Time to focus on improving the contraceptive method mix in high HIV prevalence settings and let go of unanswerable questions

Abstract

The evidence on the impact of depot medroxyprogesterone acetate (DMPA) a progestin-only injectable form of contraception on increased HIV-1 acquisition is mixed. A meta-analysis of observational data suggests that the use of DMPA increases the risk of HIV-1 acquisition by 1.5 times compared to women not using hormonal contraceptive methods. Furthermore a recent secondary analysis of women from an HIV prevention trial in Uganda South Africa and Zimbabwe (the VOICE study) found that DMPA users had 1.4 times the hazard of HIV acquisition compared to users of norethisterone enanthate (NET-EN) injectable contraception. In this study HIV incidence among DMPA users was greater than among NET-EN users resulting in 2.6 additional cases of HIV per 100 woman-years. Thus while the findings are mixed the authors’ best estimates are that DMPA use increased HIV acquisition modestly. The problem is that these estimates come from observational studies; the only way to definitively answer whether the observed increase in irsk of HIV-1 infection is caused by DMPA use or to due to residual cofounding selection bias and/or measurement error is through a well-designed randomized controlled trial (RCT). Consideration for an RCT is underway but under various circumstances to do an RCT would unfortunately be unethical. The authors encourage that resources should be dedicated to providing access to a wider range of contraceptive methods I high HIV prevalence settings rather than implementing an RCT. [excerpt] Copyright © 2014 Elsevier Inc. All rights reserved.