEast LondonSouth Africa
| | - Jennifer Sneden
- University of CaliforniaGlobal Health Sciences50 Beale StreetSan FranciscoCaliforniaUSA94105
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Xu L, Dong B, Wang H, Zeng Z, Liu W, Chen N, Chen J, Yang J, Li D, Duan Y. Progesterone suppresses Th17 cell responses, and enhances the development of regulatory T cells, through thymic stromal lymphopoietin-dependent mechanisms in experimental gonococcal genital tract infection. Microbes Infect 2013; 15:796-805. [PMID: 23835188 DOI: 10.1016/j.micinf.2013.06.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 02/02/2023]
Abstract
In most female patients, the symptoms of genital infection due to Neisseria gonorrhoeae tend to be slight or even absent. Our previous studies suggested that progesterone might play a role in female asymptomatic gonococcal infection. In this study, we demonstrated that progesterone induced the expression of thymic stromal lymphopoietin (TSLP) and regulatory T cells (Treg)-related transcription factor Foxp3, and inhibited the expression of Th17 related transcription factor RORγt, and reduced the influx of neutrophils in murine vaginal gonococcal infection. Blockade of TSLP with antibody partially reversed the effects of progesterone on the murine model of gonococcal vaginal infection. In in vitro experiments, progesterone induced a rapid up-regulation of TSLP in vaginal epithelial cells stimulated with N. gonorrhoeae. Blocking thymic stromal lymphopoietin receptor (TSLPR) with a TSLPR monoclonal antibody partially prevented progesterone suppression of IL-17-producing T cells differentiation, and progesterone promotion of CD4⁺CD25⁺Foxp3⁺ regulatory T cells differentiation. Altogether, our results indicate that the progesterone suppresses Th17 cell responses, and enhances the development of Treg cells, through TSLP-dependent mechanisms, and play a role in female asymptomatic gonococcal infections.
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Affiliation(s)
- Li Xu
- Department of Dermatology, No.1 Hospital of Wuhan, Wuhan, China
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Delvaux T, Buvé A. Hormonal contraception and HIV acquisition - what is the evidence? What are the policy and operational implications? EUR J CONTRACEP REPR 2013; 18:15-26. [PMID: 23320932 DOI: 10.3109/13625187.2012.744819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Family planning (FP) is essential in achieving the United Nations Millennium Development Goals. We critically review the evidence on HIV acquisition among women using hormonal contraception, and discuss the policy and operational implications. METHODS Longitudinal studies conducted in sub-Saharan Africa published between 2008 and 2012, as well as key policy documents related to contraception and HIV were reviewed. RESULTS Findings on hormonal contraception and HIV acquisition conducted in sub- Saharan Africa are inconsistent. While in the large scale studies no statistically significant association between oral contraceptive use and HIV acquisition was found, results for injectables were mixed. Potential biases, such as those resulting from self-selection, related to the observational study design and main confounders such as condom use, sexual activity and contraceptive use are discussed. CONCLUSIONS It is currently not possible to conclude whether the use of hormonal contraceptives is associated with a greater risk of acquiring HIV, or not. The use of male or female condoms for dual protection should be promoted in FP programmes. While there is need for further research on a broader range of contraceptive methods and HIV transmission, studies documenting acceptability of currently less used/more recent contraceptive methods are also warranted.
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Affiliation(s)
- Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
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Fung KY, Mangan NE, Cumming H, Horvat JC, Mayall JR, Stifter S, De Weerd N, Roisman LC, Rossjohn J, Robertson S, Schjenken J, Parker B, Gargett C, Nguyen HPT, Carr DJ, Hansbro PM, Hertzog PJ. Interferon-ε protects the female reproductive tract from viral and bacterial infection. Science 2013; 339:1088-92. [PMID: 23449591 PMCID: PMC3617553 DOI: 10.1126/science.1233321] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The innate immune system senses pathogens through pattern-recognition receptors (PRRs) that signal to induce effector cytokines, such as type I interferons (IFNs). We characterized IFN-ε as a type I IFN because it signaled via the Ifnar1 and Ifnar2 receptors to induce IFN-regulated genes. In contrast to other type I IFNs, IFN-ε was not induced by known PRR pathways; instead, IFN-ε was constitutively expressed by epithelial cells of the female reproductive tract (FRT) and was hormonally regulated. Ifn-ε-deficient mice had increased susceptibility to infection of the FRT by the common sexually transmitted infections (STIs) herpes simplex virus 2 and Chlamydia muridarum. Thus, IFN-ε is a potent antipathogen and immunoregulatory cytokine that may be important in combating STIs that represent a major global health and socioeconomic burden.
