Overview of contraceptive options for women including women at risk of HIV infection, or living with HIV.

1. Contraception
update and HIV issues
RHRU

2. Pregnancies: Unintended vs.
Intended
Intended
51% Unintended
49%:
Unintended
births (22.5%)
Elective abortions
(26.5%)

3. Contraceptive Choices
• Oral contraceptives: combined, progestin-only
• Long-acting
– Injectable
– Implants
– IUD: copper T, progestin-only
• Barrier contraceptives
• Spermicides
• Natural family planning
• Emergency contraceptives
• Female/male sterilization

4. Current Trends in Contraception
• Developing new delivery systems
• Increasing access to a full range of
options
• Emphasizing better compliance:
Longer acting hormonal contraceptives
that do not require daily attention.
• Widening use of emergency
contraception

5. Case for Long-Acting and
Permanent Methods (LAPMs)
• Convenient for users and effectively prevent
pregnancy
• Cost effective for programs over time - result in
substantial cost savings for governments and
attainment of health goals
• Long-acting, reversible methods fulfill the need
for healthier timing and spacing of pregnancies
• Permanent (and long acting) methods would
meet the need of individuals and couples who
want no more children.
• Are between 3 & 60 times more effective than
most short-acting methods

6. Progestin-Only Injectables
• The new, revised WHO guidance (April 2008) states that
reinjections of DMPA can be given up to four weeks late
without otherwise ruling out pregnancy.
• The data came from a 2007 prospective study in
Thailand, Uganda, and Zimbabwe. Women followed for
up to 24 months. The 2,290 DMPA users contributed
13,608 DMPA injection intervals.
• Implications for practice:
– Providers need not and should not turn away clients who are late
for DMPA reinjection.
– If a client is up to four weeks late, her provider should give her
the injection.
– If a client is more than fours weeks late, rule out pregnancy
before giving injection.
– If the injection cannot be given immediately, the provider should
offer back-up methods of contraception. DMPA injections should
still be scheduled three months apart.
• NET-EN grace period still 2 weeks

7. Progestin-Only Injectables: Bone
density
• Summary:
– New studies contribute further evidence that bone
mineral density decreases during use of progestin
only injectable contraceptives but increases again
when use stops.
– Studies need to look at possible long-term effects for
adolescents and women entering menopause.
• Implications for practice:
– The new evidence supports WHO’s guidance that the
loss of bone mineral density does not limit use of
progestin-only injectables.
– Providers and users of progestin-only injectables who
are adolescents or over age 45 may want to consider
the advantages of using injectables and the
theoretical risks of their effect on bone mineral
density.

8. New methods

9. Newer pills
• Yasmin:
– COC that contains a synthetic progesterone
(drospirenone) with antiandrogenic and
antimineralocorticosteroid properties.
– Less water retention than other COCs, less negative
emotional affect, and less appetite increase after six
months' use.
– Note contains spironolactone, a potassium-sparing
diuretic, certain restrictions.
• Cerazette:
– POP (75mcg of desogestrel daily) designed to inhibit
ovulation.
– 12 hour pill taking safety margin
– Bleeding pattern more variable than with Microval,
but greater tendency towards infrequent bleeding
and amenorrhoea by the end of the first year.

10. Monthly Injection: Lunelle/
Cycloprovera
• Intramuscular injection q 28-30 days
•Combined injectable (25mg Medroxyprogesterone
acetate / 5 mg estradiol cypionate)
• Rapid return to fertility after discontinuation
• Adverse events are similar to COCs
• Excellent cycle control

11. Contraceptive Implant: Implanon
• Single implant rod (4 cm in
length and 2 mm in diameter)
made of ethylene vinyl acetate
• Contains 68 mg of etonogestrel
(3-keto-desogestrel), the active
metabolite of desogestrel
• Effective for 3 years
– Inhibits ovulation during the
entire treatment period

12. Levonorgestrel Intrauterine System:
Mirena
• Releases 20 µg of
levonorgestrel per 24 hrs
• Duration: 5 years
• Packaged with sterile
inserter
• High efficacy
– Pearl Index of 0.1

