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Access to safe and effective contraceptive choices is a reproductive right and contributes tremendously to improvements in maternal and child health. Progestin-only injectables, particularly intramuscularly injected depot medroxyprogesterone acetate (DMPA-IM), have received increased attention given findings suggesting a potential association with increased HIV risk. For women at high risk of HIV, the World Health Organization's Medical eligibility criteria for contraceptive use currently aggregate recommendations for all progestin-only injectables, including DMPA-IM, subcutaneously injected DMPA (DMPA-SC) and intramuscularly injected norethindrone/ norethisterone enanthate (NET-EN), except in the case of some drug interactions. We considered whether published data indicate differences or similarities between these injectables relevant to risk of acquiring HIV. In vitro data confirm different biological activities of these distinct progestins, including that MPA, and not NET, binds and activates the glucocorticoid receptor resulting in different biological effects relevant to immune function. Limited clinical data suggest changes in immunologic activity following DMPA-IM and NET-EN initiation, but interstudy variation and study design differences diminish ability to determine clinical relevance and the degree to which DMPA-IM and NET-EN could act differentially. The highest-quality epidemiologic studies suggest a potential 40% increase in HIV incidence in users of DMPA-IM relative to women not using hormonal contraception but no significant increase in risk in users of NET-EN. In our opinion, most of the available biologic activity and epidemiologic data indicate that DMPA and NET-EN are likely to act differently, and data remain too limited to evaluate differences between DMPA-IM and DMPA-SC.

BACKGROUND: Subdermal contraceptive implants have low discontinuation rates but are underused among young women in Africa. This study aimed to isolate the role initial contraceptive method has on preventing unintended pregnancy. STUDY DESIGN: We recruited 399 Kenyan women aged 18-24 years into a prospective cohort study if they wanted short-acting hormonal methods (injectable or oral contraceptives). We offered an implant and formed two study groups: implant and short-acting. For contraceptive discontinuation/pregnancy we used log-rank tests and proportional hazards models. We applied intent-to-treat principles to evaluate the role of initial method choice on future pregnancy. RESULTS: Twenty-four percent opted for an implant (n=97) and the remainder opted for a short-acting method (n=299). The 18-month discontinuation probability was 21 per 100 for implant users and 43 per 100 for the short-acting method group (p=.001). Twenty-two unintended pregnancies occurred; all were among the short-acting group. The adjusted relative risk of pregnancy among the short-acting group vs. implant group was 7.4 (95% confidence interval: 1.6-34.5). CONCLUSIONS: Many young Kenyan women found implants to be a reasonable alternative to short-acting methods. Having choice is essential and starting on implants provides substantial and clear protection from unintended pregnancy relative to short-acting methods. Copyright (c) 2012 Elsevier Inc. All rights reserved.

Background Subdermal contraceptive implants may be a reasonable option for young women in sub-Saharan Africa; little is known about factors associated with method uptake in this subpopulation. Study Design Four hundred women aged 18���24 years who sought short-acting hormonal contraception were offered an opportunity to use an implant instead. Cross-tabulations and logistic regression analysis were used to examine participant characteristics and other factors associated with choosing an implant. Results Twenty-four percent of participants chose the implant. Participants with greater than 4 years of contraceptive need were over three times more likely to choose an implant [odds ratio (OR), 3.4; 95% confidence interval (CI), 1.6���6.9]. Women with health concerns over short-acting hormonal methods (OR, 2.2; 95% CI, 1.3���3.6) and those who expressed some difficulty returning to a clinic (OR, 1.9; 95% CI, 1.1���3.1) were about twice as likely to choose an implant. Product attributes such as long-acting protection and convenience were cited reasons for choosing an implant. Conclusions The implant appears to be an attractive option for a fairly large proportion of young women in Kenya. Within this age group of implant users, homogeneity of demographic characteristics relative to short-acting users suggests that the product has broad appeal.

With the renewed focus on family planning, a clear and transparent understanding is needed for the consistent classification of contraceptives, especially in the commonly used modern/traditional system. The World Health Organization Department of Reproductive Health and Research and the United States Agency for International Development (USAID) therefore convened a technical consultation in January 2015 to address issues related to classifying contraceptives. The consultation defined modern contraceptive methods as having a sound basis in reproductive biology, a precise protocol for correct use and evidence of efficacy under various conditions based on appropriately designed studies. Methods in country programs like Fertility Awareness Based Methods [such as Standard Days Method (SDM) and TwoDay Method], Lactational Amenorrhea Method (LAM) and emergency contraception should be reported as modern. Herbs, charms and vaginal douching are not counted as contraceptive methods as they have no scientific basis in preventing pregnancy nor are in country programs. More research is needed on defining and measuring use of emergency contraceptive methods, to reflect their contribution to reducing unmet need. The ideal contraceptive classification system should be simple, easy to use, clear and consistent, with greater parsimony. Measurement challenges remain but should not be the driving force to determine what methods are counted or reported as modern or not. Family planning programs should consider multiple attributes of contraceptive methods (e.g., level of effectiveness, need for program support, duration of labeled use, hormonal or nonhormonal) to ensure they provide a variety of methods to meet the needs of women and men.

Objective To estimate the effect of increased body weight and body mass index (BMI) on pregnancy rates with levonorgestrel (LNG) 1.5mg used as emergency contraception (EC). Methods The study reviewed data from 6873 women in four WHO-HRP randomized trials on EC conducted between 1993 and 2010. Participants took either 1.5mg of LNG as a single dose or in two doses 12h apart, up to 120h of unprotected intercourse. Contraceptive efficacy (pregnancy rates) at different weight and BMI categories was evaluated. Results Overall pregnancy rate was low at 1.2%. Pregnancy rates were also low in women weighing over 80kg (0.7%) and who were obese (BMI over 30kg/m 2 ) (2.0%). The pooled analyses for pregnancy demonstrated that BMI over 30kg/m 2 decreased efficacy significantly (odds ratio 8.27, 95% confidence interval=2.70–25.37) when compared to women in lower BMI categories, mainly influenced by pregnancies in obese women from one study site. Sensitivity analyses excluding that site showed that obesity was no longer a risk factor; however, the other studies included too few obese women in the sample to exclude a substantial decrease in efficacy. Conclusions Pregnancy rates with use of LNG 1.5mg for EC were low at less than 3% across different weight and BMI categories. Pooled analyses showed an increase in pregnancy rates among obese women (BMI more than 30kg/m 2 ) compared to women with normal BMI levels, influenced by pregnancies all coming from one study site. Implications Access to LNG as EC should still be promoted to women who need them, and not be restricted in any weight or BMI category, with additional attention for counselling and advice for obese women.