Contraceptive options for HIV-infected women.

Women with HIV have a right to decide whether they want to become pregnant and bear children. But if an HIV-infected woman chooses not to have children, or wants to space her family, she should be able to make informed, voluntary decisions about contraception and then receive her method of choice. Such use of contraception by HIV-infected women is an important way to reduce HIV-positive births.

HIV-infected women can use most contraceptive methods safely. While weighing the advantages and disadvantages of various methods, however, a woman living with HIV must consider the effects of each method on her own health, risk of infecting others with HIV, and response to HIV/AIDS treatment. Thus, counselors should help each HIV-infected woman assess her contraceptive needs, review all the contraceptive options available to her, and determine whether she and her partner will be able to use a particular method or combination of methods safely, correctly, and consistently. (1)

Hormonal methods

The World Health Organization (WHO) recommends that HIV-infected women can safely use hormonal contraceptives--including combined oral contraceptives (COCs), the injectables depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), and implants such as Norplant. Yet, questions remain about the effects of hormonal contraception on a woman's HIV infectiousness (see article, page 14) and disease progression (see article, page 15) and about the consequences of interactions between these methods and antiretroviral (ARV) drugs (see articles, pages 20 through 22).

Condoms

Male and female condoms are the only contraceptive methods that can prevent the transmission of sexually transmitted infections (STIs), including HIV. Male condoms can be 97 percent effective in preventing pregnancy if used correctly and consistently; as typically used, they are about 86 percent effective. (2) Likewise, male condom use reduces HIV incidence by 80 percent to 97 percent, but only if condoms are used correctly during each act of sexual intercourse with an infected partner. (3)

Female condoms can be 95 percent effective for pregnancy prevention if used correctly and consistently; as typically used, they are about 79 percent effective. (4) No clinical trial has assessed whether female condoms protect against HIV. But estimates based on studies of pregnancy prevention and evidence from laboratory and epidemiological studies of the female condom's ability to protect against STI pathogens suggest that when used correctly and consistently, the device is likely to be about as effective as a male condom in reducing the risk of HIV and other STIs. (5) Consistent condom use can protect an already HIV-infected woman against reinfection with another strain of HIV or from acquiring STIs such as gonorrhea and chlamydial infection. It can also reduce the risk of an HIV-infected woman transmitting the virus to an uninfected partner. (6) Even when a woman is unlikely to infect others with HIV because her own infection is controlled by ARV therapy, she should be encouraged to use condoms because treatment may not completely eliminate her risk of infecting others. (7)

Since condoms as they are typically used are not as effective in preventing pregnancy as are many other contraceptive methods, (8) HIV-infected women who do not want to become pregnant should consider using a more effective form of contraception while using condoms for STI protection. Some studies suggest that women with HIV who use more effective contraceptives, such as oral contraceptives or an intrauterine device (IUD), are less likely to use condoms consistently or at all, even with an uninfected partner. (9) One U.S. study, however, found that condom use remained consistent among women using condoms and another method simultaneously for dual protection against both infection and pregnancy. Consistency of condom use was reduced only among women who alternated the two methods; for example, using a condom as a backup method after a missed pill. (10)

Another dual protection option--consistent use of condoms alone--is unpopular with providers because they fear its adoption would increase pregnancy rates. One way to address this concern would be to ensure access to emergency contraception as a backup method of contraception. (11)

IUDs

A highly effective yet reversible non-hormonal contraceptive method became more available to HIV-infected women in 2004, when WHO removed most of its previously recommended restrictions on use of the IUD by women with HIV. Those restrictions, based on theoretical concerns about increased risk of pelvic inflammatory disease and HIV infectivity, were lifted after studies demonstrated that complications of IUD use are no more common among HIV-infected IUD users than they are among uninfected IUD users (12) and that IUD use does not appear to increase HIV infectivity. (13) These findings suggest that appropriately selected HIV-infected women with regular access to medical services can use IUDs safely.

