Long-Acting Reversible Contraception: The Contraceptive CHOICE Project
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1 Long-Acting Reversible Contraception: The Contraceptive CHOICE Project Jeffrey F. Peipert, M.D., Ph.D. Vice Chair of Clinical Research Robert J. Terry Professor Department of Obstetrics & Gynecology Washington University in St. Louis School of Medicine March 15, 2016
2 FINANCIAL CONFLICTS Research Grant Support Bayer, Merck, Teva Advisory Boards Perrigo, Teva
3 OBJECTIVES Describe the contraceptive choices of participants in the Contraceptive CHOICE Project Provide the continuation rates of contraceptive options Provide evidence for compliance/adherence and contraceptive failure rates
4 U.S. Percent of Pregnancies Unintended is High 60% 50% 40% 30% 20% 10% 51% 33% 33% 0% United States 2008 France 2001 Italy 2006 Finer and Zolna 2011; Bajos 2003; Carbone 2009
5 Disparities by Race & Ethnicity Persist Across Income Groups <100% of poverty %+ of poverty White Hispanic Black Unintended pregnancy rate, 2008
6 Typical Use - First Year Failure Rates No Contraception 85.0 Spermicides 29.0 Condom - Male 15.0 Oral Contraceptives 8.0 *Patch/Ring IUD - Copper T 380A IUD - Levonorgestrel REVERSIBLE LONG- TERM CONTRACEPION IS HIGHLY EFFECTIVE, RIVALING STERLIZATION Injectable (DMPA) 3.0 Implant *Estimates in lieu of actual data Trussell J. Contraception 2004;70: **Funk S et al. Contraception 2005;71:
7 Long-Acting Reversible Contraception There is a need for effective contraceptive methods that are Finer LB, et al. Perspect Sexual Reprod Health Hillis SD, et al. Obstet Gynecol Stanwood NL, et al. Obstet Gynecol
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9 Contraceptive Cohort Study Remove financial barriers to most effective long-term reversible methods Recruit 10,000 participants over 4 years No-cost contraception Participant choice 2-3 years follow-up Assess continuation, satisfaction Population outcomes: Unintended/teen pregnancy
10 Long-Acting Reversible Contraception LNG-IUS 99% effective 20 mcg levonorgestrel/day Up to 5 years Copper T IUD 99% effective Copper ions Up to 10 years Subdermal Implant 99% effective 60 mcg etonogestrel/day Up to 3 years
11 CHOICE: Inclusion Criteria years Primary residency in STL City or Country Sexually active with male partner (or soon to be) Does not desire pregnancy during next 12 months Desires reversible contraception Willing to try a new contraceptive method
12 Contraceptive CHOICE Project: Study Details ELIGIBLE Tiered Contraceptive Counseling 94% 87% 81% LNG-IUS Cu-IUD Implant DMPA Pills Patch Ring Other 12 Secura G, Am J Obstet & Gynecol 2010 Madden T, Contraception 2012
13 Baseline Characteristics Age (years) N % , Race n % Black White Other
14 Baseline Characteristics (N=9,256) SES n % Public assistance Trouble meeting basic needs Insurance n % None Private Public
15 Baseline Characteristics Parity N % Unintended pregnancy History of STI
16 LARC Acceptance LNG-IUS 46.0 CuT380A 11.9 Implant 16.9 DMPA 6.9 Pills 9.4 Ring 7.0 Patch 1.8 Other <1.0 % 75% 16
17 Choice of LARC Methods in Adolescents 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% years years IUD Implant
18 NEJM CHOICE Publication
19 Unintended Pregnancy by Contraceptive Method HR adj = 22.3 (95% CI 14.0, 35.4) TWENTY-FOLD DIFFERENCE! Winner, et al. NEJM 2012.
20 Method Failure by Age HR adj = 1.9; 95% CI 1.2, 2.8 Winner NEJM 2012
21 12- & 24-Month Continuation: Overall Cohort Method 12-Month (%) 24-Month (%) LNG-IUS Copper IUD Implant Any LARC DMPA OCPs Ring Patch Non-LARC Peipert, et al. Obstet Gynecol 2011; O Neil, et al. Obstet Gynecol In Press
22 Rosenstock Obstet Gynecol Month Satisfaction*: Overall Cohort & By Age Method Overall (%) (%) (%) LNG- IUS % 84% Copper IUD % 81% Implant % 78% Any LARC % 82% DMPA % 52% Pills % 50% Ring % 52% Patch % 38% Non-LARC % 50% *Very or somewhat satisfied combined
23 Intent to Use versus As Used Where does DMPA fit? Reeves et al. AJOG 2016
24 GAP Analysis: Multivariable Risk Factors for Unintended Pregnancy FACTOR HR adj 4+ College 0.5 < 20 years 1.3 Low SES 1.3 Prior UIP 2.0 GAP 14.0 Madden T, et al. (in preparation)
25 NEJM CHOICE Publication
26 Teen Outcomes: CHOICE Compared to U.S. Pregnancy among sexually active teens CHOICE Annual Rate* 2008 U.S. Rate* Reduction % Birth % Abortion % *All rates per 1,000 teens years Secura et al. NEJM CHOICE Data: Unpublished; U.S. Data: Kost 2012
27 Pregnancy Rates: Sexually Experienced U.S. Teens Compared to CHOICE Stratified by Race U.S. CHOICE White White Black Black Secura et al. NEJM 2014.
28 Take-Home Messages WHY such a high uptake of LARC? EFFECTIVENESS: key attribute Forgettable: not dependent on adherence HIGH continuation rates for long-acting methods, but NOT DMPA, pills, patch or ring Why? Speculation Application to Microbicides: Longer-acting methods are best (?)
29 Thank you
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