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ORIGINAL ARTICLE
Open Access

Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis

Maria Isabel Rodriguez, Mary E Gaffield, Leo Han and Aaron B Caughey
Global Health: Science and Practice December 2017, 5(4):581-591; https://doi.org/10.9745/GHSP-D-17-00243
Maria Isabel Rodriguez
aDepartment of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.
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  • For correspondence: rodrigma@ohsu.edu
Mary E Gaffield
bDepartment of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
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Leo Han
aDepartment of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.
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Aaron B Caughey
aDepartment of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA.
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    FIGURE

    Decision Analysis Model

    Abbreviations: ARVs, antiretrovirals; COCs, combined oral contraceptives; IUD, intrauterine device; POI, progestin-only injectable.

    All branches are followed to the same outcome of life expectancy; truncated here for clarity. Red triangles represent terminal nodes while green circles represent decision nodes.

    When calculating the number of HIV cases averted if no POIs were available, we considered 2 scenarios for women currently using POIs: (1) they all switch to no method, and (2) they switch to another reversible modern method (COCs, an IUD, or an implant).

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    TABLE 1.

    Model Inputs

    VariableAll Regions
    Increase in HIV acquisition with POI use2840%
    Average maternal age at time of birth25 years
    Reduction in life expectancy for women with HIV on ART3825%
    Reduction in life expectancy for women with HIV not on ART3875%
    Probability of maternal-to-child transmission of HIV if ARVs used in labor402%
    Probability of maternal-to-child transmission of HIV if ARVs not used in labor4025%
    Standard discount ratea,393%
    Regional Inputs
    Central AfricaEastern AfricaSouthern AfricaWestern Africa
    ChadDRCKenyaTanzaniaUgandaMalawiSouth AfricaBurkina FasoSenegal
    Life expectancy (years)4151.558.761.665.058.562.757.258.266.4
    HIV36
    HIV incidence.001.0003.003.002.005.004.015.0005.0001
    Probability of ARVs in labor.46.67.74.86.97.79.99.89.36
    Probability of accessing ARVs.36.33.59.57.57.61.48.54.40
    Contraceptive use8,9
    POIs.09.012.14.087.14.32.28.061.052
    COCs.005.007.07.06.03.02.05.02.041
    Implant.00.007.016.005.025.09.00.08.012
    IUD.00.002.023.002.005.01.01.001.006
    Sterilization.001.007.041.041.027.10.14.002.002
    Unmet need for contraceptionb,8.22.28.29.26.35.38.13.25.31
    Maternal mortality6
    Live birthc856693510546d343634138371315
    Unsafe abortiond,e808010010010040408080
    Pregnancy outcomes (per 100 women)13
    Live birth.77.77.76.76.76.66.66.78.78
    Induced abortion.13.13.14.14.14.24.24.12.12
    Spontaneous abortion.09.09.09.09.09.09.09.09.09
    Ectopic pregnancy.01.01.01.01.01.01.01.01.01
    • Abbreviations: ART, antiretroviral therapy; ARVs, antiretrovirals; COC, combined oral contraceptive; DRC, Democratic Republic of the Congo; IUD, intrauterine device; POI, progestin-only injectable.

    • ↵a The standard discount rate is routinely used in decision analysis to account for the fact that goods (dollars, health) are not as valuable in the future as they are in the present. Anywhere between 1.5% and 5% is considered a reasonable rate to discount health outcomes.37

    • ↵b The number of women of reproductive age who are married or living with a partner who are fecund, are not using contraception, and report that they do not want any more children or wish to delay their next pregnancy, divided by the number of women of reproductive age who are married or living with a partner.

    • ↵c 2015 WHO estimates of maternal mortality ratio (per 100,000 live births).

    • ↵d Country-level data were not available and so regional estimates were used.

    • ↵e 2008 WHO unsafe abortion rates (per 1,000 women ages 15–44 years).

    • View popup
    TABLE 2.