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Affiliation(s)
- Ka Yee Fung
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Niamh E Mangan
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Helen Cumming
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Jay C Horvat
- Centre for Asthma and Respiratory Disease and Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Jemma R Mayall
- Centre for Asthma and Respiratory Disease and Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Sebastian Stifter
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Nicole De Weerd
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Laila C Roisman
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Jamie Rossjohn
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Sarah Robertson
- Robinson Institute and School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia
| | - John Schjenken
- Robinson Institute and School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia
| | - Belinda Parker
- Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Caroline Gargett
- Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Hong PT Nguyen
- Ritchie Centre, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
| | - Daniel J Carr
- Department of Ophthalmology, University of Oklahoma Health Sciences Centre, Oklahoma City, OK, USA
| | - Philip M Hansbro
- Centre for Asthma and Respiratory Disease and Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Paul J Hertzog
- Centre for Innate Immunity and Infectious Diseases, Monash Institute of Medical Research, Monash University, Clayton, Victoria, Australia
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Quantifying sexual exposure to HIV within an HIV-serodiscordant relationship: development of an algorithm. AIDS 2011; 25:1065-82. [PMID: 21537113 DOI: 10.1097/qad.0b013e328344fe4a] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The risk of acquiring HIV from a single sexual contact varies enormously reflecting biological and behavioural characteristics of both infected and uninfected partners. Accurate information on HIV transmission risk is required to construct evidence-based risk reduction practices for individuals, to direct the provision of prevention strategies at the population level, and enable the definition, quantification and comparison of true exposure in individuals termed 'exposed uninfected' within clinical trials. METHODS Following a systematic review of current literature on HIV transmission estimates, an HIV risk score was developed, incorporating weighted risk factors into a Bernoulli mathematical model, allowing quantification of overall risk of HIV acquisition within HIV-serodiscordant partnerships. RESULTS The HIV risk score enumerates the relative risk of HIV acquisition from HIV-positive partners incorporating the type and frequency of specific sex acts, the index case HIV plasma viral load and stage of disease, and the presence of genital ulcer disease in either partner and pregnancy, HSV-2 seropositivity, and circumcision status (men only) in the HIV-negative partner. CONCLUSION Key determinants of HIV exposure risk can be incorporated into a mathematical model in order to quantify individual relative risks of HIV acquisition. Such a model can facilitate comparisons within clinical trials of exposed uninfected individuals and facilitate interventions to reduce HIV transmission.
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Roccio M, Gardella B, Maserati R, Zara F, Iacobone D, Spinillo A. Low-dose combined oral contraceptive and cervicovaginal shedding of human immunodeficiency virus. Contraception 2010; 83:564-70. [PMID: 21570555 DOI: 10.1016/j.contraception.2010.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 10/17/2010] [Accepted: 10/18/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND The role of low-dose oral contraceptives on HIV cervicovaginal shedding among HIV-positive women is controversial. STUDY DESIGN We evaluated the effect of low-dose oral contraceptives on HIV cervicovaginal shedding in a cohort of 285 HIV-seropositive women followed for a median of 20 months. A sensitive, competitive polymerase chain reaction (cPCR) and a reverse transcription PCR (cRT-PCR) were applied for the quantification of HIV-associated and cell-free RNA and proviral DNA in cervicovaginal cells, as well as HIV-RNA in plasma. RESULTS In multivariable logistic generalized estimating equations, plasma viral load >100 copies/mL (OR=1.81, 95% CI=1.3-2.53) and bacterial vaginosis (OR=1.49, 95% CI=1.1-2.02) were associated with an increased risk of HIV-1 DNA shedding, whereas current use of oral contraceptive was associated with a reduced risk (OR=0.55, 95% CI=0.33-0.92). Oral contraceptives were also associated with a reduction of risk (OR=0.38, 95% CI=0.21-0.69) of cell-associated but not cell-free HIV-1 RNA. CONCLUSIONS In HIV-positive women with low levels of HIV viremia, low-dose oral contraceptives were associated with a modest but significant reduction of HIV-1 DNA and cell-associated HIV-1 RNA genital shedding.
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Affiliation(s)
- Marianna Roccio
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy.
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Hel Z, Stringer E, Mestecky J. Sex steroid hormones, hormonal contraception, and the immunobiology of human immunodeficiency virus-1 infection. Endocr Rev 2010; 31:79-97. [PMID: 19903932 PMCID: PMC2852204 DOI: 10.1210/er.2009-0018] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Worldwide, an increasing number of women use oral or injectable hormonal contraceptives. However, inadequate information is available to aid women and health care professionals in weighing the potential risks of hormonal contraceptive use in individuals living with HIV-1 or at high risk of infection. Numerous epidemiological studies and challenge studies in a rhesus macaque model suggest that progesterone-based contraceptives increase the risk of HIV-1 infection in humans and simian immunodeficiency virus (SIV) infection in macaques, accelerate disease progression, and increase viral shedding in the genital tract. However, because several other studies in humans have not observed any effect of exogenously administered progesterone on HIV-1 acquisition and disease progression, the issue continues to be a topic of intense research and ongoing discussion. In contrast to progesterone, systemic or intravaginal treatment with estrogen efficiently protects female rhesus macaques against the transmission of SIV, likely by enhancing the natural protective properties of the lower genital tract mucosal tissue. Although the molecular and cellular mechanisms underlying the effect of sex steroid hormones on HIV-1 and SIV acquisition and disease progression are not well understood, progesterone and estrogen are known to regulate a number of immune mechanisms that may exert an effect on retroviral infection. This review summarizes current knowledge of the effects of various types of sex steroid hormones on immune processes involved in the biology of HIV-1 infection.
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Affiliation(s)
- Zdenek Hel
- Department of Pathology, University of Alabama at Birmingham, 845 19th Street South, Birmingham, Alabama 35294-2170, USA.
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12
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Stringer EM, Giganti M, Carter RJ, El-Sadr W, Abrams EJ, Stringer JS. Hormonal contraception and HIV disease progression: a multicountry cohort analysis of the MTCT-Plus Initiative. AIDS 2009; 23 Suppl 1:S69-77. [PMID: 20081390 PMCID: PMC3865610 DOI: 10.1097/01.aids.0000363779.65827.e0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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.
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Sexual transmission of HIV-1. Antiviral Res 2009; 85:276-85. [PMID: 19874852 DOI: 10.1016/j.antiviral.2009.10.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 10/02/2009] [Accepted: 10/16/2009] [Indexed: 12/18/2022]
Abstract
HIV-1 transmission occurs in a limited number of ways all of which are preventable. Overall, the risk of HIV-1 transmission following a single sexual exposure is low especially in comparison with other sexually transmitted infections (STIs); with estimates of the average probability of male to female HIV-1 transmission only 0.0005-0.0026 per coital act. The risk of acquiring HIV-1 from a single contact varies enormously and is dependant upon the infectiousness of the HIV-1 positive individual and the susceptibility to HIV-1 of their sexual partner. An understanding of the determinants of HIV-1 transmission is important not only to assess the infection risk to an individual when exposed to the virus (e.g. to determine the provision of post exposure prophylaxis), but also to make accurate predictions on the potential spread of HIV-1 infection in a population and to direct appropriate targeted prevention strategies. In this review article we summarise the current literature on the major worldwide source of HIV-1 acquisition, sexual transmission. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of antiretroviral drug discovery and development, Vol 85, issue 1, 2010.
