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Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia

Haddad, Lisa B. MD, MPH; Wall, Kristin M. PhD; Tote, Katherine MPH; Kilembe, William MD, MSc; Vwailika, Bellington MSc, MD; Sharkey, Tyronza MPH; Brill, Ilene MPH; Chomba, Elwyn MD; Tichacek, Amanda MPH; Allen, Susan MD, MPH

doi: 10.1097/AOG.0000000000003404
Contents: Human Immunodeficiency Virus: Original Research

OBJECTIVE: To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis.

METHODS: Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest.

RESULTS: There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54–0.95), candidiasis (aHR 0.75, 95% CI 0.57–1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25–0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65–0.97).

CONCLUSION: We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.

Depot medroxyprogesterone acetate was associated with reduced rates of bacterial vaginosis, vaginal candidiasis, and Trichomonas vaginalis; oral contraception was associated with reduced rates of vaginal candidiasis.

Department of Gynecology and Obstetrics, Emory University, School of Medicine, the Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, and the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia; the Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; and the Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, and the Ministry of Community Development, Mother and Child Health, Lusaka, Zambia.

Corresponding author: Lisa B. Haddad, MD, MPH, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA; email:

Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD R01 HD40125); National Institute of Mental Health (NIMH R01 66767); the AIDS International Training and Research Program Fogarty International Center (D43 TW001042); the Emory Center for AIDS Research (P30 AI050409); National Institute of Allergy and Infectious Diseases (NIAID R01 AI51231; NIAID R01 AI040951; NIAID R01 AI023980; NIAID R01 AI64060; NIAID R37 AI51231); the US Centers for Disease Control and Prevention (5U2GPS000758); and the International AIDS Vaccine Initiative. This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID). Dr. Haddad's effort is supported by the NICHD (1K23HD078153). The contents do not necessarily reflect the views of USAID or the United States Government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Financial Disclosure The authors did not report any potential conflicts of interest.

Each author has confirmed compliance with the journal's requirements for authorship.

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© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.