    Comparison of Baseline Scenario of Current POI Use With the Scenario of Eliminating POIs From the Market and All POI Users Switching to No Method (per 100,000 Women)

    BaselineRemove POIsDifference
    CENTRAL AFRICA
    Chad
    Change in life-years−9000 life-years lost
    New HIV cases (total)171155−16 HIV cases
    New maternal HIV cases161134−27 HIV cases
    New neonatal HIV cases1021+11 HIV cases
    Maternal deaths363755+391 maternal deaths
    Democratic Republic of the Congo
    Change in life-years−6600 life-years lost
    New HIV cases (total)422409−13 HIV cases
    New maternal HIV cases390342−48 HIV cases
    New neonatal HIV cases3267+35 HIV cases
    Maternal deaths190500+310 maternal deaths
    EASTERN AFRICA
    Kenya
    Change in life-years−6600 life-years lost
    New HIV cases (total)423409−14 HIV cases
    New maternal HIV cases398349−49 HIV cases
    New neonatal HIV cases2560+35 HIV cases
    Maternal deaths190551+341 maternal deaths
    Tanzania
    Change in life-years−7000 life-years lost
    New HIV cases (total)267259−8 HIV cases
    New maternal HIV cases248217−31 HIV cases
    New neonatal HIV cases1942+23 HIV cases
    Maternal deaths201406+210 maternal deaths
    Uganda
    Change in life-years−5000 life-years lost
    New HIV cases (total)622592−30 HIV cases
    New maternal HIV cases581509−72 HIV cases
    New neonatal HIV cases4183+ 42 HIV cases
    Maternal deaths196406+210 maternal deaths
    SOUTHERN AFRICA
    Malawi
    Change in life-years−7500 life-years lost
    New HIV cases (total)489473−16 HIV cases
    New maternal HIV cases456400−56 HIV cases
    New neonatal HIV cases3373+40 HIV cases
    Maternal deaths252565+313 maternal deaths
    South Africa
    Change in life-years−1000 life-years lost
    New HIV cases (total)17741771−3 HIV cases
    New maternal HIV cases16241507−117 HIV cases
    New neonatal HIV cases150264+114 HIV cases
    Maternal deaths186332+146 maternal deaths
    WESTERN AFRICA
    Burkina Faso
    Change in life-year−4700 life-years lost
    New HIV cases (total)4746−1 HIV case
    New maternal HIV cases4338−5 HIV cases
    New neonatal HIV cases48+ 4 HIV cases
    Maternal deaths172349+177 maternal deaths
    Senegal
    Change in life-years−4500 life-years lost
    New HIV cases (total)1312−1 HIV case
    New maternal HIV cases1210−2 HIV cases
    New neonatal HIV cases12+1 HIV case
    Maternal deaths147304+157 maternal deaths
    • Abbreviation: POI, progestin-only injectable.

    • View popup
    TABLE 3.

    Sensitivity Analysis Results: At What Threshold Valuea Would Removal of POIs Result in an Increase in Life-Years?

    VariableCentral AfricaEastern AfricaSouthern AfricaWestern Africa
    ChadDRCKenyaTanzaniaUgandaMalawiSouth AfricaBurkina FasoSenegal
    POI contraceptive failure rate82.8%78.7%79.3%81.4%81.1%81.0%14.4%84.2%84.7%
    % of women switching to an equally effective methodb96.9%92.8%93.5%96.1%95.4%94.9%15.2%99.6%100.0%
    Maternal mortality ratio–c–c–c–c–c–c−23%–c–c
    • Abbreviation: DRC, Democratic Republic of the Congo.

    • ↵a A threshold value indicates the value a variable would need to reach or exceed for removal of POIs to result in increased life-years. For example, in South Africa the maternal mortality ratio would need to decrease by 23% for the removal of POIs to be associated with increased life-years, assuming all other variables remain the same.

    • ↵b Intrauterine device or implant.

    • ↵c No threshold value exists; across all values of the maternal mortality ratio, removal of POIs results in loss of life-years.

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Global Health: Science and Practice: 5 (4)
Global Health: Science and Practice
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December 28, 2017
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Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis
Maria Isabel Rodriguez, Mary E Gaffield, Leo Han, Aaron B Caughey
Global Health: Science and Practice Dec 2017, 5 (4) 581-591; DOI: 10.9745/GHSP-D-17-00243

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Re-Evaluating the Possible Increased Risk of HIV Acquisition With Progestin-Only Injectables Versus Maternal Mortality and Life Expectancy in Africa: A Decision Analysis
Maria Isabel Rodriguez, Mary E Gaffield, Leo Han, Aaron B Caughey
Global Health: Science and Practice Dec 2017, 5 (4) 581-591; DOI: 10.9745/GHSP-D-17-00243
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