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PLoS Med. 2015 Jan 22;12(1):e1001778. doi: 10.1371/journal.pmed.1001778. eCollection 2015 Jan.

Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis.

Author information

Clinical Sciences, FHI 360, Durham, North Carolina, United States of America.
Biostatistics, FHI 360, Durham, North Carolina, United States of America.
Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America.
Department of Epidemiology, University of California, Los Angeles, Los Angeles, California, United States of America.
Medical Research Council, Comprehensive Clinical Trials Unit at UCL, University College London, London, United Kingdom.
Department of Global Health, Bill & Melinda Gates Foundation, Seattle, Washington, United States of America.
Wits Reproductive Health and HIV Institute, Johannesburg, South Africa.
Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Population Council, New York, New York, United States of America.
Center for the AIDS Program of Research in South Africa, University of Kwa-Zulu Natal, Durban, South Africa.
Diversity Research Programs, Multicenter Protocols Group, Memorial Sloan-Kettering Cancer Center, New York, New York, United States of America.
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Social Statistics and Demography, Academic Unit of Primary Care, Population Sciences, University of Southampton, Southampton, United Kingdom.
Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Women's Global Health Imperative, RTI International, San Francisco, California, United States of America.
Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Merseyside, United Kingdom.
Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.



Observational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC.


Eligible studies measured HC exposure and incident HIV infection prospectively using standardized measures, enrolled women aged 15-49 y, recorded ≥15 incident HIV infections, and measured prespecified covariates. Our primary analysis estimated the adjusted hazard ratio (aHR) using two-stage random effects meta-analysis, controlling for region, marital status, age, number of sex partners, and condom use. We included 18 studies, including 37,124 women (43,613 woman-years) and 1,830 incident HIV infections. Relative to no HC use, the aHR for HIV acquisition was 1.50 (95% CI 1.24-1.83) for DMPA use, 1.24 (95% CI 0.84-1.82) for NET-EN use, and 1.03 (95% CI 0.88-1.20) for COC use. Between-study heterogeneity was mild (I(2) < 50%). DMPA use was associated with increased HIV acquisition compared with COC use (aHR 1.43, 95% CI 1.23-1.67) and NET-EN use (aHR 1.32, 95% CI 1.08-1.61). Effect estimates were attenuated for studies at lower risk of methodological bias (compared with no HC use, aHR for DMPA use 1.22, 95% CI 0.99-1.50; for NET-EN use 0.67, 95% CI 0.47-0.96; and for COC use 0.91, 95% CI 0.73-1.41) compared to those at higher risk of bias (p(interaction) = 0.003). Neither age nor herpes simplex virus type 2 infection status modified the HC-HIV relationship.


This IPD meta-analysis found no evidence that COC or NET-EN use increases women's risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.

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