Prevalence and Incidence of Sexually Transmitted Infection in Injectable Progestin Contraception Users in South Africa

Abstract

Introduction: Whether intramuscular depot medroxyprogesterone acetate (DMPA-IM) and norethisterone enanthate (NET-EN) have a differential impact on the incidence of sexually transmitted infection (STI) remains unclear. In the Vaginal and Oral Interventions to Control the Epidemic (VOICE) trial, HIV-1 acquisition was higher for DMPA-IM users vs. NET-EN users. We compared DMPA-IM and NET-EN users with regard to chlamydia, gonorrhea, trichomoniasis, syphilis, and herpes simplex virus type 2 (HSV-2) infection.Materials and Methods: Prospective data were analyzed from VOICE, a randomized trial of HIV-1 chemoprophylaxis. Participants were evaluated annually and as indicated for chlamydia, gonorrhea, trichomoniasis, and syphilis. Stored specimens were tested for HSV-2. Proportional hazards models compared the risk of STI between DMPA-IM and NET-EN users.Results: Among 2,911 injectable contraception users in South Africa, 1,800 (61.8%) used DMPA-IM and 1,111 used NET-EN (38.2%). DMPA-IM and NET-EN users did not differ in baseline chlamydia: 15.1 vs. 14.3%, p = 0.54; gonorrhea: 3.4 vs. 3.7%, p = 0.70; trichomoniasis: 5.7 vs.5.0%, p = 0.40; or syphilis: 1.5 vs. 0.7%, p = 0.08; but differed for baseline HSV-2: (51.3 vs. 38.6%, p < 0.001). Four hundred forty-eight incident chlamydia, 103 gonorrhea, 150 trichomonas, 17 syphilis, and 48 HSV-2 infections were detected over 2,742, 2,742, 2,783, 2,945, and 756 person-years (py), respectively (chlamydia 16.3/100 py; gonorrhea 3.8/100 py; trichomoniasis 5.4/100 py; syphilis 0.6/100 py; HSV-2 6.4/100 py). Comparing DMPA-IM with NET-EN users, no difference was noted in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV-2 infections, including when adjusted for confounders [chlamydia (aHR 1.03, 95% CI 0.85–1.25), gonorrhea (aHR 0.88, 95% CI 0.60–1.31), trichomoniasis (aHR 1.07, 95% CI 0.74–1.54), syphilis (aHR 0.41, 95% CI 0.15–1.10), and HSV-2 (aHR 0.83, 95% CI 0.45–1.54, p = 0.56)].Discussion: Among South African participants enrolled in VOICE, DMPA-IM and NET-EN users differed in prevalence of HSV-2 at baseline but did not differ in the incidence of chlamydia, gonorrhea, trichomoniasis, syphilis, or HSV-2 infection. Differential HIV-1 acquisition, previously demonstrated in this cohort, does not appear to be explained by differential STI acquisition. However, the high incidence of multiple STIs reinforces the need to accelerate access to comprehensive sexual and reproductive health services.

Contraceptive effects on the cervicovaginal microbiome: Recent evidence including randomized trials

“…While no evidence of an association between DMPA‐IM use and N. gonorrhoeae was found in any of these analyses, the evidence regarding risk of T. vaginalis and C. trachomatis overall suggested a reduced incidence with DMPA‐IM use 41,42,86–88 . A recent analysis of the VOICE trial comparing South African women choosing DMPA‐IM versus NET‐EN found no differences in C. trachomatis , N. gonorrhoeae or T. vaginalis incidence between the two groups 89 . Very few studies have evaluated implant, contraceptive IVR and IUD use on bacterial STI risk and generally, no association has been found 84,85 .…”

“…41,42,[86][87][88] A recent analysis of the VOICE trial comparing South African women choosing DMPA-IM versus NET-EN found no differences in C. trachomatis, N. gonorrhoeae or T. vaginalis incidence between the two groups. 89 Very few studies have evaluated implant, contraceptive IVR and IUD use on bacterial STI risk and generally, no association has been found. 84,85 However, in two recent longitudinal studies evaluating STI incidence in users of difference contraceptive methods in sub-Saharan African women and US adolescents, respectively, Cu-IUD use was a significant risk factor for trichomoniasis.…”

Multipurpose Prevention Technologies: Opportunities and Challenges to Ensure Advancement of the Most Promising MPTs

“…The HIV/sexually transmitted infection (STI) syndemics and the unmet need for modern contraceptive methods continue to pose significant health risks for women worldwide (1). Women are at high risk of HIV in many regions of the world, particularly young women and girls in Sub-Saharan Africa where 71% of all new infections are among adolescents (2-4).…”