Contraception and HIV

1. Contraception and HIV Professor Helen Rees Executive Director, WRHI, Wits Reproductive Health and HIV Institute & Ad Hominem Professor, Department of Obstetrics and Gynaecology, University of Witwatersrand Honorary Professor, London School of Hygiene & Tropical Medicine

2. “Love is the answer, but while you are waiting for the answer, sex raises some pretty good questions.” Woody Allen

3. Women have a right to decide whether they want to become pregnant and bear children irrespective of their HIV status. Women must be enabled to make informed, voluntary decisions about contraception and then receive a safe, effective method of her choice.

4. Trends in Maternal Mortality Ratios Avoidance of unintended pregnancy is most effective way of reducing number of deaths: 40% of global deaths averted in 2008 by contraception (Darroch & Singh 2011: Ahmed et al 2011) WHO 2010

5. Over 150 million women use hormonal contraception worldwide, primarily oral contraceptives (OCs) and injectable depot-medroxyprogesterone acetate (DMPA).

6. The overall demand for contraception is increasing % of married women aged 15–49 Latin America & Caribbean North Africa & West Asia South & Southeast Asia Sub-Saharan Africa

7. Method mix: among currently married (CM) & sexually active not married (NM) women , % using specific method Source: Demographic and Health Surveys 2006-1010

8. The importance of some reasons for non-use has changed over time % of married women aged 15–49 with unmet need 1986–1989 2002–2005

9. Adherence in contraceptive use 189 progestin injectable users followed up for 2 years in family planning clinic in Soweto • Of those who discontinued: • 40% ‘taking a break’ • >50% complained of side effects Beksinska, Rees et al. Contraception 64(2001)

10. Adult female HIV prevalence

11. The importance of contraception as part of PMTCT Prevention of HIV in women, especially young women Prevention of unintended pregnancies in HIV-infected women Prevention of transmission from an HIV-infected woman to her infant Support for mother and family Contraception Element 1 Element 2 Element 3 Element 4 . Significant contribution coming from the provision of contraceptive information, services and counselling.

12. Pregnancy Intentions & Incidence Study: Prospective Cohort Study of HIV Positive Women on ART in South Africa, Swartz S, Black V et al • 851 non-pregnantwomen on different ARV regimens recruited from 4 WRHI-supported sites between August 2009 – January 2010

13. How far can we push Dual Method use? Condom use at last sexual intercourse, amongst injectable contraception users Glass ceiling? Source: Demographic and Health Surveys 2004-1010

14. Contraception and HIV: What to consider Women at risk for HIV Women infected with HIV Disease progression Drug interactions Prevention Acquisition Infectiousness

15. Contraception and HIV: How WHO guidance has worked… Disease progression Acquisition Infectiousness

16. WHO’s Medical Eligibility Criteria for Contraceptive Use

17. Research WHO consultants & committee: Systematic review, Grading of scientific evidence The evidence is used to develop international recommendations and includes expert opinion where evidence is not available International recommendations are adapted for national guidelines Job aids (tools) are developed

18. Eligibility Criteria for Contraceptive use: WHO Classifications Definition

19. WHO Conclusions - 2008 • “Intermediate” level of evidence • COC – Category 1 - “No Restriction” • DMPA – Category 1 for women at risk of HIV – Category 2 for youth (bone concerns) “Advantages Outweigh Risks” Source: WHO Medical Eligibility Criteria (2008)

20. Hormonal contraceptive use for women at high risk of HIV • DMPA – Category 1 - No Restriction • Balance of evidence suggests no association between progestin contraceptives and HIV acquisition, although studies of DMPA use conducted among higher risk populations have repeated inconsistent findings • “Intermediate” level of evidence Source: WHO Medical Eligibility Criteria fourth edition 2009

21. Progesterone Nature Med., 1996 DMPA Virology, 2006 DMPA J. Infect. Dis., 2004 - Genescà et al., J. Med. Primatol. , 2007 - Mascola et al., Nature Med. 2000 - Veazey et al., Proc. Natl. Acad. Sci. USA 2008 - Pal et al., Virology 2009 - Turville et al., PLoS One 2008

22. Reported effects of progesterone and its derivatives on immune system & HIV-1 infection. Hel Z. et al., Endocrine Rev., 2010, 79-97.

23. Hormones and HIV Possible Mechanisms • Vaginal and cervical epithelium (ectopy, etc.) • Cervical mucus • Menstrual patterns • Vaginal and cervical immunology • Viral (HIV) replication • Acquisition of other STI

24. Studies of Injectables & HIV Acquisition Kumwenda 2008 Ungchusak 1996 Feldblum 2010 Heffron 2011 Bulterys 1994 Baeten 2007 Watson-Jones 2009 Kilmarx 1998 Morrison 2010 Myer 2007 Reid 2010 Kiddugavu 2003 Kleinschmidt 2007 Kapiga 1998 Source: Adapted from Polis (2011)

25. Prospective cohort study of 3790 HIV-­1 discordant couples from East and southern Africa Renee Heffron, Deborah Donnell, Helen Rees, Connie Celum, Edwin Were, Nelly Mugo, Guy de Bruyn, Edith Nakku-­‐Joloba, Kenneth Ngure, James Kiarie and Jared Baeten July 2011 – Partners in Prevention Study on HIV acquisition and HC presented at IAS Conference, Rome