13. Mirena Mechanisms of Action
– Cervical mucus is
thickened
– Sperm motility and
function inhibited
– Endometrium suppressed
– Weak foreign body
reaction induced
– Ovulation inhibited (in
some cycles)

14. Vaginal Ring: NuvaRing
• The NuvaRing releases 15 µg
of ethinyl estradiol and 120 µg
4 mm of etonogestrel daily for 21
days
• Begin the contraceptive
54 mm cycle when pregnancy can
be excluded
• The vaginal ring is flexible
and easy to insert and
remove
• The ring is worn for 3 weeks
and discarded, and a new
ring is inserted 1 week later
(28 day cycle)

15. Rationale for Vaginally Administered
Contraception
• Easily inserted by the user
• A monthly method
• No need for daily intake
• Continuous release with constant serum
hormone levels
• Lowest EE dose
• Avoids gastrointestinal interference with
absorption
• Avoids hepatic first-pass metabolism of the
progestin

16. Contraceptive Patch: Ortho Evra
• Patch contains 6 mg norelgestromin
and 0.75 mg ethinyl estradiol
• Delivers continuous systemic low
doses of hormones daily
– 150 µg norelgestromin (NGMN)
– 20 µg ethinyl estradiol (EE)
• Bypasses GI tract
• Ease of application and removal
• Overall annual probability of
pregnancy in patch users was
reported at 0.8%

17. Transdermal Contraceptive System
• Ortho Evra/Evra (20-µg ethinyl estradiol/
150-µg norelgestromin)
– 3 patch system
• Apply 1 patch a week for 3 weeks
• Apply each patch same day of the week
– 1 week is patch-free
Patch #1 Patch #2 Patch #3 Patch-free Start next cycle
28-day cycle 28-day cycle
Week Week Week Week Week
1 2 3 4 5

18. Emergency contraception
• Progesterone only versus Yuzpe regimen
• Single dose versus two interval doses
• Extension of 72 hour limit to 5 days
• Cu-IUD
• Three new studies looking at the mechanism of
action of levonorgestrel emergency contraceptive
pills (LNG-ECPs) contributed further evidence that
LNG-ECPs work by primarily preventing ovulation.
• Implications for practice: Clients need thorough
counseling on how and when to take ECPs, and to
correct misunderstandings about when pregnancy is
most likely.

19. Mechanical Barrier Methods
• Male and female condoms
• Male (“ez-on”) and female (bikini) condoms
• Disposable diaphragms
• Lea’s shield (silicone)
• SILCS intravaginal barrier (silicone)
• Femcap (silicone)
• BufferGel cup
• Microbicides

24. Female condom
• New, cheaper more
acceptable female
condoms being
evaluated
Modelling estimates that
perfect use of FC among
women who have
intercourse 2x week with
infected male might
reduce annual risk of
acquiring HIV by > 90%

25. Male Contraception
• Traditional: condoms, vasectomy.
• 1990s: Weekly injections of testosterone
enanthate to induce azospermia. Side effects:
weight gain, acne and serum lipid changes.
• More recent research: androgen-progestogen
combinations that suppress gonadotrophins.
• Gossypol (derivative of cottonseed oil).
• Lonidamine: reduces normal sperm
production.
• Epidydymal agents.

26. Sterilisation
• Vasectomy more effective of the 2 methods (failure rate
of 1 in 10,000) cf with female sterilisation (1 in 200
lifetime risk of failure).
• Female sterilisation is effective immediately, whereas
male sterilisation requires a “washout” period of about 3
months (2 azospermic semen analysis at least 4 weeks
apart confirms success).
• Risks of sterilisation
– Female:
• Risk of operative complications
• Effect on long-term health – Regret 6%,
uncomplicated female sterilisation has no long
term effects on menstruation or the genital tract
– Male:
• Risk of operative complications
• Effect on long-term health

27. Transcervical sterilization
• Fallopian tubes approached through cervix
instead of abdominal incision.
• Essure permanent birth control system: coil
mechanism.
• Quinacrine-induced occlusion: 2 doses of
quinacrine pellets, one month apart, between
day 7 and 10 of the menstrual cycle.
?carcinogenicity
• Erythromycin (animal studies).
• Intratubal Ligation device and two step
Adiana system

28. Checklists

33. HIV and contraception

34. Who is getting infected

35. HIV and Maternal/infant mortality
HIV is the single largest
cause of maternal and
infant death in several
parts of sub-Saharan
Africa and has reversed
previous gains made in
some countries.
Pregnancy may increase
HIV acquisition.

