Academic journal article Issues in Law & Medicine

Risk of HIV Infection in Depot-Medroxyprogesterone Acetate (DMPA) Users: A Systematic Review and Meta-Analysis

Academic journal article Issues in Law & Medicine

Risk of HIV Infection in Depot-Medroxyprogesterone Acetate (DMPA) Users: A Systematic Review and Meta-Analysis

Article excerpt

Introduction

The HIV-AIDS epidemic continues to spread in the developing world, particularly in sub-Saharan Africa. While advocacy of condom use has been persistent and pervasive, family planning advocates have also pursued advocacy of steroidal contraceptives, even though these provide no protection against HIV transmission. In fact, evidence has accrued that links the use of steroidal contraception (SC, often referred to as "hormonal" contraception. We prefer the term "steroidal," since the compounds in question are, strictly speaking, steroid drugs and not actual hormones.) to increased risk of HIV transmission. In a 1999 meta-analysis,1 Wang et al. observed a modest but significant association between HIV-1 seroconversion and oral contraceptive (OC) use. Since that time, injectable contraceptives (ICs)-especially DMPA-have been increasing in use compared to OCs. A number of studies have examined HIV-1 seroconversion as a function of IC use, and have found DMPA to facilitate HIV-transmission to an even greater extent than OCs. However, even though such evidence first appeared in the peer-reviewed literature over 20 years ago2 and though this association has been examined in nearly two dozen studies since, no consensus has yet emerged as to the potential danger of HIV acquisition to women using DMPA. Even the authors of a systematic review as recent as 20133 declined to perform a meta-analysis of extant data, because the literature consisted of studies with "heterogeneous methods and mixed results." Most recently, two meta-analyses have appeared.4 5 Importantly, these two reviews incorporated different criteria for inclusion and therefore summarized largely overlapping but somewhat different bodies of research, yet they reported almost identical, significant increased risks of HIV acquisition with DMPA use.

In the present article, we set out to assemble the literature pertaining to IC (particularly DMPA) and HIV acquisition and to quantify the overall findings of the worldwide literature. Considering the wide variation in population and primary study methodology, we have endeavored to be as inclusive as possible in the meta-analysis, specifically aiming to avoid the imposition our own biases regarding quality criteria. Consequently, the present work contrasts sharply with both of the recently published meta-analyses by including many earlier studies, including many that had incorporated a less definitive, cross-sectional methodology.

We believe that the present work therefore provides a larger perspective on the role of contraceptive interventions in the unfolding of the global HIV-A1DS epidemic. Thus it may serve not only as potential confirmation of the work of others, but also as evidence of ways by which potential dangers that may be posed by the use of new interventions may be brought to light sooner. Such earlier warnings can impart life-saving information to both family planning practitioners and the women whose right it is make their own informed reproductive choices.

Methods

Eligibility Criteria and Study Selection

We searched the Medline data base using the terms "contraceptive" or "contraception" and HIV, to identify studies that examined HIV status or acquisition as a function of IC or DMPA use. We also searched bibliographies of studies so identified. All studies that reported risk estimates or crude data that could be converted into risk estimates were included, unless the comparison group also included women who were using some other form of steroidal contraception (e.g., a comparison between IC users and OC users). In our search, we did not impose any starting date criteria, so that the earliest relevant studies could be identified.

Since the overwhelming majority of women using IC use DMPA, we have endeavored, as much as possible, to focus on DMPA, especially in light of differences in affinity among synthetic progestins for progesterone and other steroid hormone receptors. …

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