1. 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

2. 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

3. 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
(0.47,1.01)
(0.65,1.16)
(0.60,1.57)
(0.48,1.14)
(0.39,0.87)
(0.24,0.59)
NET-EN4
(0.94,2.23)
(0.48,1.57)
(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

4. 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
(0.47,1.01)
(0.65,1.16)
(0.60,1.57)
(0.48,1.14)
(0.39,0.87)
(0.24,0.59)
NET-EN4
(0.94,2.23)
(0.48,1.57)
(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

5. 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
(0.47,1.01)
(0.65,1.16)
(0.60,1.57)
(0.48,1.14)
(0.39,0.87)
(0.24,0.59)
NET-EN4
(0.94,2.23)
(0.48,1.57)
(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

6. 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
(0.47,1.01)
(0.65,1.16)
(0.60,1.57)
(0.48,1.14)
(0.39,0.87)
(0.24,0.59)
NET-EN4
(0.94,2.23)
(0.48,1.57)
(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

7. 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

8. 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.