Chelsea B. Polis

Population effect of increased access to emergency contraceptive pills: a systematic review.

OBJECTIVE: We systematically reviewed data on effects of increased access to emergency contraceptive pills on pregnancy rates and use of the pills. DATA SOURCES: We searched MEDLINE, POPLINE, EMBASE, and LILACS, and we consulted with experts. METHODS OF STUDY SELECTION: We included studies that compared the effect of different levels of access to emergency contraceptive pills on pregnancy rates, use of the pills, and other outcomes. TABULATION, INTEGRATION, AND RESULTS: Of the 717 articles identified, we selected 23 for review. The studies included randomized trials, cohort studies, and evaluations of community interventions. The quality of these studies varied. In all but one study, increased access to emergency contraceptive pills was associated with greater use. However, no study found an effect on pregnancy or abortion rates. CONCLUSION: Increased access to emergency contraceptive pills enhances use but has not been shown to reduce unintended pregnancy rates. Further research is needed to explain this finding and to define the best ways to use emergency contraception to produce a public health benefit.

Abortion and long-term mental health outcomes: a systematic review of the evidence

Claims that women who have elective abortions will experience psychological distress have fueled much of the recent debate on abortion. It has been argued that the emotional sequelae of abortion may not occur until months or years after the event. Despite unclear evidence on such a phenomenon, adverse mental health outcomes of abortion have been used as a rationale for policy-making. We systematically searched for articles focused on the potential association between abortion and long-term mental health outcomes published between January 1, 1989 and August 1, 2008 and reviewed 21 studies that met the inclusion criteria. We rated the study quality based on methodological factors necessary to appropriately explore the research question. Studies were rated as Excellent (no studies), Very Good (4 studies), Fair (8 studies), Poor (8 studies), or Very Poor (1 study). A clear trend emerges from this systematic review: the highest quality studies had findings that were mostly neutral, suggesting few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae. Conversely, studies with the most flawed methodology found negative mental health sequelae of abortion.

The effect of male circumcision on sexual satisfaction and function, results from a randomized trial of male circumcision for human immunodeficiency virus prevention, Rakai, Uganda

Associate Editor

Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence

Whether or not the use of hormonal contraception affects risk of HIV acquisition is an important question for public health. We did a systematic review, searching PubMed and Embase, aiming to explore the possibility of an association between various forms of hormonal contraception and risk of HIV acquisition. We identified 20 relevant prospective studies, eight of which met our minimum quality criteria. Of these eight, all reported findings for progestin-only injectables, and seven also reported findings for oral contraceptive pills. Most of the studies that assessed the use of oral contraceptive pills showed no significant association with HIV acquisition. None of the three studies that assessed the use of injectable norethisterone enanthate showed a significant association with HIV acquisition. Studies that assessed the use of depot-medroxyprogesterone acetate (DMPA) or non-specified injectable contraceptives had heterogeneous methods and mixed results, with some investigators noting a 1·5-2·2 times increased risk of HIV acquisition, and others reporting no association. Thus, some, but not all, observational data raise concern about a potential association between use of DMPA and risk of HIV acquisition. More definitive evidence for the existence and size of any potential effect could inform appropriate counselling and policy responses in countries with varied profiles of HIV risk, maternal mortality, and access to contraceptive services.

Impact of Maternal HIV Coinfection on the Vertical Transmission of Hepatitis C Virus: A Meta-analysis

BACKGROUND Observational studies suggest that maternal human immunodeficiency virus (HIV)-hepatitis C virus (HCV) coinfection is associated with increased odds of vertical HCV transmission. We performed a meta-analysis to summarize current evidence. METHODS We systematically searched for relevant articles published during the period from January 1992 through July 2006 and independently abstracted articles that met our inclusion criteria. Under a random effects model, we calculated the pooled odds ratio for vertical HCV transmission according to maternal HIV-HCV coinfection status and performed sensitivity analyses. RESULTS Ten articles met our inclusion criteria. Study quality varied widely, and study estimates displayed high statistical heterogeneity. Restriction of the analysis to studies that included >50 HIV-HCV-coinfected women provided our most reliable estimate: maternal HIV-HCV coinfection increases the odds of vertical HCV transmission by approximately 90% (odds ratio, 1.9; 95% confidence interval, 1.36-2.67), compared with maternal HCV infection alone. When we restricted analyses to HIV-infected mothers with HCV viremia, the odds of vertical HCV transmission were 2.82-fold (95% confidence interval, 1.17-fold to 6.81-fold) greater than the odds for HIV-infected mothers without HCV viremia. CONCLUSIONS HIV-HCV-coinfected women have significantly higher odds of transmitting HCV to their infants than do women who are infected with HCV alone.

