Contraception Key Considerations

  • Family Planning is essential for women living with HIV.
  • Public health advocates cite family planning as being integral to reducing poverty, hunger, and promoting environmental sustainability as well as reducing mortality and morbidity for women and their children.1
  • Of particular concern to women living with HIV, is the effect various contraceptive methods have on the progression of HIV.
  • The World Health Organization (WHO) in a comprehensive analysis of peer reviewed literature relevant to HIV progression in women using various hormonal contraceptive methods and with a multidisciplinary, multinational group of reviewers, found no association between HIV disease progression and use of hormonal contraception.2
  • Some hormonal contraceptive methods may have drug interactions with certain antiretrovirals and caution she be advised before prescribing a particular hormonal therapy.3

 

Table 1. WHO Recommendations on Contraception and HIV/AIDS

Women with HIV or AIDS are advised to use condoms in addition to other methods of contraception to prevent transmission of HIV Disease Status
Contraceptive Method Mechanism of Action HIV AIDS*
Low-dose Combined Oral Contraceptives Prevents Ovulation 1 1
Combined Patch Prevents Ovulation 1 1
Combined Vaginal Ring Prevents Ovulation 1 1
Combined Injectable Contraceptives Prevents Ovulation 1 1
Progestogen-only Pills Thickens Cervical Mucus/Prevents 1 1
Depot Medroxyprogesterone Acetate Prevents Ovulation 1 1
Norethisterone Enantate Prevents Ovulation 1 1
Levonorgestrel  and Etonogestrel  Implants Thickens Cervical Mucus/Prevents 1 1
Copper-IUDs (I|C) Chemical Change Damaging Egg 2/2 3†/2‡
Levonorgestrel-IUDs (I|C) Suppresses Growth of the 2/2 3†/2‡
Female Sterilization Disrupts Transport of Egg Down A
Condoms Forms Barrier Between Sperm and  1 1
Diaphragm ¶ Forms Barrier Between Sperm and 3 3
Spermicide ¶ Damages Sperm Cell Membrane 3 3

Table based on WHO recommendations2,3

I = initiation
C = continuation
A = accept
S = special 

1: No restriction.
2: Advantages generally outweigh the theoretical or proven risks.
3: The theoretical or proven risks usually outweigh the advantages.
4: An unacceptable health risk

Table 1 Key
* There may be drug interactions between hormonal contraceptives and ARV therapy.
† If well on ARV therapy, grade 2
‡ IUD users with AIDS should be closely monitored for pelvic infection
§ May require delay secondary to the presence of an AIDS-related illness and alternative temporary methods of contraception should be provided
¶ Spermicides and/or diaphragms may lead to increased viral shedding and HIV transmission to uninfected sexual partners through disruption of cervical mucosa.

 

Table 2. Interactions between Antiretroviral Drugs and Hormonal Contraceptives

Antiretroviral Drug Effect on Drug Levels Comment
Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI)
Efavirenz Oral ethinyl estradiol(EE)/norgestimate: no effect on EE

decreased active metabolites of norgestimate (levonorgestrel AUC decreased 83% norelgestromin AUC decreased 64%)

A reliable form of barrier contraception must be used in addition to hormonal contraception
Etravirine Ethinyl estradiol AUC increase 22%

Norethindrone: no effect

No dose adjustment necessary
Nevirapine Ethinyl estradiol AUC decrease 20%

Norethindrone: AUC decrease 19%

DMPA: no significant change
Use an alternate method
Rilpivirine Ethinyl estradiol: CMax  increase 17%

Norethindrone: no effect

No dose adjustment necessary
Ritonavir-boosted Protease Inhibitors (PI)
Atazanavir/ritonavir Decreased ethinly estradiol

Increased norgestimate

Oral contraceptives should contain at least 35mcg of ethinyl estradiol
Darunavir/ritonavir Ethinyl estradiol AUC decreased 44%

Norethinfrone AUC deceased 14%

Use alternative or additional method
Lopinavir/ritonavir Ethinyl estradiol AUC decreased 42%

Norethindrone AUC decreased 17%

Use alternative or additional method
Unboosted Protease Inhibitors
Atazanavir Ethinyl estradiol AUC increased 48%

Norethindrone AUC increased 110%

Oral contraceptive should contain no more than 30mcg of ethinyl estradiol or use an alternative method
CCR5 Antagonist
Maraviroc No significant effect on ethinly estradiol or levonorgesterol Safe to use in combination
Integrase Inhibitor
Raltegravir No significant effect on ethinly estradiol or norgestimate No dose adjustment required
Elvitegravir/cobicistat/tenofovir/emtricitabine Norgestimate AUC, Cmax, Cmin increase > 2 fold

Ethinyl estradiol AUC decreases 25%, Cmin decreases 44%

The effects of increases in progestin
(norgestimate) are not fully known and can
include insulin resistance, dyslipidemia, acne,
and venous thrombosis. Weigh the risks and
benefits of the drug, and consider alternative contraceptive method.

AUC = area under the concentration curve; the total amount of unaltered drug in the patient's blood after a dose
CMax = the peak serum concentration of drug after a dose.
DMPA= depot medroxyprogesterone acetate

 

For more information on drug-drug interactions, visit the Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents.

 

References

  1. WMA Statement on Family Planning and the Right of a Woman to Contraception,  48th WMA General Assembly, Somerset West, South Africa, (Oct 1996).
  2. WHO Technical statement on Hormonal Contraception and HIV. Geneva: World Health Organization; 2012.
  3. WHO Medical eligibility criteria for contraceptive use, 4th ed. Geneva: World Health Organization; 2010.