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Tacconelli E, Cataldo MA. Identifying risk factors for infections: the role of meta-analyses. Infect Dis Clin North Am 2009; 23:211-24. [PMID: 19393906 DOI: 10.1016/j.idc.2009.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Systematic review and meta-analysis are assuming greater importance in influencing policy makers and clinical opinion worldwide. Many discussions and publications have considered the merits of meta-analysis of epidemiologic data.50 Some observers suggest that meta-analysis of observational studies should be abandoned altogether. 51 In the authors' opinion, statistical combination of observational studies should not be a primary goal of a review. Analysis of heterogeneity between longitudinal studies, however, would provide more insights than mathematical calculation of the summary risk. Meta-analyses of risk factors for infections should strictly follow guidelines for meta-analyses of observational studies. A study protocol should be written in advance, completed literature searches performed, and studies selected in a reproducible and objective fashion. Biologic plausibility must be addressed. The reported findings should be interpreted with caution, taking into account the limitations of various methodologic aspects of risk factors studies. An important role for meta-analyses in this field would be to clarify hypotheses to be formulated for future Identifying Risk Factors for Infections 221 studies and stress limitations strictly related to studies on risk factors for bacterial and viral infections.
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Affiliation(s)
- Evelina Tacconelli
- Department of Infectious Diseases, UniversitA Cattolica Sacro Cuore, Roma, Italy.
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15
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Highly effective contraception and acquisition of HIV and other sexually transmitted infections. Best Pract Res Clin Obstet Gynaecol 2009; 23:263-84. [DOI: 10.1016/j.bpobgyn.2008.11.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 11/13/2008] [Accepted: 11/14/2008] [Indexed: 11/22/2022]
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Sheffield JS, Wendel GD, McIntire DD, Norgard MV. The effect of progesterone levels and pregnancy on HIV-1 coreceptor expression. Reprod Sci 2009; 16:20-31. [PMID: 19144888 DOI: 10.1177/1933719108325510] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The upregulation of HIV-1 co-receptor expression during certain clinical settings may explain the predisposition of individuals to enhanced HIV-1 acquisition. We sought to determine the effect of estrogen and progesterone on the HIV-1 coreceptors, CCR5 and CXCR4. Co-receptor expression on CD3- and CD14-positive cells obtained systemically and locally (genital tissue in women) was determined in men, pre- and post-menopausal women, pregnant women in each trimester and in labor. CCR5 on both CD3- and CD14-positive cells was highest in pregnant women, and increased as gestation advanced ( P < .01 and P < .001, respectively). Progesterone levels were significantly associated with CCR5 expression on PBMCs ( P < .03 for CD3-positive, and P < .002 for CD14-positive cells) and from cells isolated from tissue ( P < .001).CCR5 mRNA expression correlated with the cell surface marker expression from blood and tissue. These findings suggest that pregnancy and other high progesterone states may predispose women to HIV-1 acquisition.
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Affiliation(s)
- Jeanne S Sheffield
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390, USA. Jeanne.Sheffield@ utsouthwestern.edu
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Abstract
In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.
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Affiliation(s)
- Helen E Cejtin
- Department of Obstetrics and Gynecology, John H. Stroger Jr Hospital of Cook County (formerly Cook County Hospital), 1901 W. Harrison, Chicago, IL 60612, USA.
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Vulnerability of women in southern Africa to infection with HIV: biological determinants and priority health sector interventions. AIDS 2008; 22 Suppl 4:S27-40. [PMID: 19033753 DOI: 10.1097/01.aids.0000341775.94123.75] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review biomedical determinants of women's vulnerability to infection with HIV and interventions to counter this, within the southern African context. RESULTS Apart from number of exposures, if any, several factors influence the efficiency of HIV transmission during sex. Acute HIV infection, with extraordinarily high semen viral load, in conjunction with concurrent partnerships maximizes this efficiency. Delaying sexual debut and avoiding HIV exposure among biologically and socially vulnerable youth is critical. Reducing unintended pregnancies keeps girls in school and prevents vertical (also possibly horizontal) transmission. Female condoms, especially newer versions, are an under-exploited prevention technology. Control of sexually transmitted infections (STI), which facilitate HIV acquisition and transmission, remains important, especially among the most at-risk populations. Pathogens, such as herpes simplex virus type 2, which contribute most to HIV transmission in southern Africa must be targeted, although the importance of bacterial vaginosis and Trichomonas vaginalis is under-recognized. Also, heavy episodic alcohol use affects sexual decision-making and condom skills. Moreover, prevailing social contexts, partly a consequence of poor leadership, constrain the behavioural 'choices' available for girls and women. CONCLUSIONS Priority health sector interventions for preventing HIV are: male and female condom programming; prevention and control of STI; outreach to most vulnerable populations; HIV testing in all patient-provider encounters; male circumcision; and the integration of HIV prevention within sexual and reproductive health services. Future interventions during acute HIV infection and microbicides will reduce women's biological vulnerability. Far-reaching measures, such as sexual equity and alcohol control, create conditions necessary for achieving sustained prevention results. These are, however, contingent on stronger, more informed cultural and political leadership.
