1. A Prospective Cohort Study on the effects of Hormonal Contraception on the Natural History of HIV disease among women in Nairobi and Harare Collaborating institutions: KEMRI, UCSF, UZ, WHO

2. Background As of 2005, approx 18M women were HIV- infected worldwide and 80% in sub-Saharan Africa 100M globally use hormonal contraception Increasing HC use in HIV prevalent areas Effective contraception, a preventive tool for unintended pregnancies and in reducing proportion of HIV-infected children

3. Potential Interactions between steroid hormones and HIV Plausible mechanisms for HIV-HC interactions Direct effects Binds directly to the HIV regulatory protein and enhances replication hence increasing viral load Indirect effects Influencing both humoral and cell-mediated by either increasing or decreasing various cytokines

4. Previous studies Hunt J et al, 1998 described a direct effect on virus expression via hormone response elements within the HIV-1 promoter. Marx et al, 1996 described an SIV macaque model and demonstrated increased infectivity with Progesterone treatment (thinning of the vaginal epithelium. Lavreys L, et al, 2003 found that DMPA use at the time of HIV-1 acquisition and the presence of a GUD during the early phase of infection were associated with higher levels of HIV-1 replication. Martin H et al, 1998 reported increased HIV-1 acquisition and other STI among women (CSW) using DMPA Sagar M et al, 2003 reported an association of COC use at the time of HIV-1 infection with increased risk of acquiring multiple HIV-1 genotypes leading to higher viral set points and rapid progression

5. Justification Previous studies have demonstrated effects of hormones in animal models and among high risk populations Currently limited data exists on the effects of HC on HIV progression among women in the general population Increasing concern among health care providers on the possibility of rapid disease progression among HIV infected women using HC methods

6. Overall Objective To determine the effects of hormonal contraception on HIV-1 disease progression among women in Nairobi and Harare

7. Specific Objectives To determine the effects of COC and DMPA on the rate of CD4 decline To determine the effects of COC and DMPA on WHO clinical staging To determine the effects of COC and DMPA on plasma viral load

8. Methods Study Design: Prospective Cohort Study (2000-2005) Study Sites: Nairobi, Kenya and Harare, Zimbabwe Study Population: HIV-1 infected women aged 18-49yrs presenting to FP facilities with CD4 count >500 cells/µL and on self selected FP method (COC, DMPA, non-Hormonal contraceptive methods) for at least 3 months

9. Clinical and Laboratory procedures At enrolment and every 6 month follow up visit: a medical history including social, sexual, contraceptive and examination performed using a structured questionnaire Hemogram, RPR, CD4 count, plasma viral load measurement Annual pap smear test

10. Data Analysis A Univariate comparison of baseline characteristics was done by COC, DMPA vs. non-HC methods. Potential confounding was controlled for all multivariate models. Survival Analysis (univariate comparison of mean change in CD4 counts by contraceptive method over time). Linear Mixed Effects Models, multivariate analysis of the rate of CD4 decline by contraceptive method. Cox Proportional Hazards Models (Multivariate analysis of factors associated with time to advanced HIV disease stages (III and IV). Considered two scenarios: 1) Analysis of outcomes while excluding non compliant contraceptive users and 2) the intention to treat analysis, included all non-compliant subjects

11. Results A total of 498 women enrolled beginning the year 2000 and followed through to 2005 Median follow up of 2 (0-4) years Mean age of 27.45 (5.3) years 77% were married

12. Total number of subjects enrolled: 498 Nairobi: 302 (60.6%) Harare: 196(39.4%) Overall number analyzed by contraceptive method and site: 336 (%) Nairobi: 217 (59.3%) Harare: 149 (40.7%) COC: 36 (16.6%) COC=54(36.2%) DMPA: 98 (45.2%) DMPA: 46 (30.9%) Non-HC: 83(38.2%) Non-HC: 49(32.9%) Total number excluded from analysis 9 (1.8%) women on Norplant Nairobi: 7 (1.4%) Harare: 2 (0.4%) Overall Outcomes by Contraceptive Method 4 (1.1%) of deaths COC:0 (0%) DMPA: 3( 75%) Non–HC:1 (25%) 27 (7.4%) with CD4 <200 cells/µL in 4 years COC: 2(7.4%) DMPA: 15(55.6%) Non-HC: 10(37%) Overall with contraceptive change for both sites 127 (25.6%) DMPA/COC to non-HC: 36 (28.3%) Non-HC to COC/DMPA: 39 (30.7%) Vice versa: 14 (11%) Pregnant: 38 (29.9%) Fig 1: Patient enrolment and follow up flow chart

