Long-acting injectable contraceptives have been associated with mucosal immune changes and increased HIV acquisition, but studies have often been hampered by the inaccuracy of self-reported data, unknown timing of injection, and interactions with mucosal transmission co-factors. We used mass spectrometry to quantify the plasma concentrations of injectable contraceptives in women from the CAPRISA004 study (n = 664), with parallel quantification of 48 cytokines and >500 host proteins in cervicovaginal lavage. Higher DMPA levels were associated with reduced CVL concentrations of GCSF, MCSF, IL-16, CTACK, LIF, IL-1α, and SCGF-β in adjusted linear mixed models. Dose-dependent relationships between DMPA concentration and genital cytokines were frequently observed. Unsupervised clustering of host proteins by DMPA concentration suggest that women with low DMPA had increases in proteins associated with mucosal fluid function, growth factors, and keratinization. Although DMPA was not broadly pro-inflammatory, DMPA was associated with increased IP-10 in HSV-2 seropositive and older women. DMPA–cytokine associations frequently differed by vaginal microbiome; in non-Lactobacillus-dominant women, DMPA was associated with elevated IL-8, MCP-1, and IP-10 concentrations. These data confirm a direct, concentration-dependant effect of DMPA on functionally important immune factors within the vaginal compartment. The biological effects of DMPA may vary depending on age, HSV-2 status, and vaginal microbiome composition.
Subscribe to Journal
Get full journal access for 1 year
only $92.33 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Morrison, C. S. et al. Hormonal contraception and the risk of HIV acquisition: an individual participant data meta-analysis. PLoS Med. 12, e1001778 (2015).
Noguchi, L. M. et al. Risk of HIV-1 acquisition among women who use diff erent types of injectable progestin contraception in South Africa: a prospective cohort study. Lancet HIV 2, e279–e287 (2015).
Smith-McCune, K. K. et al. Effects of depot-medroxyprogesterone acetate on the immune microenvironment of the human cervix and endometrium: implications for HIV susceptibility. Mucosal Immunol. 10, 1270–1278 (2017).
Hapgood, J. P., Kaushic, C. & Hel, Z. Hormonal contraception and HIV-1 acquisition: biological mechanisms. Endocr. Rev. 39, 36–78 (2018).
Huijbregts, R. P., Michel, K. G. & Hel, Z. Effect of progestins on immunity: medroxyprogesterone but not norethisterone or levonorgestrel suppresses the function of T cells and pDCs. Contraception 90, 123–129 (2014).
Ralph, L. J., Gollub, E. L. & Jones, H. E. Hormonal contraceptive use and women's risk of HIV acquisition: priorities emerging from recent data. Curr. Opin. Obstet. Gynecol. 27, 487–95. (2015).
Ralph, L. J. et al. Hormonal contraceptive use and women's risk of HIV acquisition: a meta-analysis of observational studies. Lancet Infect. Dis. 15, 181–189 (2015).
Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet 394, 303–313 (2019).
Kiddugavu, M. et al. Hormonal contraceptive use and HIV-1 infection in a population-based cohort in Rakai, Uganda. Aids 17, 233–240 (2003).
Morrison, C. S. et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. Aids 26, 497–504 (2012).
Crook, A. M. et al. Injectable and oral contraceptives and risk of HIV acquisition in women: an analysis of data from the MDP301 trial. Hum. Reprod. (Oxf., Engl.) 29, 1810–1817 (2014).
Heffron, R. et al. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infect. Dis. 12, 19–26 (2012).
Radzio, J. et al. Physiologic doses of depot-medroxyprogesterone acetate do not increase acute plasma simian HIV viremia or mucosal virus shedding in pigtail macaques. AIDS 28, 1431–1439 (2014).
Sodora, D. L. et al. Vaginal transmission of SIV: assessing infectivity and hormonal influences in macaques inoculated with cell-free and cell-associated viral stocks. AIDS Res Hum. Retroviruses 14(Suppl 1), S119–S123 (1998).
Vishwanathan, S. A. et al. High susceptibility to repeated, low-dose, vaginal SHIV exposure late in the luteal phase of the menstrual cycle of pigtail macaques. J. Acquir. Immune Defic. Syndr. 57, 261–264 (2011).
Sanders-Beer, B. et al. Depo-Provera(®) does not alter disease progression in SIVmac-infected female Chinese rhesus macaques. AIDS Res. Hum. Retroviruses 26, 433–443 (2010).