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Abstract
The majority of the 15.4 million human immunodeficiency virus (HIV)-infected women worldwide are of child-bearing age and need access to contraception. Hormonal methods of contraception are safe, acceptable, and effective in preventing unwanted pregnancies. Many published studies have examined the impact of hormonal contraception on HIV disease acquisition and transmissibility. Far fewer have investigated the relationship between hormonal contraception and HIV disease progression. This review examines available data on this relationship from clinical, animal, and immunological studies. Several clinical studies suggest an overall effect but are not definitive, and the mechanisms behind HIV disease progression are unclear. Animal and immunological data suggest that immunomodulation by hormonal contraceptive methods may affect the immune response to HIV infection. Additional work is needed in this area to elucidate the possible relationship between hormonal methods for birth control and progression to acquired immunodeficiency syndrome in HIV-infected women.
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Affiliation(s)
- Elizabeth Stringer
- Department of Obstetrics and Gynecology, Division of International Women's Health, University of Alabama at Birmingham, USA.
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Leclerc PM, Dubois-Colas N, Garenne M. Hormonal contraception and HIV prevalence in four African countries. Contraception 2008; 77:371-6. [DOI: 10.1016/j.contraception.2008.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 01/14/2008] [Accepted: 01/14/2008] [Indexed: 10/22/2022]
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Allen S, Stephenson R, Weiss H, Karita E, Priddy F, Fuller L, Declercq A. Pregnancy, hormonal contraceptive use, and HIV-related death in Rwanda. J Womens Health (Larchmt) 2007; 16:1017-27. [PMID: 17903079 DOI: 10.1089/jwh.2006.0151] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies have examined the influence of pregnancy and hormonal contraception on HIV-related deaths in African women. Rwanda is a country with high fertility, high HIV prevalence, and frequent use of hormonal contraception in urban areas. METHODS Data from a prospective cohort study of 460 HIV-infected urban childbearing (18-35 years) women followed at 6-monthly intervals for 6 years in Kigali, Rwanda, were analyzed. The relationship of time-dependent measures of pregnancy and hormonal contraceptive use to death from HIV disease was assessed with multivariate models. RESULTS Incident pregnancy was not associated with elevated risk of death among HIV-infected women. Oral and injectable hormonal contraceptive use had borderline protective effects associated with reduced mortality (HR 0.40, 95% CI 0.15-1.07 and HR 0.48, 95% CI 0.21-1.08 for mortality, respectively) in a multivariate model including time-dependent measures. CONCLUSIONS The results point to the benefits of integrating family planning and HIV services. In a highly pronatalist society, such as Rwanda, which is experiencing high HIV prevalence, service integration affords an opportunity to provide HIV testing to women at risk of pregnancy and to promote family planning among HIV-positive women.
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Affiliation(s)
- Susan Allen
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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22
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Baeten JM, Benki S, Chohan V, Lavreys L, McClelland RS, Mandaliya K, Ndinya-Achola JO, Jaoko W, Overbaugh J. Hormonal contraceptive use, herpes simplex virus infection, and risk of HIV-1 acquisition among Kenyan women. AIDS 2007; 21:1771-7. [PMID: 17690576 DOI: 10.1097/qad.0b013e328270388a] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies of the effect of hormonal contraceptive use on the risk of HIV-1 acquisition have generated conflicting results. A recent study from Uganda and Zimbabwe found that women using hormonal contraception were at increased risk for HIV-1 if they were seronegative for herpes simplex virus type 2 (HSV-2), but not if they were HSV-2 seropositive. OBJECTIVE To explore the effect of HSV-2 infection on the relationship between hormonal contraception and HIV-1 in a high-risk population. Hormonal contraception has previously been associated with increased HIV-1 risk in this population. METHODS Data were from a prospective cohort study of 1206 HIV-1 seronegative sex workers from Mombasa, Kenya who were followed monthly. Multivariate Cox proportional hazards analyses were used to adjust for demographic and behavioral measures and incident sexually transmitted diseases. RESULTS : Two hundred and thirty-three women acquired HIV-1 (8.7/100 person-years). HSV-2 prevalence (81%) and incidence (25.4/100 person-years) were high. In multivariate analysis, including adjustment for HSV-2, HIV-1 acquisition was associated with use of oral contraceptive pills [adjusted hazard ratio (HR), 1.46; 95% confidence interval (CI), 1.00-2.13] and depot medroxyprogesterone acetate (adjusted HR, 1.73; 95% CI, 1.28-2.34). The effect of contraception on HIV-1 susceptibility did not differ significantly between HSV-2 seronegative versus seropositive women. HSV-2 infection was associated with elevated HIV-1 risk (adjusted HR, 3.58; 95% CI, 1.64-7.82). CONCLUSIONS In this group of high-risk African women, hormonal contraception and HSV-2 infection were both associated with increased risk for HIV-1 acquisition. HIV-1 risk associated with hormonal contraceptive use was not related to HSV-2 serostatus.
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Affiliation(s)
- Jared M Baeten
- Seattle HIV Prevention Trials Unit, Department of Medicine, University of Washington, 9012 Boren Avenue, Seattle, WA 98104, USA.
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Baeten JM, Lavreys L, Overbaugh J. The influence of hormonal contraceptive use on HIV-1 transmission and disease progression. Clin Infect Dis 2007; 45:360-9. [PMID: 17599316 DOI: 10.1086/519432] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Accepted: 04/04/2007] [Indexed: 11/03/2022] Open
Abstract
Women account for nearly one-half of new human immunodeficiency virus type 1 (HIV-1) infections worldwide, including the majority of infections in Africa. Biological and epidemiological studies suggest that hormonal contraceptive use could influence susceptibility to HIV-1, as well as infectivity and disease progression for those who become infected. However, not all studies have shown this relationship, and many questions remain. Safe and effective contraceptive choices are essential for women with and at risk for HIV-1 infection. Thus, understanding the effect, if any, of hormonal contraception on HIV-1 disease among women is a public health priority.