13. Table 1: Sociodemograhic characteristics by contraceptive method among HIV-1 infected women in Nairobi and Harare CharacteristicCOC N= 90 (24.7%) DMPA N= 144 (39.2%) Non-HC N= 132 (36.2%) P-value Study site: Kenya Zimbabwe 36(40.0%) 54(60.0%) 98(68.1%) 46(31.9%) 83(62.9%) 49(37.1%)0.000 Mean age (sd) yrs27.5 (5.31)26.2(4.5)29.9 (6.56)0.000 Education None Primary Secondary College 0 (0%) 38(42.2%) 51(56.7%) 1(1.1%) 1 (0.7%) 66 (46.2%) 75 (52.4%) 1 (0.7%) 4 (3.0%) 44 (33.3%) 66 (50.0%) 18 (13.6%) 0.000 Marital Status Single (never married) Married (cohabiting) Regular partn(not cohabiting) Divorced/separated/widowed 0(0%) 84(93.3%) 4 (4.4%) 2 (2.2%) 2 (1.4%) 126 (87.5%) 9 (6.3%) 7 (4.9%) 12 (9.2%) 66 (50.4%) 21 (16.0%) 32 (24.4%) 0.000 Current smoker2 (2.2%)3 (2.1%)11(8.3%)0.028 Currrent alcoholic drinks23(25.6%)25(17.4%)47(35.6%)0.003

14. Table 1 continued: Sexual history by contraceptive method CharacteristicCOCDMPANon-HCP-value Mean (sd) age of sexual debut (yrs) 17.8 (2.54)16.87(2.44)17.7(2.94)0.02 No of lifetime sexual partners One 2-3 4-10 11 and more 37 (41.1%) 39 (43.3%) 13 (14.4%) 1 (1.1%) 38(26.4%) 69(47.9%) 35(24.3%) 2(1.4%) 31(23.5%) 53(40.2%) 34(25.8%) 14(10.6%) 0.000 Condom use with regular partner Never Less than half More than half always 60 (68.2%) 7 (8.0%) 9 (10.2%) 12(13.6%) 95 (78.5%) 10 (8.3%) 5 (4.1%) 11 (9.1%) 13 (17.6%) 3 (4.1%) 4 (5.4%) 54(73.0%) 0.000 Currently having other sexual partners 2(2.2%)3(2.1%)20(15.2%)0.000

15. Table 1 continued: Sexual, reproductive history and Clinical parameters by contraceptive method CharacteristicCOCDMPANon-HCP-value Ever exchanged sex for money or gifts 2(2.2%)4(2.8%)20(15.2%)0.000 Lifetime number of sexual partners: One 2-3 4-10 11 or more 37 (41.1%) 39 (43.3%) 13 (14.4%) 1 (1.1%) 38 (26.4%) 69 (47.9%) 35 (24.3%) 2 (1.4%) 31(23.5%) 53 (40.2%) 34 (25.8%) 14 (10.6%) 0.000 Reproductive history Currently breastfeeding Median (range) number of births 24 (26.7%) 2 (1-5) 57 (39.6%) 2 (1-6) 16 (12.2%) 2 (0-8) 0.000 CD4 count, median (range)639 (502 -1457)684 (505-1383)630 (500-1689)0.343 Baseline WHO clinical stages WHO stage I WHO stage II 80 (88.9%) 10 (11.1%) 126 (87.5%) 18 (12.5%) 117(90.0%) 13 (10.0%) 0.807

16. Table 2: Multivariate analysis of the association of contraceptive use on CD4 count decline among HIV-1 infected women in Nairobi and Harare CharacteristicEstimate (95% CI)P-value Study site Kenya Zimbabwe 0.015 (-0.066, 0.096) ref 0.719 - Age (mean, SD) years-0.001 (-0.008, 0.006)0.749 Contraceptive method COC DMPA Non-HC -0.266 (-0.612, 0.081) -0.145 (-0.426, 0.137) ref 0.133 0.313 - Baseline CD4 count0.001 (0.000, 0.002)0.024 WHO Disease Staging Stage I Stage II Advanced stage 0.464 (-0.223, 1.152) 0.198 (-0.511, 0.908) ref 0.185 0.584 - Age of sexual debut-0.017 (-0.032, -0.003)0.019