36. Contraception and HIV:
What to consider
Women at risk Women infected
for HIV with HIV
Disease Drug
Prevention Acquisition Infectiousness interactions
progression

37. HIV acquisition
• Large prospective cohort study, funded by the U.S.
NICHD, was conducted by FHI and collaborating
institutions among some 6,100 family planning clients in
Uganda, Zimbabwe, and Thailand.
• Involved HIV-negative, 18- to 35-year-old women in
three exposure groups of roughly equal size: combined
oral contraceptive (COC) users, DMPA users, and
women not using hormonal contraception.
• Designed specifically to evaluate the relationship
between the use of low-dose COCs or DMPA and HIV
acquisition
• Four-year study found no overall association between
the use of either combined oral contraceptive (COC) pills
or depot-medroxyprogesterone acetate (DMPA) and HIV
acquisition.

38. HIV acquisition
• Women were tested for HIV infection every 12
weeks until they became infected or had been
followed for 15 to 24 months (overall retention
rate of 91 percent).
• Strongest study to date exploring this issue.
However, not a randomized controlled trial,
therefore cannot provide evidence to establish a
direct cause-effect relationship.
• Morrison C, Richardson B, Mmiro F, et al.
Hormonal contraception and the risk of HIV
acquisition. AIDS 2007;21(1):85-95.

39. HIV Acquisition: For Most, No Additional
Risk With Hormonal Methods, IUDs
• A study in South Africa (Palesa Study) found
that the numbers of new cases of HIV were
similar among women using either progestin-
only injectables or COCs and among women not
using any hormonal method, after adjusting for
differences in sexual risk behaviors and the
presence of STIs.
• Limited evidence from other studies also
suggest that women using the copper-bearing
IUD are not at greater risk of acquiring HIV.
Kleinschimdt 2005

40. HIV Acquisition: High risk groups
• Among populations at high risk of HIV exposure,
such as sex workers, some studies (Mombasa
study) find that hormonal contraception
increases the risk of HIV acquisition. For
example, sex workers in Kenya using COCs or
DMPA had a 1.5 times and 1.8 times greater
risk, respectively, of acquiring HIV than sex
workers who were not using these methods,
after adjusting for condom use and number of
sexual partners.
Lavreys 2005

41. HIV infectivity: Limited and Unclear
Evidence on Viral Shedding
• Unknown whether HC use by HIV-infected women
increases their risk of infecting sexual partners.
• Limited studies: Only 2 studies have been
prospective, and the results of cross-sectional
studies of HIV shedding from the genital tract are
conflicting, perhaps due to relatively small study
samples.

42. HIV infectivity: Limited and Unclear
Evidence on Viral Shedding
• How to determine a woman's HIV infectiousness
also is unclear.
– Amount of HIV genital shedding necessary to
increase infectiousness is unknown.
– Questions remain about the best technique
for detecting HIV in genital tract secretions.
• No consensus exists on what indicators best
reflect the risk of HIV infectivity.

43. HIV infectivity
• 213 HIV-infected family planning clients in Mombasa, Kenya
(2004)
– Only prospective study of the direct effect of hormonal
contraceptive use on genital tract shedding of HIV
– Detected a significant but modest increase in cervical
shedding of HIV-1 DNA after initiation of hormonal
contraceptives. Not noted for separate groups.
• Increase in cervical shedding of HIV-1 DNA associated with
hormonal contraceptive use overall was not accompanied by
an increase in cervical shedding of HIV-1 RNA.
– Possible explanation that HC use attracts infected cells to
the genital mucosa (evidenced by increased HIV-1 DNA)
but does not increase local viral replication in the mucosa
(which increased HIV-1 RNA would reflect).

