Abstract
The association between increased risk of HIV acquisition and use of progestin-only injectables (POIs) is controversial. We sought to compare the competing risks of maternal mortality and HIV acquisition with use of POIs using updated data on this association and considering an expanded number of African countries. We designed a decision-analytic model to compare the benefits and risks of POIs on the competing risks of maternal mortality and HIV acquisition on life expectancy for women in 9 African countries. For the purposes of this analysis, we assumed that POIs were associated with an increased risk of HIV acquisition (hazards ratio of 1.4). Our primary outcome was life-years and the population was women of reproductive age (15-49 years) in these countries, who did not have HIV infection and were not currently planning a pregnancy. Probabilities for each variable included in the model, such as HIV incidence, access to antiretroviral therapy, and contraceptive prevalence, were obtained from the literature. Univariate and multivariate sensitivity analyses were performed to check model assumptions and explore how uncertainty in estimates would affect the model results. In all countries, discontinuation of POIs without replacement with an equally effective contraceptive method would result in decreased life expectancy due to a significant increase in maternal deaths. While the removal of POIs from the market would result in the prevention of some new cases of HIV, the life-years gained from this are mitigated due to the marked increase in neonatal HIV cases and maternal mortality with associated life-years lost. In all countries, except South Africa, typical-use contraceptive failure rates with POIs would need to exceed 39%, and more than half of women currently using POIs would have to switch to another effective method, for the removal of POIs to demonstrate an increase in total life-years. Women living in sub-Saharan Africa cope with both high rates of HIV infection and high rates of pregnancy-related maternal death relative to the rest of the world. Based on the most current estimates, our model suggests that removal of POI contraception from the market without effective and acceptable contraception replacement would have a net negative effect on maternal health, life expectancy, and mortality under a variety of scenarios.
Highlights
Global Health: Science and Practice 2017 | Volume 5 | Number 4Prevention efforts have been limited by inconsistent usage of barrier methods, lower-than-expected uptake of male circumcision, and slow implementation and uptake of preexposure prophylaxis.[2,3,4,5] Africa continues to be the area of the world most affected by the HIV epidemic, and women are at high risk of HIV infection.[1]
When calculating the number of HIV cases averted if no progestin-only injectables (POIs) were available, we considered 2 scenarios for women currently using POIs: (1) they all switch to no method, and (2) they switch to another reversible modern method (COCs, an intrauterine device (IUD), or an implant)
Women living in sub-Saharan Africa cope with both high rates of HIV infection and high rates of pregnancy-related maternal death relative to the rest of the world
Summary
Global Health: Science and Practice 2017 | Volume 5 | Number 4Prevention efforts have been limited by inconsistent usage of barrier methods (male or female condoms), lower-than-expected uptake of male circumcision, and slow implementation and uptake of preexposure prophylaxis.[2,3,4,5] Africa continues to be the area of the world most affected by the HIV epidemic, and women are at high risk of HIV infection.[1]. Risk of HIV acquisition, especially in sub-Saharan Africa, must be considered within the context of maternal mortality. Risk of HIV deaths.[6] Use of contraception plays a critical role in acquisition, preventing maternal deaths by allowing women especially in sub- to delay early childbearing, limit childbearing, Saharan Africa, must be and avoid unintended pregnancies and subsequent unsafe abortions.[7] there is high considered within unmet need for contraceptive services across the context of Africa,[8,9] with only 22% of married women using maternal a modern method of contraception.[8,10] As a contimortality
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