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Affiliation(s)
- Jared M Baeten
- Department of Medicine, University of Washington, Seattle, WA, USA.
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Kleinschmidt I, Rees H, Delany S, Smith D, Dinat N, Nkala B, McIntyre JA. Injectable progestin contraceptive use and risk of HIV infection in a South African family planning cohort. Contraception 2007; 75:461-7. [PMID: 17519153 DOI: 10.1016/j.contraception.2007.02.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Revised: 02/14/2007] [Accepted: 02/14/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate whether the incidence of HIV infection is higher among sexually active women using depot medroxyprogesterone acetate (DMPA) or noresthisterone enanthate (NET-EN) injections for contraception than among women using nonhormonal or no contraception. METHODS Five hundred and fifty-one initially HIV-negative women were followed up for a total of 491 person-years. Participants were interviewed, counselled, examined, tested for HIV and other STIs, and treated, at three monthly intervals for 1 year. RESULTS There was no significant association between progestin contraceptive use and HIV infection (rate ratio 1.1, 95% CI 0.5 to 2.8; log-rank test, p=.73). In proportional hazards regression, the only significant hazard ratios for HIV acquisition were prevalent Neisseria gonorrhoea (5.2; 95% CI 1.1 to 23.7, p=.035) and Trichomonas vaginalis (4.8; 95% CI 1.0 to 22.8, p=.049); bacterial vaginosis was marginally significant (2.8; 95% CI 1.0 to 8.3, p=.057). The adjusted hazard ratios for NET-EN and DMPA were 1.76 (95% CI 0.64 to 4.84) and 0.46 (95% CI 0.06 to 3.79), respectively, relative to nonuse. Five hundred and twelve of 551 women had one or more confirmed STIs during the study. CONCLUSIONS There is no evidence of an association between HIV infection and injectable contraceptives. Due to the limited power of this study and because similar studies have not included young women using NET-EN, we recommend that further research be carried out to focus on the use of NET-EN and HIV acquisition in high risk groups.
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Affiliation(s)
- Immo Kleinschmidt
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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25
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Morrison CS. Commentary: Hormonal contraception and HIV acquisition--current evidence and ongoing research needs. Int J Epidemiol 2007; 36:175-7. [PMID: 17251242 DOI: 10.1093/ije/dyl304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
MESH Headings
- Adult
- Age Distribution
- Contraceptives, Oral/administration & dosage
- Contraceptives, Oral/adverse effects
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Epidemiologic Research Design
- Female
- HIV Infections/epidemiology
- HIV Infections/etiology
- HIV Infections/transmission
- Humans
- Middle Aged
- Risk Factors
- Sexually Transmitted Diseases/epidemiology
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Affiliation(s)
- Charles S Morrison
- Family Health International, PO Box 13950, Research Triangle Park, NC 27709, USA.
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Morrison CS, Richardson BA, Mmiro F, Chipato T, Celentano DD, Luoto J, Mugerwa R, Padian N, Rugpao S, Brown JM, Cornelisse P, Salata RA. Hormonal contraception and the risk of HIV acquisition. AIDS 2007; 21:85-95. [PMID: 17148972 DOI: 10.1097/qad.0b013e3280117c8b] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined oral contraceptives (COC) and depot-medroxyprogesterone acetate (DMPA) are among the most widely used family planning methods; their effect on HIV acquisition is not known. OBJECTIVE To evaluate the effect of COC and DMPA on HIV acquisition and any modifying effects of other sexually transmitted infections. METHODS This multicenter prospective cohort study enroled 6109 HIV-uninfected women, aged 18-35 years, from family planning clinics in Uganda, Zimbabwe and Thailand. Participants received HIV testing quarterly for 15-24 months. The risk of HIV acquisition with different contraceptive methods was assessed (excluding Thailand, where there were few HIV cases). RESULTS HIV infection occurred in 213 African participants (2.8/100 woman-years). Use of neither COC [hazard ratio (HR), 0.99; 95% confidence interval (CI), 0.69-1.42] nor DMPA (HR, 1.25; 95% CI, 0.89-1.78) was associated with risk of HIV acquisition overall, including among participants with cervical or vaginal infections. While absolute risk of HIV acquisition was higher among participants who were seropositive for herpes simplex virus 2 (HSV-2) than in those seronegative at enrolment, among the HSV-2-seronegative participants, both COC (HR, 2.85; 95% CI, 1.39-5.82) and DMPA (HR, 3.97; 95% CI, 1.98-8.00) users had an increased risk of HIV acquisition compared with the non-hormonal group. CONCLUSIONS No association was found between hormonal contraceptive use and HIV acquisition overall. This is reassuring for women needing effective contraception in settings of high HIV prevalence. However, hormonal contraceptive users who were HSV-2 seronegative had an increased risk of HIV acquisition. Additional research is needed to confirm and explain this finding.
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Affiliation(s)
- Charles S Morrison
- Clinical Research Department, Family Health International, Research Triangle Park, North Carolina, USA.