Hild-Petito, S. et al. Effects of two progestin-only contraceptives, Depo-Provera and Norplant-II, on the vaginal epithelium of rhesus monkeys. AIDS Res. Hum. Retroviruses 14(Suppl 1), S125–S130 (1998).
Trunova, N. et al. Progestin-based contraceptive suppresses cellular immune responses in SHIV-infected rhesus macaques. Virology 352, 169–177 (2006).
Veazey, R. S. et al. Prevention of virus transmission to macaque monkeys by a vaginally applied monoclonal antibody to HIV-1 gp120. Nat. Med. 9, 343–346 (2003).
Mauck, C. K. et al. The effect of one injection of Depo-Provera on the human vaginal epithelium and cervical ectopy. Contraception 60, 15–24 (1999).
Achilles, S. L. & Hillier, S. L. The complexity of contraceptives: understanding their impact on genital immune cells and vaginal microbiota. AIDS (London, England) 27, (S5–S15 (2013).
Miller, L. et al. Depomedroxyprogesterone-induced hypoestrogenism and changes in vaginal flora and epithelium. Obstet. Gynecol. 96, 431–439 (2000).
Ildgruben, A. K., Sjoberg, I. M. & Hammarstrom, M. L. Influence of hormonal contraceptives on the immune cells and thickness of human vaginal epithelium. Obstet. Gynecol. 102, 571–582 (2003).
Zalenskaya, I. A. et al. Use of contraceptive depot medroxyprogesterone acetate is associated with impaired cervicovaginal mucosal integrity. J. Clin. Investig. 128, 4622–4638 (2018).
Quispe Calla, N. E. et al. Medroxyprogesterone acetate and levonorgestrel increase genital mucosal permeability and enhance susceptibility to genital herpes simplex virus type 2 infection. Mucosal Immunol. 9, 1571–1583 (2016).
Chandra, N. et al. Depot medroxyprogesterone acetate increases immune cell numbers and activation markers in human vaginal mucosal tissues. AIDS Res. Hum. Retroviruses 29, 592–601 (2013).
Bahamondes, L. et al. The effect upon the human vaginal histology of the long-term use of the injectable contraceptive Depo-Provera. Contraception 62, 23–27 (2000).
Morrison, C. et al. Cervical inflammation and immunity associated with hormonal contraception, pregnancy, and HIV-1 seroconversion. J. Acquir. Immune Defic. Syndr. 66, 109–117 (2014).
Fleming, D. C. et al. Hormonal contraception can suppress natural antimicrobial gene transcription in human endometrium. Fertil. Steril. 79, 856–863 (2003).
Huijbregts, R. P. et al. Hormonal contraception and HIV-1 infection: medroxyprogesterone acetate suppresses innate and adaptive immune mechanisms. Endocrinology 154, 1282–1295 (2013).
Kleynhans, L. et al. The contraceptive depot medroxyprogesterone acetate impairs mycobacterial control and inhibits cytokine secretion in mice infected with Mycobacterium tuberculosis. Infect. Immun. 81, 1234–1244 (2013).
Francis, S. C. et al. Immune activation in the female genital tract: expression profiles of soluble proteins in women at high risk for HIV infection. PLoS ONE 11, e0143109–e0143109 (2016).
Keller, M. J. et al. PRO 2000 elicits a decline in genital tract immune mediators without compromising intrinsic antimicrobial activity. AIDS 21, 467–476 (2007).
Fichorova, R. N. Guiding the vaginal microbicide trials with biomarkers of inflammation. J. Acquir. Immune Defic. Syndr. 37(Suppl 3), S184–S193 (2004).
McKinnon, L. R. et al. Genital inflammation undermines the effectiveness of tenofovir gel in preventing HIV acquisition in women. Nat. Med. 24, 491–496 (2018).
Halpern, V. et al. Pharmacokinetics of subcutaneous depot medroxyprogesterone acetate injected in the upper arm. Contraception 89, 31–35 (2014).
Pyra, M. et al. Concordance of self-reported hormonal contraceptive use and presence of exogenous hormones in serum among African women. Contraception 97, 357–362 (2018).
Klatt, N. R. et al. Vaginal bacteria modify HIV tenofovir microbicide efficacy in African women. Science 356, 938–945 (2017).
Roxby, A. C. et al. Changes in vaginal microbiota and immune mediators in HIV-1-seronegative Kenyan women initiating depot medroxyprogesterone acetate. J. Acquir. Immune Defic. Syndr. 71, 359–366 (2016).