26. Contraception and HIV acquisition from men to women 21.2% of women used HC at least once during study

27. Contraception and HIV acquisition from women to men

28. Conclusion • Mounting evidence that hormonal contraceptives – particularly injectable methods - increase a woman’s risk of acquiring HIV-1 • First study to demonstrate that hormonal contraceptives increase an HIV‐1 infected woman’s risk of transmitting HIV‐1 to her partner

29. The Dilemma for an Uninfected Woman • If she uses DMPA, • Less risk of pregnancy • More risk of HIV acquisition • If she stops DMPA • Does she have other contraceptive options? • If not, she may become pregnant • More risk of HIV acquisition • More risk of pregnancy morbidity & mortality • Unwanted pregnancy may have worse infant outcomes

30. The Dilemma for the Infected woman • If she uses hormonal contraception • Less risk of pregnancy • More risk of HIV transmission to partner • If she stops hormonal methods • Does she have other contraceptive options? • If not she may become pregnant • More risk of HIV transmission to partner • More risk of pregnancy Morbidity & Mortality • Potential for transmission to infant • Unwanted HIV infected babies have higher morbidity and mortality than wanted infants

32. Studies of Injectables & HIV Acquisition Kumwenda 2008 Ungchusak 1996 Feldblum 2010 Heffron 2011 Bulterys 1994 Baeten 2007 Watson-Jones 2009 Kilmarx 1998 Morrison 2010 Myer 2007 Reid 2010 Kiddugavu 2003 Kleinschmidt 2007 Kapiga 1998 Source: Adapted from Polis (2011)

33. WHO Expert Consultation on HC and HIV • January 2012, Geneva, 75 participants from 18 countries • HIV Acquisition • HIV Transmission • HIV Progression • GRADE rating of the evidence • Discussion of MEC criteria • Programmatic implications • Research agenda

34. WHO Consultation – GRADE Rating • HC/HIV progression evidence • 1 RCT, 6 cohort studies • Rated “low overall quality” • No change from Category 1

35. WHO Consultation – GRADE Rating • HC/HIV transmission evidence • Rated “low overall quality” • No change from Category 1

36. WHO Consultation – GRADE Rating • HC/HIV acquisition evidence • 8 cohort studies met minimum quality criteria • Rated “low overall quality” but better studies tended towards harm • Major focus of meeting

37. Contraception and HIV acquisition from men to women 21.2% of women used HC at least once during study

38. The Great Debate Observational data Possible selection bias Potential for Confounding Not always primary study endpoint HC use not always well documented Self reported condom use unreliable Condom use differed between non-HC arms and HC arms

39. Progestin injectables and HIV acquisition: The Great debate 1. If left an MEC 1 – no change implies that the data are not convincing enough to support even theoretical concerns about injectable progestins and HIV acquisition 2. If moved to MEC 2 – a change implies that there are theoretical concerns which still allows use but if misunderstood might scare women and jeopardize global use without many alternatives being available 3. The meeting was divided between 1 & 2

40. The WHO Statement – February 2012

41. The WHO statement on Progestin-only injectables and HIV acquisition, 2012 ………the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV.However…..

42. The WHO statement on Progestin-only injectables and HIV acquisition, 2012 ……..because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also use condoms and other preventive measures. The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits.

44. What then happened…… • Some activists, women's organisations and journalists said they did not understand the Category ‘1’ and the clarification • Requested clarity on the messaging that should be given to women users • Some researchers and donors considering an RCT as a definitive study • Widespread calls for increasing the method mix in developing countries • And the modellers are involved……

45. Where does high HIV prevalence coincide with high use of injectable hormonal contraceptives? HIV prevalence among 15-49 year-old women* The overlap between use of injectables and HIV prevalence *Adult HIV prevalence given for China. Injectable hormonal contraceptive use among 15-49 year-old women HIV: ‘high’ = > 1%; IHC: ‘high’ = upper quartile. From: AR Butler, JA Smith, D Stanton, TB Hallett. The global impact of an interaction between injectable hormonal contraception and HIV risk (subm.).

46. Number of HIV infections attributable to hypothesised IHC-HIV interaction per year • Regions with high HIV incidence and high IHC use have the most HIV infections attributable to use of injectable hormonal contraceptives From: AR Butler, JA Smith, D Stanton, TB Hallett. The global impact of an interaction between injectable hormonal contraception and HIV risk (subm.)

47. Net effect: balance of reduced AIDS deaths & increased maternal deaths • Absolute change in the number of maternal and AIDS deaths on cessation of IHC use • Maximum benefits of stopping or reducing HC in regions of high HIV incidence and low maternal mortality • Increase in total number of deaths in areas of high HC use and high maternal mortality From: AR Butler, JA Smith, D Stanton, TB Hallett. The global impact of an interaction between injectable hormonal contraception and HIV risk (subm.)

48. And WHO went further to clarify its guidance

49. WHO’s programmatic and research recommendations Based on current evidence, family planning programmes delivering services to women at risk of, or living with, HIV infection can continue to offer all methods of hormonal contraception. However, as none of these methods protects against HIV, the use of condoms or other HIV preventive measures should always be strongly recommended.

50. WHO’s programmatic and research recommendations Provide easy-to-understand and comprehensive information to women and their partners about the benefits of contraceptive options available to them as well as any associated risks, including information regarding the inconclusive nature of the evidence on possible increased risk of HIV acquisition among women using progestogen only injectables.