Under the revised WHO guidelines, most HIV-infected women generally can initiate and use IUDs and the levonorgestrel- releasing intrauterine system, and IUD users who become infected with HIV may continue using the device. The only exceptions are for insertions among women who have developed AIDS and are not receiving ARV drugs or women with AIDS who are not responding well to ARV treatment. IUD initiation is not recommended for such women because their suppressed immune systems can make them more vulnerable at the time of IUD insertion to infections that could lead to pelvic inflammatory disease. However, HIV-infected IUD users who develop AIDS may generally continue using the device. (14)

Sterilization

The stigma associated with HIV and fear of coming in contact with the blood of HIV-infected women have resulted in some surgeons not wanting to perform sterilizations on such women. However, sterilization offers couples a safe, highly effective, permanent method of contraception. It may be a good option for HIV-positive women and their partners who have decided to forgo or end childbearing, and it raises no particular health concerns for HIV-infected women. If a woman has an AIDS-related illness, however, female sterilization should be postponed until her condition improves. HIV-discordant couples in which the man is HIV-negative and the woman is HIV-positive may want to consider male sterilization because it does not depend on the woman's health. (15) Studies show a reduction in consistent condom use in couples after one partner has undergone sterilization. (16) As with other methods, couples should be counseled about the importance of using condoms if they might be at risk of HIV infection. This advice is particularly important for discordant couples, to prevent the infected partner from transmitting the virus to the uninfected partner.

Other methods

Barrier methods other than condoms offer only modest protection against pregnancy and are generally not recommended for women with HIV. (17) Frequent use of spermicides containing nonoxynol-9 (N-9) may increase the risk of re-infection with other strains of HIV because N-9 can disrupt the lining of the vagina, making it more vulnerable to infection. (18) Studies have also shown that N-9 offers no protection against STIs. (19)

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Diaphragms and cervical caps are not recommended for women with HIV or AIDS and women at high risk of HIV infection because they are usually used with spermicides containing N-9. Studies are under way to determine whether diaphragms offer any protection against STIs and HIV. A protective effect is considered possible because these barrier methods may block entry of pathogens to the cervix, which is the site of infection with gonorrhea and chlamydia and may be more susceptible than the vagina is to HIV infection. (20)

Pregnancy rates of 1 percent to 9 percent with perfect use and 25 percent with typical use are seen for fertility awareness-based methods (natural family planning). These methods require abstaining from sex or using barrier methods only during the fertile days of the menstrual cycle in order to prevent pregnancy. (21) But protected sex throughout the menstrual cycle--even during nonfertile periods--is necessary to prevent HIV transmission to a partner. Therefore, sexually active HIV-infected women and their partners should use male or female condoms consistently throughout the woman's menstrual cycle.

The use of breastfeeding as a temporary method of contraception (the lactational amenorrhea method) is highly effective in preventing pregnancy for up to six months postpartum in nonmenstruating women who are fully or nearly fully breastfeeding. (22) HIV-infected women who are able to use safe breast milk alternatives to avoid transmitting the virus to their children do not benefit from lactational amenorrhea and will resume ovulating sooner than breastfeeding women. Their future contraceptive needs should be discussed during pregnancy or early in the postpartum period. (23)

In summary, HIV-infected women face few restrictions on their use of modern contraceptive methods. Furthermore, use of effective contraception can play a key role in preventing HIV-positive births.

References

(1) Cates W Jr, Steiner MJ. Dual protection against unintended pregnancy and sexually transmitted infections. What is the best contraceptive approach? Sex Transm Dis 2002;29(3):168-74.

(2) Trussell J, Kowal D. The essentials of contraception. In Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology. Seventeenth Revised Edition. (New York, NY: Ardent Media, Inc., 1998)216.

(3) Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission (Cochrane Review). In The Cochrane Library, Issue 1. Oxford, UK: Update Software, 2002; Mann K, Stine C, Vessey J. The role of disease-specific infectivity and number of disease exposures on long-term effectiveness of the latex condom. Sex Transm Dis 2002; 29(6):344-49; Holmes KK, Levine R, Weaver M. Effectiveness of condoms in preventing sexually transmitted infections. Bull WHO 2004;82(6):454-61.