44. HIV infectivity
• Another prospective study, conducted in 2005 among
967 U.S. women (654 of whom were HIV-infected),
found that:
– Progesterone-based contraceptives appeared to raise
the number of cervicovaginal inflammatory cells,
assumed to be associated with increased HIV-1 viral
load in genital secretions.
– Limitation: small number of participants using
progesterone contraception - the analysis had little
statistical power.
• IUDs do not appear to increase the infectiousness of
women with HIV. The two studies that have looked at the
prevalence of HIV-infected cells in the cervix found no
greater shedding due to IUD use.

45. HIV progression: Could Hormonal
Methods Speed Up Disease?
• Does the use of HC during the early or later stages of
HIV infection affect disease progression?
• Only evidence so far that HC use might affect HIV
disease progression comes from a prospective study
conducted among 161 sex workers in Mombasa, Kenya.
This evidence suggests that using HC at the time of
infection — before women know that they are infected —
may accelerate HIV-related deterioration of the immune
system and thus speed the natural course of the
infection.
• Evidence of risk considered insufficient to warrant any
restrictions on hormonal contraceptive use by women
with HIV/AIDS or women at high risk of infection.

46. Viral set point and diversity
• In Kenya study, median viral set point was significantly
higher among women using the DMPA at the estimated time
of HIV infection than among women using no hormonal
contraception at that time. Persisted during follow-up
(median of 34 months). However, continuing use of DMPA
did not appear to further increase viral load.
• Overall, use of oral contraceptive pills was not associated
with higher viral set points. But in subset of 156 HIV-infected
sex workers use of either OCs or DMPA at the time of HIV
infection was associated with acquiring genetically diverse
virus populations from one partner.
• Limited evidence suggests any impact HC use may have on
HIV disease progression occurs during the early stages of
the infection.

47. Drug Interactions: Do ARVs Reduce
Effectiveness of LD Hormonal Contraceptives?
• Limited evidence suggests certain ARVs could alter
blood levels of contraceptive hormones in women
using low dose OCs.
• Two small studies reported that the ARVs
nevirapine and ritonavir could lower both estrogen
and progestin levels enough to increase risk of
contraceptive failure. Both studies evaluated the
effect of just a single dose of COC. No information
is available on women taking a pill every day. Thus,
it is not clear whether or how much contraceptive
effectiveness would be reduced.
• Despite the theoretical concern about contraceptive
effectiveness, women taking ARVs still generally
can use COCs.

48. Drug Interactions: Do ARVs Reduce
Effectiveness of LD Hormonal Contraceptives?
• The few studies available find that ARVs have
little or no effect on hormone levels in DMPA
users with HIV. Providers can emphasize
returning on time for the next injection. This will
help to ensure that hormone levels remain high
enough to prevent pregnancy. .
• Hormonal contraceptives do not appear to
reduce the effectiveness of ARVs.

50. Contraceptive Options for HIV-infected
Women
• Women with HIV have a right to decide whether
they want to become pregnant and bear
children.
• 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.

51. Contraceptive Options for HIV-infected
Women
• Need to weigh the advantages and
disadvantages of various methods and consider
the effects of each method on her own health,
risk of infecting others with HIV, and response to
HIV/AIDS treatment.
• Counsellors should help each HIV-infected
woman assess her contraceptive needs, review
all 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.

52. Contraception and HIV:
Options
Barrier methods

53. Condom Effectiveness
Contraceptive Contraceptive STI/HIV
effectiveness effectiveness effectiveness
Consistent and Typical use
correct use
Male 97% 86% Proven to protect
Condom against STI/HIV
Reduces HIV
incidence by 80-
97% when used
correctly and
consistently
Female 95% 79% Effective in vitro.
Condom Limited data on
efficacy in real use

54. Condoms
• Condoms should be promoted, together with an
additional form of contraception, as an ideal method of
contraception.
• This reduces the transmission of HIV to her current and
possible future partners if they are at risk of HIV
infection. If they are already infected the use of condoms
is still advised, as in addition to the prevention of
conception, it prevents the transmission of sexually
transmitted infections and prevents infection with new
strains of HIV
• The effect of condoms is not
altered by the use of ART.