Hormonal contraceptive use and female-to-male HIV transmission: a systematic review of the epidemiologic evidence.

Objective:To systematically review epidemiologic evidence assessing whether hormonal contraception alters the risk of HIV transmission from an HIV-positive woman to an HIV-negative male partner. Design:Systematic review. Methods:We included articles published or in press through December 15, 2011. We assessed studies with direct evidence on hormonal contraception use and HIV transmission, and summarized studies with indirect evidence related to genital or plasma viral load. Results:One study provided direct evidence on oral contraceptive pills (OCPs) or injectable contraception and female-to-male HIV transmission; both injectables [Cox-adjusted hazard ratio (adjHR) 1.95, 95% confidence interval (CI) 1.06–3.58; marginal structural model (MSM) adjusted odds ratio (adjOR) 3.01, 95% CI 1.47–6.16] and OCPs (Cox adjHR 2.09, 95% CI 0.75–5.84; MSM adjOR 2.35, 95% CI 0.79–6.95) generated elevated point estimates, but only estimates for injectables were significant. Findings from 11 indirect studies assessing various hormonal contraception methods and viral genital shedding or setpoint were mixed, and seven of eight studies indicated no adverse effect of various hormonal contraception methods on plasma viral load. Conclusion:The only direct study on OCPs or injectable contraception and female-to-male HIV transmission suggests increased risk with the use of injectables. Given the potential for confounding in observational data, the paucity of direct evidence on this subject, and mixed indirect evidence, additional evidence is needed.

Advance provision of emergency contraception for pregnancy prevention: a meta-analysis.

OBJECTIVE: Advance provision of emergency contraception can circumvent some obstacles to timely use. We performed a meta-analysis to summarize randomized controlled trials evaluating advance provision of emergency contraception to explore effects on pregnancy rates, sexually transmitted infections, and sexual and contraceptive behaviors. DATA SOURCES: In August 2006, we searched CENTRAL, EMBASE, POPLINE, MEDLINE, a specialized emergency contraception article database, and contacted experts to identify published or unpublished trials. METHODS OF STUDY SELECTION: We included randomized controlled trials comparing advance provision to standard access, defined as any of the following: counseling (with or without information about emergency contraception) or provision of emergency contraception on request at a clinic or pharmacy. TABULATION, INTEGRATION AND RESULTS: Two reviewers independently assessed study quality. We performed a meta-analysis using Review Manager software. Eight randomized controlled trials met inclusion criteria, representing 6,389 patients in the United States, China, and India. Advance provision did not decrease pregnancy rates, despite increased use (single use, odds ratio [OR] 2.52, 95% confidence interval [CI] 1.72–3.70; multiple use: OR 4.13, 95% CI 1.77–9.63) and faster use (weighted mean difference –14.6 hours, 95% CI –16.77 to –12.4 hours). Advance provision did not increase rates of sexually transmitted infections (OR 0.99, 95% CI 0.73–1.34), unprotected intercourse, or changes in contraceptive methods. Women who received emergency contraception in advance were as likely to use condoms as other women. CONCLUSION: Advance provision of emergency contraception did not reduce pregnancy rates and did not negatively affect sexual and reproductive health behaviors and outcomes compared with conventional provision. LEVEL OF EVIDENCE: III

Effect of hormonal contraceptive methods on HIV disease progression: a systematic review.

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 womens and infants’ health and to prevent vertical transmission of HIV.

Modelling the global competing risks of a potential interaction between injectable hormonal contraception and HIV risk

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.

An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women

Objective and design:Some studies suggest that specific hormonal contraceptive methods [particularly depot medroxyprogesterone acetate (DMPA)] may increase womens 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.