Abstract
ObjectivesTo assess the effect of the depot medroxyprogesterone acetate injectable (DMPA) and of the levonorgestrel (LNG) implant on genital HIV shedding among women receiving antiretroviral therapy (ART).MethodsWe randomized HIV-infected Malawian women to either DMPA or LNG implant from May 2014 to April 2015. HIV RNA was measured in cervicovaginal lavage (CVL) fluid and TearFlo Strips (TFS), and HIV DNA was measured in cells collected by CVL. We compared the frequency and magnitude of HIV genital shedding before and for 6 months after initiation of contraception and between arms among women receiving ART. We also compared genital HIV RNA levels obtained by sample type (TFS versus CVL).ResultsWe analyzed data for 68 HIV-infected women receiving ART: 33 randomized to DMPA and 35 randomized to the LNG implant. Overall, HIV RNA was more often detectable and the quantity was higher on TFS compared with CVL. HIV DNA was detected very rarely in CVL cell samples (4 of 360 samples). The frequency of genital shedding and the genital HIV quantity did not increase after contraceptive initiation with either DMPA or LNG implant among women receiving ART.ConclusionsHIV-infected women receiving ART initiating contraception with either DMPA or LNG implant did not have any increase in genital HIV shedding during the first 6 months of contraceptive use. These findings are consistent with growing evidence that progestin contraception is not associated with increased HIV transmission risk from such women to their male partners. Consistent with other studies, genital HIV RNA detection was higher in TFS than in CVL fluid.ImplicationsIn this randomized trial, neither DMPA nor the LNG implant, two of the most commonly used hormonal contraceptives among African women with HIV, was associated with increased genital HIV shedding in HIV-infected women receiving ART. These findings are reassuring and add to the currently limited information available for the highly effective contraceptive, LNG implant.
Highlights
Worldwide, there are over 16 million women living with human immunodeficiency virus type 1 (HIV) [1]
Plasma HIV viral load at enrollment was below the limit of quantification (b40 copies/ml) in 81.8% (n=27) of women in the depot medroxyprogesterone acetate (DMPA) arm and 71.4% (n=25) in the LNG implant arm
There was a significantly higher detection rate of HIV RNA in TearFlo Strips (TFS) before starting the LNG implant than after starting it, which was not seen with DMPA
Summary
There are over 16 million women living with human immunodeficiency virus type 1 (HIV) [1]. Plasma HIV RNA viral load is a strong predictor of heterosexual transmission, and antiretroviral therapy (ART) effectively decreases viral load in both the blood and the genital tract [6,7]. Genital tract HIV RNA viral load from cervical swab was shown to correlate significantly but imperfectly with plasma viral load (r=0.56) and to be an independent risk factor for HIV transmission [7]. Some studies have shown an association between hormonal contraceptive use and increased frequency of shedding of HIV-1 DNA but not RNA in the genital tract [8,9,10,11,12]. The World Health Organization (WHO) encourages further studies on the impact of hormonal contraception on HIV acquisition and transmission [16]
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