17. Table 3: Multivariate analysis of the association of contraceptive use with time to advanced WHO clinical stages among HIV-1 infected women in Nairobi and Harare CovariateAdjusted HR (95%CI) P-value Study site Kenya Zimbabwe 0.30 (0.11, 0.82) ref.018 - Age (years)1.12 (1.03, 1.21).006 Contraceptive method COC DMPA Non-HC 0.91 (0.25, 3.27) 0.56 (0.19, 1.64) ref 0.883 0.290 - Initial CD4 count0.994 (0.990, 0.999)0.021 Education level None Primary Secondary Post Secondary 1.84(0.12, 27.63) 0.12 (0.02, 0.88) 0.32 (0.05, 1.87) ref 0.658 0.038 0.205 -

18. Table 3 continued….: Multivariate analysis of the association of contraceptive use with time to advanced disease CovariateHR (95% CI)P-value Psychosocial characteristics Had support from friends Had support from other groups Let others know of their HIV status 1.56 (0.58, 4.22) 1.57 (0.55, 4.49) 0.28 (0.10, 0.78) 0.378 0.400 0.015 Body weight0.95 (0.91, 0.99)0.010 Sexual and social behavior Age of sexual debut Taking alcoholic beverages Exchanged sex for gifts 0.98 (0.81, 1.18) 1.86 (0.62, 0.77) 0.21 (0.06, 0.77) 0.804 0.271 0.019

19. Fig 2: Kaplan Meier Curves for survival to advanced WHO clinical stages by contraceptive method

20. Slopes of mean CD4 count by hormonal contraceptive method Follow-up visit (in yrs)) 4.003.50 3.00 2.50 2.00 1.501.00.50.00 100 0 -100 -200 -300 Method Combined pills DMPA Non-hormonal

21. Mean change in CD4 count by contraceptive method Follow-up visit (in yrs)) 4.003.50 3.00 2.50 2.00 1.501.00.50.00 100 0 -100 -200 -300 Method Combined pills DMPA Non-hormonal Follow-up visit (in yrs)) 4.003.503.002.502.001.501.00.50.00 Mean change in CD4 100 0 -100 -200 -300 Method Combined oral pills DMPA Non-hormonal

22. Kaplan Meier curves on time to WHO advanced disease stages (intent-to-treat analysis)

23. Comparison of analyses of the effect of contraceptive on CD4 count decline: intent-to treat analysis vs. per exposure analysis Intent-to-treat Analysis CharacteristicEstimate cells/µL/yr (95%CI) P- value WHO clinical stages I II Advanced stage 0.268(0.0173, 0.362) 0.215(0.111,0.320) -ref <0.001 Per exposure Analysis CharacteristicEstimate cells/µL(95%CI) P- value WHO clinical stages I II Advanced stage 0.464(-0.223, 1.152) 0.198(-0.511, 0.908) -ref 0.185 0.584

24. Comparison of Multivariate analysis on the effect of HC on time to advanced WHO clinical stages: intent-to-treat vs. per exposure analysis Intent-to-treat analysisPer exposure analysis CharacteristicHR (95%CI)P- value CharacteristicHR (95%CI)P-value Country Kenya Zimbabwe 0.69 (0.29, 1.69) Ref 0.427 Country Kenya Zimbabwe 0.30 (0.11, 0.82) Ref 0.018 Ever exchanged sex for gifts 0.310 (0.095, 1.011)0.052Ever exchanged sex for gifts 0.21 (0.06, 0.77)0.019

25. Pending Analysis Effects of HC on Plasma viral load Effects of COC vs. DMPA on CD4 decline

26. Study Limitations Switching from one contraceptive method to another Stringent inclusion criteria thereby missing women who were likely faster progressors Follow up period shorter to attain study endpoints

27. Discussion Differences in baseline CD4 counts and time to advanced WHO stages by country CD4 decline compared to other natural history studies Non-HC group risky sexual and social behavior Why findings differ from those among high risk populations: issues of residual confounding in terms of sexual practice or STI

28. Discussion Factors significantly associated with CD4 decline, faster progression to advanced WHO clinical stages: Baseline CD4 count, age of sexual debut, age and body weight

29. Summary Findings suggest that COC and DMPA have no effects on HIV-1 progression among women attending FP facilities in Nairobi and Harare Baseline CD4 and age of sexual debut were associated with the rate of CD4 decline. Older age and body weight were associated with faster progression to advanced WHO clinical stages

30. Summary These findings will contribute to findings that HIV-1 infected women using either COC or DMPA are not at increased risk of rapid disease progression compared to their counterparts using non hormonal contraceptive methods

31. Acknowledgements Dr. Craig Cohen (UCSF) Dr. Tsungai Chipato (UZ) Tim Farley (WHO) Estie Hudes (CAPS, UCSF) Research teams (Kenya and Zimbabwe) Study participants Collaborating institutions (UCSF,KEMRI, UZ) and funding orgs (WHO, CFAR)