(4) Trussell.

(5) Trussell J, Sturgen K, Stickler J, et al. Comparative contraceptive efficacy of the female condom and other barrier methods. Fam Plann Perspect 1994; 26(2):66-72; Minnis AM, Padian NS. Effectiveness of female barrier methods in preventing sexually transmitted infections and HIV: current evidence and future research directions. Sex Transm Infect 2005;81(3):193-200.

(6) Holmes; Cates.

(7) Family Health International (FHI), EngenderHealth. Contraception for Women and Couples with HIV. Research Triangle Park, NC, USA: FHI and EngenderHealth, 2005. Available: http://www.fhi.org/en/RH/Training/trainmat/ARVmodule.htm.

(8) Johnstone FD. Contraception for HIV-infected women. J Int Assoc Phys AIDS Care 1997;3(10):10-11.

(9) Diaz T, Schable B, Chu SY, et al. Relationship between use of condoms and other forms of contraception among human immunodeficiency virusinfected women. Obstet Gynecol 1995;86(2):277-82; Cushman LF, Romero D, Kalmuss D, et al. Condom use among women choosing long-term hormonal contraception. Fam Plann Perspect 1998;30(5):240-43; Darney PD, Callegari LS, Swift A, et al. Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception. Am J Obstet Gynecol 1999;180(4):929-37.

(10) Wilson T, Koenig L, Walter E, et al. Dual contraceptive method use for pregnancy and disease prevention among HIV-infected and HIV-uninfected women. The importance of event-level focus for promoting safer sexual behaviors. Sex Transm Dis 2003;30(11):809-12.

(11) Glasier A, Baird D. The effects of self-administering emergency contraception. N Engl J Med 1998;339(1): 1-4; Cates.

(12) Morrison C, Sekadde-Kigondu C, Sinei S, et al. Is the intrauterine device appropriate contraception for HIV-1 infected women? Br J Obstet Gynaecol 2001;108(8):784-90.

(13) British Medical Association. Comparison of female to male and male to female transmission of HIV in 563 stable couples. European Study Group on Heterosexual Transmission of HIV. Br Med J 1992; 304(6830):809-13; Mostad SB, Overbaugh J, DeVange DM, et al. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997;350(9082):922-27; Richardson BA, Morrison CS, Sekadde-Kigondu C, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS 13(15):2091-97.

(14) World Health Organization (WHO). Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva, Switzerland: WHO, 2004. Available: http://www.who.int/reproductive-health/publications/mec/.

(15) WHO; FHI.

(16) Magalhaes J, Amaral E, Giraldo PC, et al. HIV infection in women: impact on contraception. Contraception 2002;66(2):87-91; Diaz.

(17) WHO.

(18) FHI.

(19) Wilkinson D, Ramjee G, Tholandi M, et al. Nonoxynol-9 for preventing vaginal acquisition of sexually transmitted infections by women from men (Cochrane Review). In The Cochrane Library, Issue 4. Oxford, UK: Update Software, 2004.

(20) Moench TR, Chipato T, Padian NS. Preventing disease by protecting the cervix: the unexplored promise of internal vaginal barrier devices. AIDS 2001; 15(13):1595-1602; Hu J, Gardner MB, Miller CJ. Simian immunodeficiency virus rapidly penetrates the cervicovaginal mucosa after intravaginal inoculation and infects intraepithelial dendritic cells. J Virol 2000;74(13):6087-95.

(21) Jennings V, Lamprecht V, Kowal D. Fertility awareness methods. In Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology. Seventeenth Revised Edition. (New York: Ardent Media, Inc., 1998)311-12.

(22) Kennedy K, Trussell J. Postpartum contraception and lactation. In Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology. Seventeenth Revised Edition. (New York: Ardent Media, Inc., 1998)589-614.

(23) Mitchell HS, Stephens E. Contraception choice for HIV-positive women. Sex Transm Infect 2004; 80(3):167-73.