Acquisition of STIs among Women Using a Variety of Contraceptive Options: A Prospective Study among High-Risk African Women Flavia Matovu Kiweewa, Elizabeth.

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Acquisition of STIs among Women Using a Variety of Contraceptive Options: A Prospective Study among High-Risk African Women Flavia Matovu Kiweewa, Elizabeth Brown, Anu Mishra, Gonasagrie Nair, Thesla Palanee-Phillips, Nyaradzo Mgodi, Katie Schwartz, Clemensia Nakabiito, Nahida Chakhtoura, Sharon Hillier, Jared Baeten for the MTN-020/ASPIRE Study Team 9th IAS Conference on HIV Science 26 July 2017

Introduction Long-acting reversible contraceptive methods are being promoted widely STIs cause significant morbidity and mortality adverse effects on reproductive health increased risk of HIV-1 acquisition Few studies have evaluated STI risk among hormonal implants and IUDs users We compared STI risk among a variety of contraceptive users in the ASPIRE study

Results Analysis population: 2264 women (50.2% from South Africa) DMPA (n=1147), Implants (n=692), NET-EN (n=438) or IUD (n=541) 817 cases of STIs detected over 3,440 pyrs of follow-up; 408 cases of C.trachomatis (incidence 11.86/100 pyrs) 196 cases of N.gonorrhoeae (5.70/100 pyrs) 213 cases of T.vaginalis (6.19/100 pyrs) Incidence of STIs by contraceptive method Method Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) IUD3 Implant DMPA 12.92 1 9.19 0.69 (0.47,1.01) 12.44 0.86 (0.65,1.16) 6.77 1 5.92 0.97 (0.60,1.57) 5.13 0.74 (0.48,1.14) 9.07 1 6.01 0.58 (0.39,0.87) 4.75 0.37 (0.24,0.59) NET-EN4 17.35 1.45 (0.94,2.23) 6.55 0.86 (0.48,1.57) 5.84 0.40 (0.20,0.81) 1 incidence per 100 person-years; 2hazard ratios adjusted for randomization arm, age, baseline sexual behavior, baseline STIs 3copper IUD; 4NET-EN only South African women

Results Analysis population: 2264 women (50.2% from South Africa) DMPA (n=1147), Implants (n=692), NET-EN (n=438) or IUD (n=541) 817 cases of STIs detected over 3,440 pyrs of follow-up; 408 cases of C.trachomatis (incidence 11.86/100 pyrs) 196 cases of N.gonorrhoeae (5.70/100 pyrs) 213 cases of T.vaginalis (6.19/100 pyrs) Incidence of STIs by contraceptive method Method Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) IUD3 Implant DMPA 12.92 1 9.19 0.69 (0.47,1.01) 12.44 0.86 (0.65,1.16) 6.77 1 5.92 0.97 (0.60,1.57) 5.13 0.74 (0.48,1.14) 9.07 1 6.01 0.58 (0.39,0.87) 4.75 0.37 (0.24,0.59) NET-EN4 17.35 1.45 (0.94,2.23) 6.55 0.86 (0.48,1.57) 5.84 0.40 (0.20,0.81) 1 incidence per 100 person-years; 2hazard ratios adjusted for randomization arm, age, baseline sexual behavior, baseline STIs 3copper IUD; 4NET-EN only South African women

Results Analysis population: 2264 women (50.2% from South Africa) DMPA (n=1147), Implants (n=692), NET-EN (n=438) or IUD (n=541) 817 cases of STIs detected over 3,440 pyrs of follow-up; 408 cases of C.trachomatis (incidence 11.86/100 pyrs) 196 cases of N.gonorrhoeae (5.70/100 pyrs) 213 cases of T.vaginalis (6.19/100 pyrs) Incidence of STIs by contraceptive method Method Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) IUD3 Implant DMPA 12.92 1 9.19 0.69 (0.47,1.01) 12.44 0.86 (0.65,1.16) 6.77 1 5.92 0.97 (0.60,1.57) 5.13 0.74 (0.48,1.14) 9.07 1 6.01 0.58 (0.39,0.87) 4.75 0.37 (0.24,0.59) NET-EN4 17.35 1.45 (0.94,2.23) 6.55 0.86 (0.48,1.57) 5.84 0.40 (0.20,0.81) 1 incidence per 100 person-years; 2hazard ratios adjusted for randomization arm, age, baseline sexual behavior, baseline STIs 3copper IUD; 4NET-EN only South African women

Results Analysis population: 2264 women (50.2% from South Africa) DMPA (n=1147), Implants (n=692), NET-EN (n=438) or IUD (n=541) 817 cases of STIs detected over 3,440 pyrs of follow-up; 408 cases of C.trachomatis (incidence 11.86/100 pyrs) 196 cases of N.gonorrhoeae (5.70/100 pyrs) 213 cases of T.vaginalis (6.19/100 pyrs) Incidence of STIs by contraceptive method Method Chlamydia trachomatis Neisseria gonorrhoeae Trichomonas vaginalis Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) Incidence1 aHR2 (95% CI) IUD3 Implant DMPA 12.92 1 9.19 0.69 (0.47,1.01) 12.44 0.86 (0.65,1.16) 6.77 1 5.92 0.97 (0.60,1.57) 5.13 0.74 (0.48,1.14) 9.07 1 6.01 0.58 (0.39,0.87) 4.75 0.37 (0.24,0.59) NET-EN4 17.35 1.45 (0.94,2.23) 6.55 0.86 (0.48,1.57) 5.84 0.40 (0.20,0.81) 1 incidence per 100 person-years; 2hazard ratios adjusted for randomization arm, age, baseline sexual behavior, baseline STIs 3copper IUD; 4NET-EN only South African women

Discussion and Conclusions Incidence of C.trachomatis and N.gonorrhoeae was not significantly different across contraceptive methods Incidence of T.vaginalis was significantly lower for DMPA, implant, and NET-EN users compared with IUD users Significantly lower rates of T.vaginalis among users of progestin-based methods likely due to hypoestrogenic states Strengths: - frequent capture of contraceptive exposure - inclusion of over 3,440 person-years of follow-up Limitations: Lack of randomization to contraceptive method Results support current WHO guidance, no restriction on contraceptive options for women at risk for STIs

Acknowledgements The Research participants ASPIRE Study team MTN Laboratory Central The Microbicide Trials Network is funded by the National Institute of Allergy and Infectious Diseases (UM1AI068633, UM1AI068615, UM1AI106707), with co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health, all components of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The International Partnership for Microbicides (IPM) developed and supplied the vaginal rings.