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Bulterys M, Smith D, Chao A, Jaffe H. Hormonal contraception and incident HIV-1 infection: new insight and continuing challenges. AIDS 2007; 21:97-9. [PMID: 17148973 DOI: 10.1097/qad.0b013e3280117cb5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trunova N, Tsai L, Tung S, Schneider E, Harouse J, Gettie A, Simon V, Blanchard J, Cheng-Mayer C. Progestin-based contraceptive suppresses cellular immune responses in SHIV-infected rhesus macaques. Virology 2006; 352:169-77. [PMID: 16730772 DOI: 10.1016/j.virol.2006.04.004] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Revised: 03/08/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
Nine rhesus macaques in groups of three received a single dose of the injectable progestin-based contraceptive Depo-Provera 5 weeks prior to challenge intravaginally with varying doses of a mixture of the pathogenic CXCR4 (X4)-SHIV(SF33A) and CCR5 (R5)-SHIV(SF162P3) isolates. As controls, seven Depo-naive animals were inoculated once with a high-dose of the mixed inoculum. Irrespective of inoculum dose, acute viremia was higher in the Depo-treated than in the Depo-naive animals. Further, genetic complexity of the replicating virus was greater and replication of the X4 virus was favored in dually infected animals treated with Depo-Provera. Analysis of cellular immune responses revealed slower response rates in virus-specific IFN-gamma production to SIV Gag in the Depo-treated macaques. The immunosuppressive effect of Depo-Provera on mounting an antiviral cellular immune response may account for the increase viral burden and diversity, and the predominance of X4 virus replication in SHIV infected macaques that were administered the progestin-based contraceptive.
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Affiliation(s)
- Nataliya Trunova
- Aaron Diamond AIDS Research Center, The Rockefeller University, 455 First Ave, 7th Floor, New York, NY 10016, USA
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Roye C, Perlmutter Silverman P, Krauss B. A brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents: a randomized clinical trial. HEALTH EDUCATION & BEHAVIOR 2006; 34:608-21. [PMID: 16740522 DOI: 10.1177/1090198105284840] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
HIV/AIDS disproportionately affects young women of color. Young women who use hormonal contraception are less likely to use condoms. Brief, inexpensive HIV-prevention interventions are needed for high-volume clinics. This study was a randomized clinical trial of two interventions: (a) a video made for this study and (b) an adaptation of Project RESPECT counseling. Four hundred Black and Latina teenage women completed a questionnaire about their sexual behaviors and were randomly assigned to (a) see the video, (b) get counseling, (c) see the video and get counseling, or (d) receive usual care. At 3-month follow-up, those who saw the video and received counseling were 2.5 times more likely to have used a condom at last intercourse with their main partner than teens in the usual care group. These differences did not persist at 12-month follow-up. This suggests that a brief intervention can positively affect condom use in the short term.
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Affiliation(s)
- Carol Roye
- Hunter College, New York, New York, USA.
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HIV Infection and AIDS. Sex Transm Dis 2006. [DOI: 10.1007/978-1-59745-040-9_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Martin HL, Richardson BA, Mandaliya K, Achola JO, Overbaugh J, Kreiss JK. The early work on hormonal contraceptive use and HIV acquisition. J Acquir Immune Defic Syndr 2005; 38 Suppl 1:S12-4. [PMID: 15867600 DOI: 10.1097/01.qai.0000167027.33525.1c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Baeten JM, Lavreys L, Sagar M, Kreiss JK, Richardson BA, Chohan B, Panteleeff D, Mandaliya K, Ndinya-Achola JO, Overbaugh J, Farley T, Mwachari C, Cohen C, Chipato T, Jaisamrarn U, Kiriwat O, Duerr A. Effect of Contraceptive Methods on Natural History of HIV: Studies from the Mombasa Cohort. J Acquir Immune Defic Syndr 2005; 38 Suppl 1:S18-21. [PMID: 15867603 DOI: 10.1097/01.qai.0000167030.18278.0e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prakash M, Patterson S, Gotch F, Kapembwa MS. Ex vivo analysis of HIV-1 co-receptors at the endocervical mucosa of women using oral contraceptives. BJOG 2004; 111:1468-70. [PMID: 15663139 DOI: 10.1111/j.1471-0528.2004.00283.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Combined oral contraceptives may alter the microenvironment of the female genital tract and, thus, influence susceptibility of endocervical cells to HIV-1 transmission. The mechanism for this effect is unknown but might involve combined oral contraceptive up-regulation of chemokine receptors on CD4+ endocervical cells. We measured chemokine co-receptor (CCR5 and CXCR4) expression on cervical intraepithelial CD4+ T lymphocytes, macrophages and dendritic cells using flow cytometry in 32 healthy women, 16 of whom were combined oral contraceptive users and 16 non-users. All women tested negative for sexually transmitted infections. Combined oral contraceptive users showed a higher proportion of CCR5+ CD4+ T lymphocytes compared with combined oral contraceptive non-users (P < 0.05). However, expression of both co-receptors on cervical intraepithelial macrophages and dendritic cells was no different between the two groups. Up-regulation of CCR5 on cervical intraepithelial CD4+ T lymphocytes offers a potential explanation by which women receiving combined oral contraceptives may be at increased risk of HIV transmission.
