CONTRACEPTIVE CHOICES FOR THE NEW MOTHER

In an update to its 2010 report Medical Eligibility Criteria for -Contraceptive Use, the Centers for Disease Control and Prevention has said that because use of combined hormonal contraceptives is associated with an elevated risk of venous thromboembolism, it “represents an unacceptable health risk” for women who are less than 21 days postpartum.1 (During pregnancy, normal changes in blood chemistry result in an increase in clotting factors and a reduction in natural anticoagulants.) At 21–42 days postpartum, these methods—the pill, patch and ring—remain unsafe for women who have other risk factors for venous thromboembolism; for those who do not, however, the benefits outweigh the risks at this point. Beyond 42 days, postpartum status does not call for any restriction on the use of combined hormonal contraceptives. Recommendations for other methods remain unchanged: Women can use progestin-only methods, IUDs and condoms at any time after giving birth, and they can begin using the diaphragm or cap after six weeks.

1. Centers for Disease Control and Prevention, Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period, Morbidity and Mortality Weekly Report, 2011, 60(26):878–883.

NEWEST PILLS LINKED TO RISK

Users of the newest combined oral contraceptives, which contain the synthetic progestin drospirenone, had twice as high odds of nonfatal venous thromboembolism as users of pills containing levonorgestrel in a study based on claims data from managed care plans.1 The results were essentially unchanged in analyses adjusting for prescribing biases and potentially confounding factors. Overall, nonfatal venous thromboembolism occurred at a rate of 30.8 per 100,000 users of pills containing drospirenone and 12.5 per 100,000 among users of pills with levonorgestrel. As the researchers report, earlier work has yielded conflicting conclusions about how the risk of this condition compares between users of these oral contraceptives, but they took a number of steps to overcome the limitations of previous work; notably, they excluded from their analyses women who had risk factors for venous thromboembolism. Given their findings, they conclude that “in the absence of other considerations, [pills containing drospirenone] should not be the first choice in oral contraception.”

1. Jick SS and Hernandez RK, Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data, BMJ, 2011, 340:d2151, DOI: 10.1136/bmj.d2151.

ORAL SEX: STDs MAY GO IN BOTH DIRECTIONS

The risk that oral sex can transmit chlamydia or gonorrhea from a male’s urethra to his partner’s mouth or throat has been well documented, but it now appears that the risk may work in the other direction, too.1 In a study conducted in 2006–2010 in a municipal STD clinic in San Francisco, 227 men who had a chlamydia test and 161 of those tested for gonorrhea reported that their only potential exposure to these diseases in the past three months was through having received oral sex from a woman; 4% and 3%, respectively, tested positive. The results, according to the researchers, suggest that “the female oropharynx might be an unaddressed reservoir” for the pathogens that cause chlamydia and gonorrhea. Consequently, they write, “patients should be counseled that urethral infections can be acquired through fellatio.”

1. Marcus JL et al., Chlamydia trachomatis and Neisseriea gonorrhoeae transmission from the female oropharynx to the male urethra, Sexually Transmitted Diseases, 2011, 38(5):372–373.

HIV RISK: SEXUAL BEHAVIOR MAY OUTWEIGH DRUG USE

Risky sexual behavior appears to have accounted for most HIV infections in a sample of injection-drug users in New York City, where a large-scale syringe exchange program was in place when all of the study participants began injecting drugs.1 Eight percent of the sample had HIV infection, 39% were infected with herpes simplex virus type 2 (a marker for risky sexual behavior) and 55% had hepatitis C (which can be transmitted when infected individuals share injection-drug paraphernalia). Those with herpes had significantly elevated odds of being HIV-positive (odds ratio, 7.9), but no association was found between HIV and hepatitis C infection. The researchers calculate that 71% of HIV infections in this sample were sexually acquired. By contrast, in the early years of the epidemic—and before syringe exchange programs were introduced—unsafe drug-related activities accounted for the major share of HIV infections. As the epidemic evolves, the researchers conclude, interventions should address “the increasing importance of sexual transmission” among users of injection drugs.

1. Des Jarlais DC et al., Associations between herpes simplex virus type 2 and HCV with HIV among injection drug users in New York City: the current importance of sexual transmission of HIV, American Journal of Public Health, 2011, 101(7):1277–1283.

