Women living with HIV are often of reproductive age, and many desire effective contraceptive options to delay or prevent pregnancy. We review the safety of various hormonal and non-hormonal contraceptive methods for women living with human immunodeficiency virus (HIV). Additionally, we discuss drug interactions between contraceptive methods and antiretrovirals and the safety of methods with respect to onward transmission to HIV-negative partners for women in sero-discordant partnerships. In general, most methods are safe for most women living with HIV. An understanding of the reproductive goals of each individual patient, as well as her medical condition and medication, should be taken into account when counselling women on their contraceptive options. Further research is needed to understand drug interactions between contraceptives and antiretrovirals better and how to fulfil the contraceptive needs of HIV-positive women.
Introduction
Globally, an estimated 35.3 million people were living with human immunodeficiency virus (HIV) in 2012. This number continues to increase as life-saving anti-retroviral (ARV) treatment becomes more available. In 2012, there were an estimated 2.3 million new HIV infections globally, a 33% decline from a high of 3.4 million in 2001. More than half of people worldwide living with HIV are women; in sub-Saharan Africa, this figure is closer to 60% .
Most of these women are in their childbearing years. Although some women will wish to become pregnant, and require full information and support for this decision, many will want to avoid pregnancy. Voluntary contraception is a proven, cost-effective strategy for reducing HIV infection among children , and is an essential component of providing optimal care and support to HIV-positive women. Despite this, women living with HIV have a high unmet need for contraceptive services and often face inequalities in care due to discrimination and the limited evidence base upon which providers may determine their decision making . In low-income countries and in countries with a high prevalence of HIV, access to safe and effective contraception is of critical importance to maintain women’s health, to reduce maternal and infant deaths and to uphold women’s rights.
When counselling women living with HIV about options for fertility regulation, clinicians should provide full information, not only about the safety of the methods with respect to their HIV status but also about the relative efficacy of various methods, both with perfect use and typical use . While long-acting reversible methods, such as implants or intrauterine devices (IUDs), are ideal for some women due to their high efficacy, lack of susceptibility to user error, and their potential for covert use , some women will prefer to use shorter-acting methods over which they have more control or that confer non-contraceptive benefits. Regardless of the method chosen, informed choice is critical to ensure that women’s rights are upheld.
Hormonal contraception
Hormonal contraceptives, including combined oral contraceptives pills (COCs), contraceptive patches and rings, progestin-only pills (POPs) and progestin-only injectables (POIs), are all highly effective and are recommended by the World Health Organization (WHO) without restriction as contraceptive options for women who are HIV-positive ( Tables 1 and 2 ) . All of these options also have significant non-contraceptive benefits.
| Category | Description |
|---|---|
| 1 | A condition for which there is no restriction for the use of the contraceptive method |
| 2 | A condition where the advantages of using the method generally outweigh the theoretical or proven risks |
| 3 | A condition where the theoretical or proven risks usually outweigh the advantages of using the method |
| 4 | A condition which represents an unacceptable health risk if the contraceptive method is used |
| Condition | Combined oral contraceptives | Contraceptive patch/ring | Progestin-only pill | DMPA NET-EN | LNG/ETG implant |
|---|---|---|---|---|---|
| HIV-infected | 1 | 1 | 1 | 1 | 1 |
| AIDS | 1 | 1 | 1 | 1 | 1 |
Combined oral contraceptives, contraceptive patches and contraceptive rings (combined hormonal contraceptives, CHCs)
Combined hormonal contraceptives (CHCs) can be used to treat pre-menstrual disorders, dysfunctional menstrual bleeding, some benign breast disorders and acne, and are protective against several kinds of cancer . Although CHCs are safe for most women, women with severely elevated blood pressure (≥160/90), with vascular disease or with migraines with aura, in addition to certain other medical conditions, should not use CHCs . Additionally, women who weigh over 80 kg are more likely to become pregnant while using the contraceptive patch .
Progestin-only pills
For some women with medical conditions, progestin-only pills represent an important alternative if they wish to use oral contraceptive preparations. Progestin-only pills have the benefit of being safe for women with medical conditions, such as a history of venous thrombosis, multiple cardiac risk factors or for women who are <6 months post-partum and breast-feeding . There is some concern that they may be less effective with typical use than combined oral contraceptives; however, evidence thus far is insufficient to determine if this is in fact the case .
POIs and implants
As contraceptive pills require daily administration at the same time of day to maintain their high efficacy, some women may prefer longer-acting or long-acting methods. Widely available options include POIs and implants. These methods have the advantage of lasting months (in the case of injectables) or years (as in the case of implants), and are not dependent on remembering to take a daily pill.
All of these hormonal methods are safe for HIV-positive women (see Table 2 ). A recent systematic review identified 10 observational studies and one randomized clinical trial (RCT) that assessed disease progression or death among women living with HIV using hormonal contraceptive methods, compared with non-users of hormonal contraceptives . None of the observational studies identified for the systematic review found an association between the use of any hormonal contraceptive method and HIV disease progression or mortality. An additional recently published cohort study similarly failed to find a negative association between the use of either POI contraceptives or oral contraceptive pills and HIV disease progression or non-traumatic mortality .
On the contrary, the RCT that compared HIV-positive women allocated to either the copper IUD or to their choice of hormonal contraceptive method (either depot medroxyprogesterone acetate (DMPA) or oral contraceptive pills) found that women using either oral contraceptive pills or DMPA were significantly more likely to reach a composite end point indicative of disease progression (either death or eligibility for anti-retroviral therapy – ART) . It is unclear why this RCT found results different from the multiple observational studies on the topic, although there was a significant amount of discontinuation of allocated method, loss to follow-up and contraceptive switching that may have impacted the trial.