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Affiliation(s)
- Manyu Prakash
- Department of GU/HIV Medicine, Imperial College of Science, Technology and Medicine, Northwick Park Hospital, Harrow, Middlesex, UK
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Lavreys L, Baeten JM, Martin HL, Overbaugh J, Mandaliya K, Ndinya-Achola J, Kreiss JK. Hormonal contraception and risk of HIV-1 acquisition: results of a 10-year prospective study. AIDS 2004; 18:695-7. [PMID: 15090778 DOI: 10.1097/00002030-200403050-00017] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ludo Lavreys
- Departments of Epidemiology and Medicine, University of Washington, Seattle, WA, USA
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Sagar M, Lavreys L, Baeten JM, Richardson BA, Mandaliya K, Ndinya-Achola JO, Kreiss JK, Overbaugh J. Identification of modifiable factors that affect the genetic diversity of the transmitted HIV-1 population. AIDS 2004; 18:615-9. [PMID: 15090766 DOI: 10.1097/00002030-200403050-00005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our previous studies have shown that the majority of African women were infected with multiple HIV-1 genetic variants, while in the remaining women only a single viral genotype was detected early in infection. Infection with multiple viral variants was associated with higher plasma HIV-1 RNA levels and faster CD4 T-cell decline. METHOD Socio-behavioral characteristics, use of hormonal contraceptives, and the presence of sexually transmitted diseases were prospectively assessed at approximately monthly intervals around the time of HIV-1 acquisition in female sex workers in Kenya. We assessed the relationship between these factors and HIV-1 genetic complexity early in infection. RESULTS One hundred and fifty-six women were included in this analysis, of whom 89 had multiple viral genotypes and 67 had a single genotype at primary infection. Women with multiple variants were more likely to have a genital tract infection [odds ratio (OR), 4.7; 95% confidence interval (CI), 1.4-18.1] or to be using hormonal contraceptives (OR, 2.7; 95% CI, 1.3-5.6) at the time of their infection than those with a single variant. In multivariate analyses, these factors were independent predictors of early HIV-1 genetic complexity, and the presence of multiple viral variants early in infection remained significantly associated with a higher steady state plasma HIV-1 RNA level. CONCLUSION The presence of genital tract infections and hormonal contraceptive use at the time of transmission were associated with the acquisition of multiple HIV-1 variants.
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Affiliation(s)
- Manish Sagar
- Division of Human Biology, Fred Hutchinson Cancer Research Center, University of Washington, 1100 Fairview Avenue, Seattle, WA 98109, USA
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Wang CC, McClelland RS, Overbaugh J, Reilly M, Panteleeff DD, Mandaliya K, Chohan B, Lavreys L, Ndinya-Achola J, Kreiss JK. The effect of hormonal contraception on genital tract shedding of HIV-1. AIDS 2004; 18:205-9. [PMID: 15075537 DOI: 10.1097/00002030-200401230-00009] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A previous cross-sectional study reported that hormonal contraception may be associated with increased infectivity in HIV-1 infected women. We conducted a prospective study to determine if cervical shedding of HIV-1 increased after initiating hormonal contraception. DESIGN Shedding of HIV-1 DNA (a marker of HIV-1 infected cells) and HIV-1 RNA were measured before and after initiating hormonal contraception. METHODS HIV-1 seropositive women were recruited from a Kenyan family planning clinic. At baseline, cervical secretions were collected for HIV-1 DNA and RNA assays in women initiating hormonal contraception; follow-up samples were collected a median of 64 days later. RESULTS One-hundred and one women chose depot medroxyprogesterone (Depo), 53 chose low-dose oral contraceptives (OC), seven high-dose OC, and 52 progesterone-only OC. At follow-up, there was a significant increase in the prevalence of cervical HIV-1 DNA detection [from 42% to 52%, odds ratio (OR), 1.62; 95% confidence interval (CI), 1.03-2.63) for all hormonal contraception combined, and a trend for an increase for each individual type. Although the prevalence of cervical HIV-1 RNA increased slightly (from 82% to 86%; OR, 1.56; 95% CI, 0.83-3.03), the concentration of cervical HIV-1 RNA did not change significantly overall (from 2.81 to 2.84 log10 copies/swab; P = 0.77) or for individual contraception types. CONCLUSIONS A modest but significant increase in shedding of HIV-1 DNA but not of HIV-1 RNA was detected after starting hormonal contraception. Our results may have important implications regarding the infectivity of women using hormonal contraception, and highlight the need for epidemiologic studies of transmission rates from women using and not using hormonal contraception.
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Affiliation(s)
- Chia C Wang
- Department of Medicine, University of Washington, Seattle, Washington 98104-2499, USA
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37
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Heard I, Palefsky JM, Kazatchkine MD. The Impact of HIV Antiviral Therapy on Human Papillomavirus (Hpv) Infections and Hpv-Related Diseases. Antivir Ther 2004. [DOI: 10.1177/135965350400900117] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Human papillomavirus (HPV) infections play an important role in the pathogenesis of anogenital cancer and its precursors. HIV-infected individuals exhibit a high prevalence of HPV DNA. Several studies have further shown that HIV-infected individuals have an increased prevalence of squamous intraepithelial lesions (SIL) of the cervix, vulva and anus. The incidence of invasive cervical cancer is also elevated in HIV-positive women as well as that of anal cancer in HIV-positive women and men. Given the relationship between HIV-induced immunosuppression and HPV-associated disease, treatment with highly active antiretroviral therapy (HAART) has the potential, through immune reconstitution of the host, to alter the natural history of HPV infection and SIL. However, data on the impact of HAART on HPV disease are sparse and mixed results have been reported.
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Affiliation(s)
- Isabelle Heard
- Institut National de la Santé et de la Recherche Médicale (Inserm) U430 and Unité d'Immunologie Clinique, Hôpital Européen G Pompidou, Paris, France
| | - Joel M Palefsky
- Department of Medicine, Laboratory Medicine and Stomatology, University of California, San Francisco, San Francisco, Calif., USA
| | - Michel D Kazatchkine
- Institut National de la Santé et de la Recherche Médicale (Inserm) U430 and Unité d'Immunologie Clinique, Hôpital Européen G Pompidou, Paris, France
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Abstract
Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.
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Affiliation(s)
- Helen E Cejtin
- Department of Obstetrics and Gynecology, John H. Stroger Jr. Hospital of Cook County, 1901 W. Harrison, Chicago, IL 60612, USA.
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39
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Delvaux T, Crabbé F, Seng S, Laga M. The need for family planning and safe abortion services among women sex workers seeking STI care in Cambodia. REPRODUCTIVE HEALTH MATTERS 2003; 11:88-95. [PMID: 12800706 DOI: 10.1016/s0968-8080(03)02163-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method--5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n = 1744) and 21.9% (n = 588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.