Polis, C. B. et al. Assessing the effect of hormonal contraception on HIV acquisition in observational data: challenges and recommended analytic approaches. AIDS (Lond., Engl.) 27(Suppl 1), S35–S43 (2013).
Zevin, A. S. et al. Microbiome composition and function drives wound-healing impairment in the female genital tract. PLoS Pathog. 12, e1005889 (2016).
Liebenberg, L. J. et al. Genital-systemic chemokine gradients and the risk of HIV acquisition in women. J. Acquir. Immune Defic. Syndr. 74, 318–325 (2017).
Masson, L. et al. Genital inflammation and the risk of HIV acquisition in women. Clin. Infect. Dis. 61, 260–269 (2015).
Mishell, D. R. Jr Pharmacokinetics of depot medroxyprogesterone acetate contraception. J. Reprod. Med. 41(5 Suppl), 381–390 (1996).
Kleynhans, L. et al. Medroxyprogesterone acetate alters Mycobacterium bovis BCG-induced cytokine production in peripheral blood mononuclear cells of contraceptive users. PLoS ONE 6, e24639 (2011).
Michel, K. G. et al. Effect of hormonal contraception on the function of plasmacytoid dendritic cells and distribution of immune cell populations in the female reproductive tract. J. Acquir. Immune Defic. Syndr. 68, 511–518 (2015).
Bendall, L. J. & Bradstock, K. F. G-CSF: from granulopoietic stimulant to bone marrow stem cell mobilizing agent. Cytokine Growth Factor Rev. 25, 355–367 (2014).
Xu, S. et al. Granulocyte colony-stimulating factor (G-CSF) induces the production of cytokines in vivo. Br. J. Haematol. 108, 848–853 (2000).
Keiser, P. et al. Granulocyte colony-stimulating factor use is associated with decreased bacteremia and increased survival in neutropenic HIV-infected patients. Am. J. Med. 104, 48–55 (1998).
Hensley-McBain, T. & Klatt, N. R. The dual role of neutrophils in HIV infection. Curr. HIV/AIDS Rep. 15, 1–10 (2018).
Paris, A. J. et al. Neutrophils promote alveolar epithelial regeneration by enhancing type II pneumocyte proliferation in a model of acid-induced acute lung injury. Am. J. Physiol. Lung Cell Mol. Physiol. 311, L1062–l1075 (2016).
Eroglu, E. et al. Effects of granulocyte-colony stimulating factor on wound healing in a mouse model of burn trauma. Tohoku J. Exp. Med. 204, 11–16 (2004).
Huang, H. et al. Granulocyte-colony stimulating factor (G-CSF) accelerates wound healing in hemorrhagic shock rats by enhancing angiogenesis and attenuating apoptosis. Med. Sci. Monit. 23, 2644–2653 (2017).
Shen, G.-Y. et al. Local injection of granulocyte-colony stimulating factor accelerates wound healing in a rat excisional wound model. Tissue Eng. Regenerative Med. 13, 297–303 (2016).
Keane, T. J. et al. Restoring mucosal barrier function and modifying macrophage phenotype with an extracellular matrix hydrogel: potential therapy for ulcerative colitis. J. Crohns Colitis 11, 360–368 (2017).
Li, Y., Jalili, R. B. & Ghahary, A. Accelerating skin wound healing by M-CSF through generating SSEA-1 and -3 stem cells in the injured sites. Sci. Rep. 6, 28979–28979 (2016).
Byrnes, A. A. et al. Immune activation and IL-12 production during acute/early HIV infection in the absence and presence of highly active, antiretroviral therapy. J. Leukoc. Biol. 84, 1447–1453 (2008).
Fichorova, R. N. et al. The contribution of cervicovaginal infections to the immunomodulatory effects of hormonal contraception. MBio 6, e00221–15 (2015).
Spear, G. T., St John, E. & Zariffard, M. R. Bacterial vaginosis and human immunodeficiency virus infection. AIDS Res. Ther. 4, 25–25 (2007).
Antonio, M. A., Hawes, S. E. & Hillier, S. L. The identification of vaginal Lactobacillus species and the demographic and microbiologic characteristics of women colonized by these species. J. Infect. Dis. 180, 1950–1956 (1999).