THE SPECTER OF HIV MORTALITY

Men who have sex with men are much more likely than others to die young, and the difference is explained by HIV, according to an analysis of data from the 1988–1994 cohort of participants in the National Health and Nutrition Examination Survey.1 The men were aged 17--–59 when first interviewed and were followed for up to 18 years. During that period, 21% of those who had ever had sex with a man died, two-thirds of them from causes related to HIV. By contrast, 6–7% of those who had had only female partners or no partners at all died during follow-up; almost none of these deaths were from HIV-related causes. Analyses adjusting for background and risk-related characteristics confirmed that compared with men who had had only female partners, those who had had sex with men had an elevated overall mortality risk (hazards ratio, 3.6) and a dramatically higher risk of dying from HIV-related causes (157.4); the mortality risk from other causes did not differ between the two groups. The analysts propose that “routinely collecting information on markers of sexual orientation in health surveys…will facilitate tracking the health of people with minority sexual orientation and will reduce the impact of modifiable health threats that may be elevated among gay and bisexual men.”

1. Cochran SD and Mays VM, Sexual orientation and mortality among US men aged 17 to 59 years: results from the National Health and Nutrition Examination Survey III, American Journal of Public Health, 2011, 101(6):1133–1138.

NOT FILLING THE BILL

The need to obtain monthly refills may be a significant obstacle to contraceptive adherence, according to findings from the Contraceptive CHOICE Project, in which enrollees can receive the pill, patch or ring for free from a local pharmacy chain that is “ubiquitous” in their local area.1 Of the 619 women who received a prescription for one of these methods and obtained at least one refill in an 18-month period in 2008–2009, only 30% got every refill on time; 31% were late in getting one refill, and 38% were late for two or more. On average, pill users first failed to obtain a refill after seven months; users of the patch and ring, five months each. In multivariate analysis, women using the ring (but not patch users) were more likely than those who chose the pill to have been late for a refill two or more times (relative risk, 1.6); the risk of missing refills this often was also elevated among women who were neither white nor black and women who had had an abortion. The researchers point out that since study participants do not have to pay for their contraceptives, the results probably understate levels of contraceptive nonadherence. More generally, they conclude, the findings underscore the benefits of contraceptive methods that “do not require daily, weekly or monthly action.”

1. Pittman ME et al., Understanding prescription adherence: pharmacy claims data from the Contraceptive CHOICE Project, Contraception, 2011, 83(4):340–345.

INFECTIOUS SYPHILIS SOARS AMONG MEN

Between 2000 and 2008, levels of infectious syphilis climbed steeply among men in three metropolitan areas, where young blacks appear to be particularly at risk.1 The number of infected men rose from 107 to 1,027 in New York City, from 109 to 374 in Miami–Fort Lauderdale and from 41 to 142 in Philadelphia. In each area, the majority of those infected were men who have sex with men, and blacks had higher rates of infection than whites; the majority of infected teenagers were black. Among adolescent men with infectious syphilis, 15% of those in New York and Philadelphia, and 25% of those in Miami–Fort Lauderdale, also had HIV. Rates of infection per 100,00 rose sharply among black teenagers: in New York, from 2.6 to 43.0; in Miami–Fort Lauderdale, from 5.5 to 48.1; and in Philadelphia, from 8.3 to 40.3. Because the infectious syphilis epidemic involves diverse age, racial and ethnic groups “with their own subcultures,” researchers stress the need for targeted interventions to reach populations at risk.

1. Brewer TH et al., Infectious syphilis among adolescent and young adult men: implications for human immunodeficiency virus transmission and public health interventions, Sexually Transmitted Diseases, 2011, 38(5):367–371.

IN BRIEF

• The American College of Obstetricians and Gynecologists has updated its practice bulletin on long-acting reversible contraceptives (IUDs and implants). The bulletin reviews the evidence regarding these methods’ mechanisms of action, effectiveness and potential side effects, as well as provides guidance for assessing women’s eligibility to use these methods. [Committee on Practice Bulletins–Gynecology, Long-acting reversible contraception: implants and intrauterine devices, Obstetrics & Gynecology, 2011, 118(1):184–196.]

• Results of a broad-ranging survey of women’s health are now available in the Henry J. Kaiser Family Foundation’s Women’s Health Care Chartbook (<http://www.kff.org/womenshealth/upload/8164.pdf>). Using data from a nationally representative sample of women who were interviewed in 2008, the report paints a picture of women's health status, insurance coverage, use of health care services, access to care, and role in family members' health care. The findings, according to the authors, may “provide a useful baseline of understanding women’s experiences as…health reform implementation moves forward.”

• Another report from the Kaiser Family Foundation documents trends in public opinion about HIV and AIDS. Among the key findings of the 2011 survey on which it is based: Fewer than one in 10 Americans now consider HIV and AIDS “the most urgent health problem facing this nation,” and half think of HIV as a “manageable chronic disease”; one in five adults are “very concerned” about their own risk of contracting HIV, but the proportion is twice that among blacks. HIV/AIDS at 30: A Public Opinion Perspective is available at <http://www.kff.org/kaiserpolls/upload/8186.pdf>.