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Affiliation(s)
- Thérèse Delvaux
- STD/HIV Research and Intervention Unit, Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium.
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40
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Coombs RW, Reichelderfer PS, Landay AL. Recent observations on HIV type-1 infection in the genital tract of men and women. AIDS 2003; 17:455-80. [PMID: 12598766 DOI: 10.1097/00002030-200303070-00001] [Citation(s) in RCA: 181] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Robert W Coombs
- Departments of Laboratory Medicine and Medicine, University of Washington, Seattle, Washington, USA
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41
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Abstract
The purpose of this article is to review the gynecologic conditions encountered among women with HIV and to outline elements of gynecologic care for these women. The most prevalent problems are vulvo-vaginal candidiasis and cervical dysplasia; however, other sexually transmitted diseases, pelvic inflammatory disease, genital ulcer disease, and menstrual abnormalities are also seen. Drug interactions may limit the effectiveness or increase the toxicities associated with hormonal contraception. Intrauterine devices are contraindicated.
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42
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Politch JA, Anderson DJ. Use of assisted reproductive technology to prevent the transmission of HIV-1 in HIV-discordant couples desiring children. Immunol Allergy Clin North Am 2002. [DOI: 10.1016/s0889-8561(02)00020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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43
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44
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Exploring the Context of Women's Relationship Perceptions, Sexual Behavior, and Contraceptive Strategies. ACTA ACUST UNITED AC 2002. [DOI: 10.1300/j056v13n02_01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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45
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Røttingen JA, Cameron DW, Garnett GP. A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known? Sex Transm Dis 2001; 28:579-97. [PMID: 11689757 DOI: 10.1097/00007435-200110000-00005] [Citation(s) in RCA: 387] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many studies have explored the role of "classic" sexually transmitted diseases (STDs) in determining the pattern of HIV epidemics. However, the many different STDs may contribute in different ways, at different magnitudes. GOAL To review available studies on the bidirectional interactions of HIV and STDs to explore the extent of current knowledge on the different influences of the varied STDs in heterosexual HIV epidemics. METHODS Longitudinal studies on susceptibility and controlled studies on infectiousness and duration of disease identified on electronic databases through reference lists and citation indices up to the end of 1999 were systematically reviewed, including meta-analyses assessing the influence of STDs on susceptibility to HIV. RESULTS Studies have a clear publication bias with a significant result that hinders robust interpretation. However, genital ulcerative disease appears to have a greater impact than nonulcerative disease, and men are more affected than women by the effects of STDs on susceptibility to HIV. There is evidence that STDs increase the infectiousness of HIV from men to women, whereas the evidence is more equivocal for the infectiousness of women. Few studies identify the impact of different STDs, and there is a marked lack of studies investigating the impact of HIV infection on the transmission of other STDs. CONCLUSIONS A large body of work has measured the association between STDs and HIV. However, publication bias and gaps in the focus of studies mean that a detailed, quantitative understanding of the interaction requires much more attention.
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Affiliation(s)
- J A Røttingen
- Department of Infectious Disease Epidemiology, Imperial College School of Medicine at St Mary's, London, United Kingdom.
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46
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Brabin L. Hormonal markers of susceptibility to sexually transmitted infections: are we taking them seriously? BMJ (CLINICAL RESEARCH ED.) 2001; 323:394-5. [PMID: 11509437 PMCID: PMC1120986 DOI: 10.1136/bmj.323.7309.394] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- L Brabin
- Academic Unit of Obstetrics and Gynaecology and Reproductive Health Care, St Mary's Hospital, Manchester M13 0JH.
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47
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Altman DG. Systematic reviews of evaluations of prognostic variables. BMJ (CLINICAL RESEARCH ED.) 2001; 323:224-8. [PMID: 11473921 PMCID: PMC1120839 DOI: 10.1136/bmj.323.7306.224] [Citation(s) in RCA: 542] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- D G Altman
- Imperial Cancer Research Fund Medical Statistics Group, Centre for Statistics in Medicine, Institute of Health Sciences, Oxford OX3 7LF
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48
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Affiliation(s)
- A P Korn
- University of California, San Francisco, California, USA
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49
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Bahamondes L, Trevisan M, Andrade L, Marchi NM, Castro S, Díaz J, Faúndes A. The effect upon the human vaginal histology of the long-term use of the injectable contraceptive Depo-Provera. Contraception 2000; 62:23-7. [PMID: 11024225 DOI: 10.1016/s0010-7824(00)00132-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of the study was to evaluate the effect of long-term use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) on human vaginal histology. Twenty premenopausal women currently using DMPA as a contraceptive method for two and three years were compared with 20 regularly menstruating women, who never used Depo-Provera and/or other kind of hormonal contraceptive in the last 6 months prior to the study. Subjects and controls were matched by age (+/-1 year), body mass index (kg/m2) (+/-1.0), number of pregnancies (+/-1), age at first intercourse (+/-1 year), years of sexual activity (+/-1 year), and number of partners during their life (+/-1). Vaginal biopsies were performed in users at 90+/-7 days after the last injection and in nonusers at day 20-25 of the menstrual cycle. In addition, at the day of the biopsy a blood sample was collected to measure estradiol (in all women) and DMPA in users. The level of serum estradiol was significant lower in Depo-Provera users than in controls (p < 0.001). The thickness of the vaginal epithelium was not smaller among DMPA users than among controls, the mean count of Langerhans cells per mm of epithelium were almost identical in both groups, and no significant differences were found on the vaginal maturation indices. In conclusion, the use of Depo-Provera between two and three years did not affect vaginal thinning of the epithelium, Langerhans cell count or maturation index.
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Affiliation(s)
- L Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medicine, Universidade Estadual de Campinas, (UNICAMP), Campinas, Brazil.
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