Contraception safe for HIV-positive women
Today, women account for more than one-quarter of all new HIV/AIDS diagnoses in the United States, according to the Centers for Disease Control and Prevention.1 Most of those women use some form of contraception, with condoms as the most popular choice.2
With the advent of potent antiretroviral therapy (ART), the outlook has greatly improved the outlook for HIV-infected women, even those with an AIDS diagnosis.3 Recent findings presented at the February 2009 Conference on Retroviruses and Opportunistic Infections indicate that HIV progression is not affected by hormonal contraception.4
While results are encouraging, more research is needed to examine the effects of different types of contraceptive agents on disease progression, researchers conclude.
To perform the current analysis, researchers from the University of Alabama at Birmingham and the Centre for Infectious Disease Research in Zambia studied women enrolled in nine developing countries in Africa and Asia as part of the MTCT (Mother-to-Child Transmission) Plus Initiative, a multicountry program of family-based HIV care and treatment. Women who qualified for the study were not yet on ART, were not pregnant or were at least three months postpartum, and had documentation of exposure to hormonal or nonhormonal contraceptive methods. HIV disease progression was defined as becoming eligible for ART or death. Scientists used Cox regression and categorized exposure by the method reported at the time of entry into the cohort. Because some women switched methods over time, researchers also performed a separate time-varying analysis where women who switched contributed person-time to each exposure category.
The research team enrolled 5,993 women between August 2002 and December 2006. Of these women, 3,837 fit criteria for inclusion in the analysis. At baseline, 2,577 of 3,837 reported using no or nonhormonal contraception and 1,106 of 3,837 reported use of hormonal contraception. A further breakdown of contraceptive users shows 800 of 1,106 used injectables or implants, and 216 of 1,106 used oral contraceptive pills.
Risk factors for HIV disease progression were CD4 count > 200 to < 350 cells/mm3 [adjusted hazards ratio (AHR) 5.69, 95% confidence interval (CI) 4.83 to 6.71] and World Health Organization (WHO) HIV Clinical Stage II (AHR 1.52, 95% CI 1.23 to 1.88) and WHO Stage III (AHR 3.46, 95% CI 2.51 to 4.75).
Researchers found that exposure to hormonal contraceptives was not associated with HIV disease progression.
How to counsel women
Research indicates that HIV-positive women have reproductive patterns similar to those of HIV-negative women, with most having borne children and many wanting children in the future.3 What are some important counseling messages for those women when it comes to reversible contraception?
Highly effective, long-acting reversible birth control methods, such as intrauterine contraception and the contraceptive implant, can be safely used by women who are HIV-positive and receiving medical care, says Nancy Stanwood, MD, MPH, associate professor of obstetrics and gynecology in the Department of Obstetrics & Gynecology at the University of Rochester (NY) Medical Center. Women need to hear that having HIV still will allow them to have a successful pregnancy with a healthy, uninfected baby, she says. Women also need to understand that tubal ligation is permanent surgical sterilization, Stanwood notes. Stanwood's research indicates relatively high rates of tubal ligation regret in HIV-positive women.3
The WHO Expert Working Group in 2003 concluded that a woman generally can start using an intrauterine device, even if she has AIDS, provided she is receiving ART and is clinically well, or if she has HIV infection, or she is at high risk of HIV infection.5
When it comes to hormonal contraception, some studies have suggested that antiretroviral drugs might reduce the effectiveness of hormonal contraceptives and might increase the risk of pregnancy.6 Because the limited number of pharmacokinetic studies of ARTs used with combined oral contraceptives showed positive and negative effects on hormone levels, the Expert Working Group placed hormonal contraceptives for users of ART as a Category 2 (a condition where the advantages of using the method generally outweigh the theoretical or proven risks.)
Clinicians should remember to stress the importance of condoms when discussing reproductive health with HIV-positive women. A woman who is infected with HIV should use condoms to prevent HIV transmission and to avoid reinfection. Consistent and correct use of condoms might compensate for any decrease in the effectiveness of hormonal methods theoretically linked to hormonal contraceptive use.6
Spermicides are not suitable for women with high HIV risk, HIV, or AIDS, due to research indicating that nonoxynol-9 use is associated with an increase in irritation, and colposcopic and histologic evidence of inflammation.7 The Working Group classified spermicide as Category 4 (not to be used).6 Diaphragms used with spermicide were classified as Category 3 (usually not recommended) for conditions related to HIV/AIDS.
References
- Centers for Disease Control and Prevention. HIV/AIDS Among Women. Fact Sheet. Accessed at www.cdc.gov/hiv.
- Wilson TE, Massad LS, Riester KA, et al. Sexual, contraceptive, and drug use behaviors of women with HIV and those at high risk for infection: Results from the Women's Interagency HIV Study. AIDS 1999; 13:591-598.
- Stanwood NL, Cohn SE, Heiser JR, et al. Contraception and fertility plans in a cohort of HIV-positive women in care. Contraception 2007; 75:294-298.
- Stringer E, Sinkala M, Giganti M, et al. Effect of hormonal contraception on HIV disease progression: A multi-country cohort analysis. Presented at the 16th Conference on Retro-viruses and Opportunistic Infections. Montreal; February 2009.
- World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Third edition. Geneva; 2004.
- Rinehart W. WHO updates medical eligibility criteria for contraceptives. INFO Reports 2004; pp. 1-8.
- Stafford MK, Ward H, Flanagan A, et al. Safety study of nonoxynol-9 as a vaginal microbicide: Evidence of adverse effects. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 17:327-331.
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