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HIV, CONTRACEPTION AND ASSISTED REPRODUCTIVE TECHNOLOGY

PERSEPECTIVES FROM A DEVELOPING COUNTRY (KENYA) Elizabeth Bukusi. HIV, CONTRACEPTION AND ASSISTED REPRODUCTIVE TECHNOLOGY. OVERVIEW. Contraceptive use among HIV positive women in a cohort in Nairobi Hormonal contraceptive use and their effects among a sex worker cohort in Mombasa

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HIV, CONTRACEPTION AND ASSISTED REPRODUCTIVE TECHNOLOGY

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  1. PERSEPECTIVES FROM A DEVELOPING COUNTRY (KENYA) Elizabeth Bukusi HIV, CONTRACEPTION AND ASSISTED REPRODUCTIVE TECHNOLOGY

  2. OVERVIEW Contraceptive use among HIV positive women in a cohort in Nairobi Hormonal contraceptive use and their effects among a sex worker cohort in Mombasa Assisted reproduction technology- a needs perspective from Kenya

  3. Kenyan Research Sites

  4. Characteristics of a cohort of HIV infected women on steroid and non-steroid hormone contraception Mwachari C1, Omondi C 1, Kariuki J1, Thiongo L1, Cohen CR2* 1. Kenya Medical Research Institute, Nairobi 2. University of Washington, Seattle,* Current affiliation University of San Francisco, California

  5. BACKGROUND • Dec 2002 UNAIDS/WHO estimated 19.2M women were infected with HIV worldwide • The majority of these women in the reproductive age hence need for reliable contraception • Many women use steroid hormones for contraception • Steroid hormones may interact with HIV virus or alter the immune function through various mechanisms

  6. CONT…BACKGROUND • Identified a need to study the effects of hormonal contraception on HIV progression

  7. METHODS • Study sites: Nairobi, Kenya and Harare, Zimbabwe, Chula, Thailand. • Study Design: Prospective non-randomized cohort study • Subjects assigned to contraceptive group (current contraceptive method of their choice at least 3 months prior to enrollment)

  8. METHODS (cont..) • Subject population: 18-35 years documented HIV infection CD4 count ≥ 500 cells/ul At least 3 months of contraception Nairobi resident • Follow up every 3 months for 4 years

  9. CLINICAL PROCEDURES • Obtain study and HIV consent • Medical, behavioral, contraception history • Medical examination

  10. Laboratory Procedures • At Enrollment - FBC, RPR, plasma viral load, CD4/CD8 - pap smear - CVL • Every 6 months - FBC, CD4/CD8, plasma viral load • Every 12 months - pap smear - CVL - RPR

  11. RESULTS • 5,188 WOMEN SCREENED • 25.8% HIV SEROPREVALENCE • 227(4.5%) HIV-1 INFECTED WOMEN ENROLLED • 175 (77%) ON STEROID HORMONE CONTRACEPTIVES AND 52 (23%) ON NON-STEROID HORMONE CONTRACEPTIVES • 75% FOLLOW-UP AFTER ONE YEAR

  12. Steroid hormone contraceptives

  13. Table 1: Socio-demographic profile of cohort

  14. Cont…Table 1: Socio-demographic profile of cohort

  15. SUMMARY • HIV + women using steroid hormone contraceptives tended to be younger, married, lower SES, and likely to be breastfeeding at one year. • There was significantly lower condom use among hormonal contraceptive users than that of non-hormonal contraceptive users.

  16. SUMMARY • In this cohort steroid hormonal users tended to have higher median CD4 counts, lower at one year. • Median rate of CD4 decline over one year was not significant between steroid hormonal users Vs non-steroid hormonal users

  17. Acknowledgements • Dr. Craig Cohen, Dr. Abuaba, Kariuki J, Lucy S, Lilian M, Jabuya E, Miheso B, Lawrence T, Jane M, Scola M, Jarmen K, Henry K • Study participants • KEMRI

  18. Hormonal contraception and sexually transmitted infections / HIV-1 infection in women Ludo Lavreys University of Washington, Seattle, USA University of Nairobi, Nairobi, Kenya Annual Review Meeting UoN STD/AIDS Collaborative Group Holiday Inn Mayfair Hotel, Nairobi, 2 February 2005

  19. Contraceptive use inMombasa Cohort and in Kenya a % married: cohort: 1.5%; National survey: 100% b Kenya Demographic and Health Survey 2003 Preliminary Report

  20. Hormonal contraception and sexually transmitted infections Does the use of hormonal contraception increase a woman’s risk for cervical sexually transmitted infections?

  21. HCC use and cervical STIs among HIV-1 negative sex workers in Mombasa Adjusted for age, yrs of education, yrs of prostitution, parity, workplace, number of sexual partners per week, numbers of sex encounters per week, and condom use Baeten J, et al. Am J Obstet Gynecol 2001; 185:380-385.

  22. Hormonal contraceptive use and cervical STIs among HIV-1 positive sex workers in Mombasa Adjusted for age, yrs of education, yrs of prostitution, parity, workplace, number of sexual partners per week, and condom use Lavreys L , et al. AIDS 2004;18:2179-84.