Despite this outlier, the preponderance of evidence indicates that POIs and combined oral contraceptives are safe for women living with HIV, and the WHO’s expert committee determined in 2012 that all hormonal contraceptives may be used without restriction for women living with HIV . It should be noted that no information is available on the safety of newer forms of hormonal contraceptive methods, such as the contraceptive patch, ring or contraceptive implants, but that these methods are assumed to have properties similar enough to other combined hormonal contraceptives and progestin-only contraceptives that evidence of their safety can be extrapolated from studies of other methods .
Hormonal contraception
Hormonal contraceptives, including combined oral contraceptives pills (COCs), contraceptive patches and rings, progestin-only pills (POPs) and progestin-only injectables (POIs), are all highly effective and are recommended by the World Health Organization (WHO) without restriction as contraceptive options for women who are HIV-positive ( Tables 1 and 2 ) . All of these options also have significant non-contraceptive benefits.
| Category | Description |
|---|---|
| 1 | A condition for which there is no restriction for the use of the contraceptive method |
| 2 | A condition where the advantages of using the method generally outweigh the theoretical or proven risks |
| 3 | A condition where the theoretical or proven risks usually outweigh the advantages of using the method |
| 4 | A condition which represents an unacceptable health risk if the contraceptive method is used |
| Condition | Combined oral contraceptives | Contraceptive patch/ring | Progestin-only pill | DMPA NET-EN | LNG/ETG implant |
|---|---|---|---|---|---|
| HIV-infected | 1 | 1 | 1 | 1 | 1 |
| AIDS | 1 | 1 | 1 | 1 | 1 |
Combined oral contraceptives, contraceptive patches and contraceptive rings (combined hormonal contraceptives, CHCs)
Combined hormonal contraceptives (CHCs) can be used to treat pre-menstrual disorders, dysfunctional menstrual bleeding, some benign breast disorders and acne, and are protective against several kinds of cancer . Although CHCs are safe for most women, women with severely elevated blood pressure (≥160/90), with vascular disease or with migraines with aura, in addition to certain other medical conditions, should not use CHCs . Additionally, women who weigh over 80 kg are more likely to become pregnant while using the contraceptive patch .
Progestin-only pills
For some women with medical conditions, progestin-only pills represent an important alternative if they wish to use oral contraceptive preparations. Progestin-only pills have the benefit of being safe for women with medical conditions, such as a history of venous thrombosis, multiple cardiac risk factors or for women who are <6 months post-partum and breast-feeding . There is some concern that they may be less effective with typical use than combined oral contraceptives; however, evidence thus far is insufficient to determine if this is in fact the case .
POIs and implants
As contraceptive pills require daily administration at the same time of day to maintain their high efficacy, some women may prefer longer-acting or long-acting methods. Widely available options include POIs and implants. These methods have the advantage of lasting months (in the case of injectables) or years (as in the case of implants), and are not dependent on remembering to take a daily pill.
All of these hormonal methods are safe for HIV-positive women (see Table 2 ). A recent systematic review identified 10 observational studies and one randomized clinical trial (RCT) that assessed disease progression or death among women living with HIV using hormonal contraceptive methods, compared with non-users of hormonal contraceptives . None of the observational studies identified for the systematic review found an association between the use of any hormonal contraceptive method and HIV disease progression or mortality. An additional recently published cohort study similarly failed to find a negative association between the use of either POI contraceptives or oral contraceptive pills and HIV disease progression or non-traumatic mortality .
On the contrary, the RCT that compared HIV-positive women allocated to either the copper IUD or to their choice of hormonal contraceptive method (either depot medroxyprogesterone acetate (DMPA) or oral contraceptive pills) found that women using either oral contraceptive pills or DMPA were significantly more likely to reach a composite end point indicative of disease progression (either death or eligibility for anti-retroviral therapy – ART) . It is unclear why this RCT found results different from the multiple observational studies on the topic, although there was a significant amount of discontinuation of allocated method, loss to follow-up and contraceptive switching that may have impacted the trial.
Despite this outlier, the preponderance of evidence indicates that POIs and combined oral contraceptives are safe for women living with HIV, and the WHO’s expert committee determined in 2012 that all hormonal contraceptives may be used without restriction for women living with HIV . It should be noted that no information is available on the safety of newer forms of hormonal contraceptive methods, such as the contraceptive patch, ring or contraceptive implants, but that these methods are assumed to have properties similar enough to other combined hormonal contraceptives and progestin-only contraceptives that evidence of their safety can be extrapolated from studies of other methods .
Intrauterine contraception
Intrauterine contraception – both the copper-releasing IUD and the levonorgestrel-releasing intrauterine device (LNG-IUD) – is highly effective, long-acting and reversible, and can be used by most HIV-positive women, including those with acquired immunodeficiency syndrome (AIDS), provided they are clinically well on ARV therapy ( Table 3 ) . There are, however, a number of theoretical concerns regarding intrauterine contraception use among women with HIV. These mainly include the question of increased risk of complications, such as acute pelvic inflammatory disease immediately after insertion .
| Condition | Copper IUD | Levonorgestrel IUD | ||
|---|---|---|---|---|
| Insertion | Continuation | Insertion | Continuation | |
| HIV-infected | 2 | 2 | 2 | 2 |
| AIDS | 3 | 2 | 3 | 2 |
| Clinically well on ARV therapy | 2 | 2 | 2 | 2 |
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