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Hormonal contraceptive use and women’s risk of HIV acquisition: priorities emerging from recent data

Understanding whether hormonal contraception increases women’s risk of HIV acquisition is a public health priority. This review summarizes recent epidemiologic and biologic data, and considers the implications of new evidence on research and programmatic efforts. Two secondary analyses of HIV prevention trials demonstrated increased HIV risk among depot medroxyprogesterone acetate (DMPA) users compared with nonhormonal/no method users and norethisterone enanthate (NET-EN) users. A study of women in serodiscordant partnerships found no significant association for DMPA or implants. Two meta-analyses found elevated risks of HIV among DMPA users compared with nonhormonal/no method users, with no association for NET-EN or combined oral contraceptive pills. In-vitro and animal model studies identified plausible biological mechanisms by which progestin exposure could increase risk of HIV, depending on the type and dose of progestin, but such mechanisms have not been definitively observed in humans. Recent epidemiologic and biologic evidence on hormonal contraception and HIV suggests a harmful profile for DMPA but not combined oral contraceptives. In limited data, NET-EN appears safer than DMPA. More research is needed on other progestin-based methods, especially implants and Sayana Press. Future priorities include updating modeling studies with new pooled estimates, continued basic science to understand biological mechanisms, expanding contraceptive choice, and identifying effective ways to promote dual method use.

Institutional author(s): University of California San Francisco, Robert Stempel College of Public Health and Social Work, CUNY School of Public Health
Individual author(s): Lauren J. Ralph, Erica L. Gollub, Heidi E. Jones
Publication date: December, 2015

Journal article Link to Journal Article

Health worker roles in providing safe abortion care and post-abortion contraception

Moving beyond specialist doctors to involve a wider range of health workers is an increasingly
important public health strategy. Planned and regulated task shifting and task sharing can ensure a
rational optimization of the available health workforce, address health system shortages of specialized
health-care professionals, improve equity in access to health care and increase the acceptability of
health services for those receiving them.

Institutional author(s): World Health Organization (WHO)
Publication date: 2015

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Progestin-only contraception: Injectables and implants

Progestin-only contraceptive injectables and implants are highly effective, longer-acting contraceptive methods that can be used by most women in most circumstances. Globally, 6% of women using modern contraception use injectables and 1% use implants. Injectables are the predominant contraceptive method used in sub-Saharan Africa, and account for 43% of modern contraceptive methods used. A lower-dose, subcutaneous formulation of the most widely used injectable, depot-medroxyprogesterone acetate, has been developed. Implants have the highest effectiveness of any contraceptive method. Commodity cost, which historically limited implant availability in low-resource countries, was markedly lowered between 2012 and 2013. Changes in menstrual bleeding patterns are extremely common with both methods, and a main cause of discontinuation. Advice from normative bodies differs on progestin-only contraceptive use by breastfeeding women 0–6 weeks postpartum. Whether these methods are associated with HIV acquisition is a controversial issue, with important implications for sub-Saharan Africa, which has a disproportionate burden of both human immunodeficiency virus (HIV) and maternal mortality.

Institutional author(s): University of North Carolina Gillings School of Public Health, USAID
Individual author(s): Roy Jacobstein, Chelsea B. Polis
Publication date: August, 2014

Journal article Link to Journal Article

Operational assessments of Sayana® Press provision in Senegal and Uganda

This study aimed to evaluate DMPA-SC (Sayana Press) management and administration in low-resource settings, focusing on how the delivery logistics, administration time, storage and waste-management requirements compare to the traditional intramuscular DMPA injectable (DMPA-IM).

Cover J, Blanton E, Ndiaye D, Walugembe F, Lamontagne DS. Operational assessments of Sayana® Press provision in Senegal and Uganda. Contraception. 2014 May;89(5):374-8. Epub 2014 Jan 18. PMID: 24565737.