Fredricks, D. N., Fiedler, T. L. & Marrazzo, J. M. Molecular identification of bacteria associated with bacterial vaginosis. N. Engl. J. Med. 353, 1899–1911 (2005).
Anahtar, M. N. et al. Cervicovaginal bacteria are a major modulator of host inflammatory responses in the female genital tract. Immunity 42, 965–976 (2015).
McKinnon, L. R. et al. The evolving facets of bacterial vaginosis: implications for HIV transmission. AIDS Res. Hum. Retroviruses 35, 219–228 (2019).
Deese, J. et al. Injectable progestin-only contraception is associated with increased levels of pro-inflammatory cytokines in the female genital tract. Am. J. Reprod. Immunol. 74, 357–367 (2015).
Li, Q. et al. Glycerol monolaurate prevents mucosal SIV transmission. Nature 458, 1034–1038 (2009).
Passmore, J. A., Jaspan, H. B. & Masson, L. Genital inflammation, immune activation and risk of sexual HIV acquisition. Curr. Opin. HIV AIDS 11, 156–162 (2016).
Ngcapu, S. et al. Lower concentrations of chemotactic cytokines and soluble innate factors in the lower female genital tract associated with the use of injectable hormonal contraceptive. J. Reprod. Immunol. 110, 14–21 (2015).
Govender, Y. et al. The injectable-only contraceptive medroxyprogesterone acetate, unlike norethisterone acetate and progesterone, regulates inflammatory genes in endocervical cells via the glucocorticoid receptor. PLoS ONE 9, e96497 (2014).
Birse, K. D. et al. Genital injury signatures and microbiome alterations associated with depot medroxyprogesterone acetate usage and intravaginal drying practices. J. Infect. Dis. 215, 590–598 (2017).
Gunn, B. et al. Enhanced binding of antibodies generated during chronic HIV infection to mucus component MUC16. Mucosal Immunol. 9, 1549–1558 (2016).
Habte, H. H. et al. Anti-HIV-1 activity of salivary MUC5B and MUC7 mucins from HIV patients with different CD4 counts. Virol. J. 7, 269–269 (2010).
Butler, K. et al. A depot medroxyprogesterone acetate dose that models human use and its effect on vaginal SHIV acquisition risk. J. Acquir. Immune Defic. Syndr. 72, 363–371 (2016).
Cundy, T. et al. A randomized controlled trial of estrogen replacement therapy in long-term users of depot medroxyprogesterone acetate. J. Clin. Endocrinol. Metab. 88, 78–81 (2003).
Torgrimson, B. N. et al. Depot-medroxyprogesterone acetate and endothelial function before and after acute oral, vaginal, and transdermal estradiol treatment. Hypertension (Dallas, Tex.: 1979) 57, 819–824 (2011).
Abdool Karim, Q. et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 329, 1168–1174 (2010).
Mlisana, K. et al. Rapid disease progression in HIV-1 subtype C-infected South African women. Clin. Infect. Dis. 59, 1322–1331 (2014).
Matthews, L. T. et al. Women with pregnancies had lower adherence to 1% tenofovir vaginal gel as HIV preexposure prophylaxis in CAPRISA 004, a phase IIB randomized-controlled trial. PLoS ONE 8, e56400 (2013).
Augustine, M. S. Medroxyprogesterone acetate and progesterone measurement in human serum: assessments of contraceptive efficacy. J. Anal. Bioanal. Tech. s5. 2014.
We thank all of the CAPRISA002 and 004 study participants, and the clinical and laboratory staff who worked on these studies. This project was funded by the Canadian Institutes of Health Research CIHR) (A.D.B., L.R.M. TMI 138658). R.P.M. was previously funded by the South African National Research Foundation (NRF) PhD Scholarship and University of KwaZulu-Natal College of Health Science (CHS) for PhD running expenses. L.J.L. is funded by a South African National Research Foundation (NRF) Research Career Advancement Fellowship award. L.R.M. and A.D.B are supported by a CIHR New Investigator Awards. The CAPRISA004 tenofovir gel trial was funded principally by the US Agency for International Development, grants through FHI360, and CONRAD for product manufacturing, with support from the South African Department of Science and Technology (DST).
The authors declare no conflicts of interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Molatlhegi, R.P., Liebenberg, L.J., Leslie, A. et al. Plasma concentration of injectable contraceptive correlates with reduced cervicovaginal growth factor expression in South African women. Mucosal Immunol 13, 449–459 (2020). https://doi.org/10.1038/s41385-019-0249-y