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Hormonal contraception is associated with increased risk of cardiometabolic disease in women living with HIV

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BACKGROUND: Women living with HIV (WLWH) have a high incidence of cardiometabolic disease. Hormonal contraception (HC) can affect cardiometabolic risk in women but has not been studied in WLWH.
METHODS: Observational clinical cohort included cis-female WLWH aged 18-45 years in Nashville, Tennessee, between 1998-2018. Women with breast/ovarian cancer, hysterectomy, or bilateral tubal ligation at/before clinic entry were excluded. Person-time during pregnancies was censored. Outcomes included incident clinical or laboratory diagnoses of cardiovascular/thrombotic disease (CVD) (hypertension, atherosclerotic disease, heart failure, and deep venous thrombosis) and metabolic disease (diabetes, dyslipidemia, obesity, and non-alcoholic steatohepatitis). Multivariable marginal structural models examined time-varying current and cumulative HC use and cardiometabolic outcomes, adjusting for age, race, smoking, prevalent cardiometabolic comorbidities, and CD4 count at clinic entry. WLWH with prevalent CVD were excluded from analyses evaluating incident CVD; WLWH with prevalent metabolic disease were excluded from analyses evaluating incident metabolic disease. Comparator groups included WLWH on other contraception or none.
RESULTS: Of 729 women included, median age was 31 years (IQR 26-37), median CD4 count was 442 cells/"┬ÁL (IQR 232-678), 111 (15%) women had CVD, and 350 (48%) women had a metabolic disorder at baseline. During follow-up, 235 (32%) women used HC (median duration 1.65 years (IQR 0.61-3.61)). CVD analyses included 618 women and 117 events; metabolic analyses included 379 women and 172 events. Current and cumulative HC use increased risk of CVD, particularly oral HC (Figure). HC use was less associated with incident metabolic disorders. Metabolic disorder risk increased with cumulative oral HC use and decreased with cumulative DMPA use. Non-white race, smoking, prevalent comorbidities, time from baseline, and older age also increased risk of cardiometabolic disease.


CONCLUSIONS: Current and cumulative HC use was independently associated with cardiometabolic disease risk, particularly CVD, among WLWH. Cardiometabolic risk should be considered when selecting contraception for WLWH.