Institutional author(s): PATH
Individual author(s): Jane Cover, Elizabeth Blanton, Dieynaba Ndiaye, Fiona Walugembe, D Scott Lamontagne
Publication date: January, 2014

Journal article Operational assessments of Sayana® Press provision in Senegal and Uganda

Pharmacokinetics of subcutaneous depot medroxyprogesterone acetate injected in the upper arm

This study evaluated the pharmacokinetic profile of medroxyprogesterone acetate (MPA) following injection of Depo-SubQ Provera 104 (DMPA-SC) in the upper arm, a preferred injection site in developing countries. Injection of Depo-SubQ Provera 104™ in the upper arm provided sufficient MPA levels for contraceptive protection for 3 months (13 weeks). The uptake and metabolism of MPA when injected in the upper arm may be different from the abdomen and thigh.


Institutional author(s): FHI 360
Individual author(s): Vera Halpern, Stephanie L Combes, Laneta J Dorflinger, Debra H Weiner, David F Archer
Publication date: July, 2013

Journal article Pharmacokinetics of subcutaneous depot medroxyprogesterone acetate injected in the upper arm

Acceptability of depo-subQ in Uniject

FHI 360’s PROGRESS project worked with ministries of health and local partners in Senegal and Uganda to conduct an acceptability study of the subcutaneous delivery of injectable contraceptives with the Uniject™ device (DMPA-SC, Sayana® Press). The study assessed acceptability among family planning clients and providers, including community health workers, and offered recommendations for the introduction of this method.

Institutional author(s): FHI 360
Publication date: June, 2013

Operational Assessment: Administration and Management of Sayana® Press in Clinics and Communities in Uganda

This operational assessment in Uganda examines the extent to which DMPA-SC (brand name Sayana® Press) facilitates the logistics of managing and administering injectable contraception and assesses whether providers in Uganda find benefits in this new presentation.

Institutional author(s): PATH
Publication date: May, 2013

Brief Operational Assessment: Administration and Management of Sayana® Press in Clinics and Communities in Uganda

Feasibility of Administering Sayana® Press in Clinics and Communities: Summary Findings From an Operational Assessment in Senegal

This study assessed the extent to which Sayana Press simplifies the logistics of managing and administering injectable contraception and whether providers in Senegal found this new presentation to be more practical and preferable to the standard syringe-vial injectable contraceptive. The operational assessment leveraged the acceptability study conducted by FHI 360 in Thies, Mbour, and Tivaouane by targeting the same 12 clinics from that study and asking providers who participated to reflect on their experience managing and administering Sayana Press. Semi-structured interviews with one provider from each of the 12 clinics and 9 affiliated CBD agents (matrones) for a total of 21 interviews, provided quantitative and qualitative data on the merits, challenges, and appeal of Sayana Press relative to DMPA-IM.

Institutional author(s): PATH
Publication date: April, 2013

Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting

Human resource shortages in the health services are widely acknowledged as a threat to the attainment of the health related Millennium Development Goals (MDGs). Attempts to optimize the potential of the existing health workforce are therefore crucial. A more rational distribution of tasks and responsibilities among cadres of health workers is seen as a promising strategy for improving access and cost effectiveness within health systems. For example, access to care may be improved by training and enabling ‘mid-level’ and ‘lay’ health workers to perform specific interventions that might otherwise be provided only by cadres with longer (and sometimes more specialized) training. Such task shifting strategies might be particularly attractive to countries that lack the means to improve access to care within short periods of time. Strategies to optimize tasks and roles for the implementation of effective interventions have achieved variable success. This is partly because the effects of these strategies are dependent on varying local health contexts and are shaped by a range of often very different social, political and cultural systems. However, the question of which health-care providers can deliver effective interventions is also linked to wider global discussions about whether health workers with lower levels of training can safely deliver key interventions. Within the arena of maternal and newborn health, for example, the implementation of contraceptive programmes and specific maternal health interventions (such as the use of uterotonics) is linked to wider debates about how task and role optimization can be achieved through task shifting. Consensus has emerged that there is a need to define which key interventions can safely and effectively be delivered by different cadres.

Institutional author(s): World Health Organization (WHO)
Publication date: 2012

Logistics and Waste Management Benefits of depo-subQ in Uniject

This four-page brief describes results from three analyses conducted by PATH and John Snow Inc. (JSI) comparing the intramuscular version of depot medroxyprogesterone acetate (DMPA) injectable contraceptive compared with the new DMPA-SC formulation packaged in the Uniject injection system. The analyses focused on waste management implications and identified key quantitative and qualitative differences between the two products.

Institutional author(s): PATH, JSI
Publication date: February, 2011