Copper intrauterine device use and HIV acquisition in women: a systematic review

Abstract

ObjectivesTo review systematically copper intrauterine device (Cu-IUD) use and HIV acquisition in women.MethodsWe searched Pubmed, Embase and the Cochrane Library between database inception and 26 June 2019 for longitudinal studies comparing incident HIV infection among women using an unspecified IUD or Cu-IUD compared with non-hormonal or no contraceptive users, or hormonal contraceptive users. We extracted information from included studies, assessed study quality, and summarised study findings.ResultsFrom 2494 publications identified, seven met our inclusion criteria. One randomised controlled trial (RCT), judged “informative with few limitations”, found no statistically significant differences in HIV risk between users of the Cu-IUD and either intramuscular depot medroxyprogesterone acetate (DMPA-IM) or levonorgestrel implant. One observational study, deemed “informative but with important limitations”, found no statistically significant difference in HIV incidence among IUD users compared with women who had tubal ligation or who were not using any contraception. Another “informative but with important limitations” observational study found no difference in HIV incidence between Cu-IUD users and DMPA or norethisterone enanthate injectable, or implant users. An RCT considered “unlikely to inform the primary question” also found no difference in HIV risk between Cu-IUD and progestogen-only injectable users. Findings from the other three “unlikely to inform the primary question” cohort studies were consistent with the more robust studies suggesting no increased risk of HIV acquisition among Cu-IUD users.ConclusionThe collective evidence, including that from a large high-quality RCT, does not indicate an increased risk of HIV acquisition among users of Cu-IUDs.

Hormonal contraception and HIV acquisition among women: an updated systematic review

“…For this review, we expanded the previous framework to include criteria for assessing RCTs and to define criteria for an additional higher-quality level of studies that were “informative with few limitations” (online supplementary appendix 2). 8…”

Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Updated Recommendations for the Use of Contraception Among Women at High Risk for HIV Infection

“…CDC considered several factors and opinions in determining whether to update its guidance. First, CDC used two systematic reviews that were conducted preceding the 2019 WHO consultation: 1) an updated systematic review on hormonal contraception and risk for HIV infection to include new evidence since the last review (7), containing a total of 36 studies, 17 of which met minimum quality criteria defined in the review (8), and 2) a systematic review on copper IUD use and risk for HIV acquisition, containing seven studies, three of which met minimum quality criteria (9). The systematic reviews included primary reports of longitudinal studies (randomized clinical trials or observational studies) identified in PubMed or Embase databases through June 2019.…”

“…Among the observational evidence examining the association between progestin-only injectables and risk for HIV acquisition, results were inconsistent across studies and limited by methodologic concerns (8). Limited evidence on other progestin-only contraceptives, combined hormonal contraceptives, and copper IUDs did not suggest increased risk for HIV acquisition, compared with other hormonal or nonhormonal contraceptives or no method (8,9). Animal and laboratory data suggest possible biologic mechanisms for an association between hormonal contraceptive use and increased risk for HIV acquisition, including hormonally mediated changes in the vaginal epithelium and alterations in local and systemic immune responses.…”

Contraception and HIV: an exercise in clarity

“…Twenty-eight years, hundreds of articles and more than half a dozen systematic reviews after the spectre of an association between the use of modern contraception and an increased risk of HIV acquisition was first raised, two systematic reviews1 2 published in this Journal issue may, at last, close the debate. The reviews update the evidence on the association, and include the findings of a randomised controlled trial (RCT), the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial 3.…”

“…A storm of correspondence supporting the author’s position followed, much of it vitriolic. The systematic reviews1 2 published in this Journal issue demonstrate that a well-conducted, adequately powered RCT trumps observational studies (although perhaps not passionately held beliefs) – but read the reviews and make up your own mind.…”