  23. Summary (1) The use of hormonal contraception is associated with increased risk for: • Cervical infections in HIV-1 negative and positive women, suggesting increased HIV-1 susceptibility and infectiousness

  24. Hormonal contraception and HIV-1 acquisition Does the use of hormonal contraception increase a woman’s risk for HIV-1 acquisition?

  25. Hormonal contraception and risk of HIV-1 acquisition Adjusting for sexual behavior, condom use, and sexually transmitted infections 1Martin HM, et al. J Infect Dis 1998;178:1053-1059.

  26. Hormonal contraception and risk of HIV-1 acquisition 1Martin HM, et al. J Infect Dis 1998;178:1053-1059. Adjusting for sexual behavior, condom use, and sexually transmitted infections 2Lavreys L, et al. AIDS 2004;18:695-697.

  27. Summary (2) The use of hormonal contraception is associated with increased risk for: • Cervical infections in HIV-1 negative and positive women, suggesting increased HIV-1 susceptibility and infectiousness • HIV-1 acquisition

  28. Hormonal contraception and natural history of HIV-1 Does the use of hormonal contraception affect the natural history of HIV-1 infection?

  29. 7 6.5 DMPA 6 NO DMPA Viral load (log copies/ml) 5.5 5 4.5 4 3.5 0 12 24 36 48 60 72 84 96 Time since infection (months) DMPA Lavreys L, et al. J Infect Dis 2004;189:303-311.

  30. Viral diversity and use of DMPA • Multiple viral variants detected in 89/156 women (57%) • HIV-1 viral diversity during primary infection was associated with use of DMPA at the time of HIV-1 acquisition (OR 3.0, 95% CI 1.3-6.9, p=0.005) Sagar M, et al. AIDS 2004;18:615-619.

  31. Summary (3) The use of hormonal contraception is associated with increased risk for: • Cervical infections in HIV-1 negative and positive women, suggesting increased HIV-1 susceptibility and infectiousness • HIV-1 acquisition • Higher viral load at set point, which might lead to faster disease progression • Acquisition of a more complex viral population, leading to a higher plasma viral load, and faster decline in CD4 count

  32. Hormonal contraception and HIV-1 infectiousness Does the use of hormonal contraception affect shedding of HIV-1 in the female genital tract, and hence the risk of transmitting HIV-1 infection?

  33. Hormonal contraception and HIV-1 infectiousness Cross-sectional N=308 Adjusted odds ratio Mostad, et al. Lancet 1997;350:922-927

  34. Hormonal contraception and HIV-1 infectiousness Cross-sectional Prospective N=308 Cervical HIV-1 DNA prevalence (n=211) Adjusted odds ratio Mostad, et al. Lancet 1997;350:922-927 Wang et al. AIDS 2004;18:205-209

  35. Summary (4) The use of hormonal contraception is associated with increased risk for: • Cervical infections in HIV-1 negative and positive women, suggesting increased HIV-1 susceptibility and infectiousness • HIV-1 acquisition • Higher viral load at set point, which might lead to faster disease progression • Acquisition of a more complex viral population, leading to a higher plasma viral load, and faster decline in CD4 count • Shedding of virus in the genital tract of HIV-1 infected women, which might lead to increased infectiousness

  36. Recommendations? Ref: Network Vol 23, number 3, 2004. Family Health International

  37. Recommendations? Ref: Network Vol 23, number 3, 2004. Family Health International

  38. Our Collaborators Nairobi (UoN): Walter Jaoko Jeckoniah Ndinya-Achola Seattle (UW and FHCRC): Jared Baeten* Julie Overbaugh Dana Panteleeff Barbra Richardson Manish Sagar IARTP staff Mombasa: Bhavna Chohan** Varsha Chohan Wisal Hassan Christine Katingima Kishor Mandaliya Scott McClelland Clinic and lab staff All patients * Current affiliation: Massachusetts General Hospital, Boston * * Current affiliation: Fred Hutchinson Cancer Research Center, Seattle

  39. High Acceptability Of Hiv-1 Testing Among Infertile Couples Attending A Refferal Infertility Clinic In Nairobi, Kenya Bukusi E1,2, Sinei S2, Cohen C 2,3 1Kenya Medical Research Institute 2University of Nairobi, 3University of Washington

  40. ACCEPTANCE OF HIV TESTING AMONG INFERTILE COUPLES

  41. HIV-1 serostatus among Infertile couples

  42. Phase III Randomized Placebo-Controlled Trial of HSV-2 Suppression to Prevent HIV Transmission among HIV-Discordant Couples Dr. Craig Cohen1, Dr. Elizabeth Bukusi2, Dr. Videlis Nduba2, Dr. Anjali Sharma2, Dr. Kawango Agot3 1University of California, San Francisco, 2Kenya Medical Research Institute, 3University of Nairobi, University of Manitoba and University of Illinois

  43. Kisumu CIS Discordant couple data* *Jan 2005, VCT sites

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