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Objective and Design: Some studies suggest that specific hormonal contraceptive methods [particularly depot medroxyprogesterone acetate (DMPA)] may increase women's HIV acquisition risk. We updated a systematic review to incorporate recent epidemiological data., Methods: We searched for articles published between 15 January 2014 and 15 January 2016 and hand-searched reference lists. We identified longitudinal studies comparing users of a specific hormonal contraceptive method against either nonusers of hormonal contraception or users of another specific hormonal contraceptive method. We added newly identified studies to those in the previous review, assessed study quality, created forest plots to display results, and conducted a meta-analysis for data on DMPA versus non-use of hormonal contraception., Results: We identified 10 new reports of which five were considered 'unlikely to inform the primary question'. We focus on the other five reports, along with nine from the previous review, which were considered 'informative but with important limitations'. The preponderance of data for oral contraceptive pills, injectable norethisterone enanthate, and levonorgestrel implants do not suggest an association with HIV acquisition, though data for implants are limited. The new, higher quality studies on DMPA (or nondisaggregated injectables), which had mixed results in terms of statistical significance, had hazard ratios between 1.2 and 1.7, consistent with our meta-analytic estimate for all higher quality studies of hazard ratio 1.4., Conclusion: Although confounding in these observational data cannot be excluded, new information increases concerns about DMPA and HIV acquisition risk in women. If the association is causal, the magnitude of effect is likely hazard ratio 1.5 or less. Data for other hormonal contraceptive methods, including norethisterone enanthate, are largely reassuring.

Introduction: Determining whether hormonal contraception, particularly the injectable contraceptive depot-medroxyprogesterone acetate (DMPA), increases a woman's risk of HIV acquisition is a priority question for public health. However, assessing the relationship between various hormonal contraceptive methods and HIV acquisition with observational data involves substantial analytic design issues and challenges. Studies to date have used inconsistent approaches and generated a body of evidence that is complex and challenging to interpret., Methods: In January 2013, the United States Agency for International Development and FHI 360 supported a meeting of epidemiologists, statisticians, and content experts to develop recommendations for future observational analyses of hormonal contraception and HIV acquisition., Results: Meeting participants generated recommendations regarding careful definition of exposure groups; handling potential confounders, mediators, and effect modifiers; estimating and addressing the magnitude of measurement error; using multiple methods to account for pregnancy; and exploring the potential for differential exposure to HIV-infected partners. Advantages and disadvantages of various statistical approaches to account for time-varying confounding and estimating total and direct effects were also discussed., Conclusion: Implementing these recommendations in future observational hormonal contraception-HIV acquisition analyses will enhance interpretation of existing studies and strengthen the overall evidence base for this complex and important area.

Objective: Systematically assess from the literature whether women living with HIV who use hormonal contraception are at increased risk of HIV-disease progression compared with those who do not use hormonal contraception., Methods: We searched PUBMED and EMBASE for articles published in peer-reviewed journals through December 15, 2011 for evidence relevant to all hormonal contraceptive methods and HIV-disease progression., Results: Twelve reports of 11 studies met inclusion criteria. One randomized controlled trial (RCT) found increased risk for the composite outcome of a reduced CD4 cell count or death among hormonal contraceptive users when compared with copper intrauterine device (IUD) users. Ten cohort studies reported no increased risk for HIV disease progression (as measured by mortality, time to a CD4 cell count below 200, time to initiation of antiretroviral therapy, an increase in HIV-RNA viral load, or a decrease in CD4 count) among women who used hormonal contraception compared with those who did not., Conclusion: The preponderance of evidence indicates that HIV-positive women can use hormonal contraceptive methods without concerns related to HIV-disease progression. Cohort studies consistently found no association between hormonal contraceptive use and HIV-disease progression compared with nonuse of hormonal contraceptives. One RCT found that hormonal contraceptive use was associated with increased risk of HIV-disease progression when compared with IUD use, but this study had important methodological shortcomings. Prevention of unintended pregnancy among women living with HIV remains a public health priority to safeguard women's and infants' health and to prevent vertical transmission of HIV.

Background: Some, but not all, observational studies have suggested an increase in the risk of HIV acquisition for women using injectable hormonal contraception (IHC)., Methods: We used country-level data to explore the effects of reducing IHC use on the number of HIV infections, the number of live births and the resulting net consequences on AIDS deaths and maternal mortality for each country., Results: High IHC use coincides with high HIV incidence primarily in southern and eastern Africa. If IHC increases the risk of HIV acquisition, this could generate 27 000-130 000 infections per year globally, 87-88% of which occur in this region. Reducing IHC use could result in fewer HIV infections but also a substantial increase in live births and maternal mortality in countries with high IHC use, high birth rates and high maternal mortality: mainly southern and eastern Africa, South-East Asia, and Central and South America. For most countries, the net impact of reducing IHC use on maternal and AIDS-related deaths is dependent on the magnitude of the assumed IHC-HIV interaction., Conclusions: If IHC use increases HIV acquisition risk, reducing IHC could reduce new HIV infections; however, this must be balanced against other important consequences, including unintended pregnancy, which impacts maternal and infant mortality. Unless the true effect size approaches a relative risk of 2.19, it is unlikely that reductions in IHC could result in public health benefit, with the possible exception of those countries in southern Africa with the largest HIV epidemics.

Objective: To assess the association between hormonal contraceptive use and HIV progression., Design: A retrospective analysis of 625 female HIV seroconverters from a Ugandan cohort study., Methods: Multivariate Cox regression analyses incorporating time-varying hormonal contraceptive exposure were used to estimate the adjusted hazard ratios of death, and a composite outcome of AIDS or death, associated with hormonal contraceptive use. Sensitivity analyses included lagging hormonal contraceptive exposure, varying comparison groups, and separately assessing effects of oral and injectable contraceptives., Results: A total of 27.5% of women reported ever using hormonal contraception. Of 625 women, 104 (16.6%) died and 291 (46.6%) progressed to AIDS or death during observation. Time-varying hormonal contraceptive use was not associated with an increased hazard of death as compared with nonuse of hormonal contraception (adjusted hazard ratio 0.76, 95% confidence interval 0.41-1.39, P = 0.37), and was associated with a significantly reduced hazard of progression to AIDS or death (adjusted hazard ratio 0.70, 95% confidence interval 0.50-0.97, P = 0.03). None of the sensitivity analyses suggested an adverse effect of hormonal contraception on HIV progression., Conclusion: Hormonal contraceptive use was not associated with faster progression to death, and was associated with a reduced hazard of progression to the composite outcome of AIDS or death.