What impact could DMPA use have had in South Africa and how might its continued use affect the future of the HIV epidemic?
What impact could DMPA use have had in South Africa and how might its continued use affect the future of the HIV epidemic?
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DOI：
10.1002/jia2.25414
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发表时间：
2019-11-01
影响因子：
6
通讯作者：
Hallett, Timothy B.
中科院分区：
文献类型：
--
作者：
Beacroft, Leo;Smith, Jennifer A.;Hallett, Timothy B.
简介 一些研究表明，使用注射避孕长效醋酸甲羟孕酮 (DMPA) 可能会增加感染 HIV 的易感性。我们的目标是确定这种关联可能对南非艾滋病毒流行产生的影响。方法 我们使用按年龄、行为风险群体、性别、男性包皮环切状况和避孕措施分层的隔室模型模拟南非异性恋成人艾滋病毒流行情况。我们模拟了两种可能的情景：(1)“有效”情景假设 DMPA 使 HIV 感染的易感性增加 1.20 倍（95% 置信区间 1.06 至 1.36），基于最近的随机对照试验（ECHO 试验）和大量观察性研究的结果。 (2) “无影响”情景假设 DMPA 对 HIV 感染风险没有影响。我们计算了有效和无效情景之间 HIV 相关结果的差异，以确定 DMPA 的使用可能对 HIV 流行产生的潜在影响。结果 1980 年至 2017 年间，DMPA 与 HIV 感染之间的因果关系可能导致南非 430,000 例（90% 的模型运行 160,000 至 960,000）例 HIV 过度感染和 230,000 例（90,000 至 470,000）例艾滋病死亡。这些数字占 4.3%（1.6% 至 4.3%）。分别占该时期南非艾滋病毒感染和艾滋病死亡模型估计总数的 9.6%）和 6.9%（2.6% 至 15.2%）。在额外的感染中，36%（25% 至 48%）发生在男性中。如果 DMPA 的使用继续保持目前的水平，潜在的因果关系可能会导致 2018 年至 2037 年间额外出现 130,000 例（50,000 至 270,000）例感染。从 1980 年至 2017 年，额外的感染需要 640,000（190,000 至 1,660,000）年的 ART 治疗，并且需要进一步治疗。从 2018 年到 2037 年，ART 治疗时间为 2,870,000（890,000 至 7,270,000）年。 结论 如果 DMPA 使用与 HIV 风险之间存在因果关系，则可能会大大增加南非 HIV 流行的规模，不仅影响 DMPA 使用者，还影响其伴侣和更广泛的人群。这种潜在影响的严重性需要仔细收集数据，并仔细考虑艾滋病毒流行地区的避孕政策选择。
Introduction Some studies suggest that use of the injectable contraceptive depot medroxyprogesterone acetate (DMPA) may increase susceptibility to HIV infection. We aim to determine the influence that such an association could have had on the HIV epidemic in South Africa. Methods We simulate the heterosexual adult HIV epidemic in South Africa using a compartmental model stratified by age, behavioural risk group, sex, male circumcision status and contraceptive use. We model two possible scenarios: (1) The "With Effect" scenario assumes that DMPA increases susceptibility to HIV infection by 1.20-fold (95% confidence interval 1.06 to 1.36) based on a combination of the results of a recent randomised controlled trial (ECHO trial) and a number of observational studies. (2) The "No Effect" scenario assumes that DMPA has no effect on HIV acquisition risk. We calculate the difference in HIV-related outcomes between the With Effect and No Effect scenarios to determine the potential impact that DMPA use could have had on the HIV epidemic. Results A causal association between DMPA and HIV acquisition could have caused 430,000 (90% of model runs 160,000 to 960,000) excess HIV infections and 230,000 (90,000 to 470,000) AIDS deaths in South Africa from 1980 to 2017. These figures represent 4.3% (1.6% to 9.6%) and 6.9% (2.6% to 15.2%) of the total modelled estimates of HIV infections and AIDS deaths respectively in South Africa in that period. Of the additional infections, 36% (25% to 48%) would have occurred among men. If DMPA use continues at current levels, a potential causal association could cause an additional 130,000 (50,000 to 270,000) infections between 2018 and 2037. The excess infections would have required an additional 640,000 (190,000 to 1,660,000) years of ART from 1980 to 2017, and a further 2,870,000 (890,000 to 7,270,000) years of ART from 2018 to 2037. Conclusions If there is a causal association between DMPA use and HIV risk, it could have substantially increased the scale of the HIV epidemic in South Africa, affecting not only the users of DMPA, but also their partners and the wider population. The magnitude of this potential effect demands careful data collection and a careful consideration of policy choices for contraception in settings with large HIV epidemics.