Hormonal Contraception and the Risk of HIV Acquisition: An Individual Participant Data Meta-analysis.

BACKGROUND Observational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC. METHODS AND FINDINGS Eligible studies measured HC exposure and incident HIV infection prospectively using standardized measures, enrolled women aged 15-49 y, recorded ≥15 incident HIV infections, and measured prespecified covariates. Our primary analysis estimated the adjusted hazard ratio (aHR) using two-stage random effects meta-analysis, controlling for region, marital status, age, number of sex partners, and condom use. We included 18 studies, including 37,124 women (43,613 woman-years) and 1,830 incident HIV infections. Relative to no HC use, the aHR for HIV acquisition was 1.50 (95% CI 1.24-1.83) for DMPA use, 1.24 (95% CI 0.84-1.82) for NET-EN use, and 1.03 (95% CI 0.88-1.20) for COC use. Between-study heterogeneity was mild (I2 < 50%). DMPA use was associated with increased HIV acquisition compared with COC use (aHR 1.43, 95% CI 1.23-1.67) and NET-EN use (aHR 1.32, 95% CI 1.08-1.61). Effect estimates were attenuated for studies at lower risk of methodological bias (compared with no HC use, aHR for DMPA use 1.22, 95% CI 0.99-1.50; for NET-EN use 0.67, 95% CI 0.47-0.96; and for COC use 0.91, 95% CI 0.73-1.41) compared to those at higher risk of bias (pinteraction = 0.003). Neither age nor herpes simplex virus type 2 infection status modified the HC-HIV relationship. CONCLUSIONS This IPD meta-analysis found no evidence that COC or NET-EN use increases women's risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.

(Table 2) Characteristics of a turbidite flow inferred from physiography and morphology of the margin and the sediment waves

This paper presents the morpho-sedimentary characterization and interpretations of the assemblage of landforms of the East Greenland continental slope and Greenland Basin, based on swath bathymetry and sub-bottom TOPAS profiles. The interpretation of landforms reveals the glacial influence on recent sedimentary processes shaping the seafloor, including mass-wasting and turbidite flows. The timing of landform development points to a predominantly glacial origin of the sediment supplied to the continental margin, supporting the scenario of a Greenland Ice Sheet extending across the continental shelf, or even to the shelf-edge, during the Last Glacial Maximum (LGM). Major sedimentary processes along the central section of the eastern Greenland Continental Slope, the Norske margin, suggest a relatively high glacial sediment input during the LGM that, probably triggered by tectonic activity, led to the development of scarps and channels on the slope and debris flows on the continental rise. The more southerly Kejser Franz Josef margin has small-scale mass-wasting deposits and an extensive turbidite system that developed in relation to both channelised and unconfined turbidity flows which transferred sediments into the deep Greenland Basin.