55. Other barrier methods
• Barrier methods other than condoms offer only modest
protection against pregnancy and are generally not
recommended for women with HIV.
• Frequent use of spermicides containing nonoxynol-9 (N-
9) may increase the risk of reinfection with other strains
of HIV because N-9 can disrupt the lining of the vagina,
making it more vulnerable to infection. Studies have also
shown that N-9 offers no protection against STIs.
• 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.
• Recent study (Mira trial) showed no increase HIV
protection with diaphragm use. (Lancet July 2007)

56. Contraception and HIV:
Options
‘Modern’ methods of
Contraception

57. 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.
• Questions remain about the effects of hormonal
contraception on a woman's HIV infectiousness and
disease progression and about the consequences of
interactions between these methods and antiretroviral
(ARV) drugs.

58. IUDs
• In 2004 the World Health Organization updated its
guidance, based on recent research, and now advises
that women with HIV can generally start using either a
copper-bearing IUD or a hormonal IUD. Specific
guidance includes:
– Women with HIV who do not have AIDS can generally
have copper-bearing and hormonal IUDs inserted.
– Women with AIDS who are on ARVs and are clinically well
generally also can have the IUD inserted.
– IUD insertion usually is not recommended for women who
have AIDS and are not on ARVs, however. The IUD also is
not usually recommended for women who are using ARVs
but are not clinically well.
– If an IUD user becomes infected with HIV or if an IUD user
with HIV develops AIDS, the IUD generally does not need
to be removed. She should be monitored for signs of PID.

59. Sterilisation
• Offers couples a safe, highly effective, permanent
method of contraception. 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.
• 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.
• Studies show a reduction in consistent condom use in
couples after one partner has undergone sterilization.
Couples should be counseled about the importance of
using condoms if they might be at risk of HIV infection.
• Avoid coercion.

60. Female Sterilization and
Vasectomy are Safe
• For people with AIDS, special arrangements should be
made to perform the procedure in a setting with a
qualified provider, with appropriate equipment and
support.
• Women or men with acute AIDS-related illness may
have to wait until their condition improves before
undergoing the procedure

61. Emergency contraception
• Should be made available for all women who use barrier
contraception only.
• Classical contra-indications for hormonal contraception
such as previous ectopic pregnancy, cardiovascular
disease, migraine, liver disease and breastfeeding are
not considered contraindications to emergency
contraception use.
• The use of antiretroviral therapy should not preclude the
use of emergency contraception and the favoured
method should be progesterone based morning after pill
for women who are on ART.

62. Other methods
• Lactational amenorrhoea method:
– Women who are infected with HIV or who have AIDS and
choose to breastfeed their infant can use LAM.
– Exclusive breastfeeding for the first six months of a baby’s
life is the safer breastfeeding pattern to minimize the risk
of HIV transmission through breastmilk.
– If a woman’s monthly bleeding returns before six months,
she will need another contraceptive method while
continuing to breastfeed exclusively.
– Women with HIV and their health care providers need to
consider the infant feeding options available and to weigh
their various risks and consequences.

63. Summary
• Increasing number of women will be aware
of their HIV status
• Providers need to be aware of new data to
advise HIV infected women regarding their
options to prevent unwanted pregnancies

64. Contraception and HIV acquisition
Method & Strength of evidence Comment
HIV acquisition of interaction
Injectable progestins - General population
+ Higher risk groups
(SWs), younger age
group, HSV2 negative
COCs - General population
+ Higher risk groups
(SWs), younger age
group
IUDs - General population

65. Contraception and HIV transmission
Method & Strength of Comment
HIV transmission evidence
Injectable progestins - General population
?+ Higher risk groups (SWs),
COCs - General population
?+ Higher risk groups (SWs)
IUDs - General population

66. Contraception and HIV progression
Method & Strength of Comment
HIV progression evidence
Injectable progestins - General population
+ Worse prognostic disease in
higher risk groups (SWs).
Worse disease progression?
(from RCT with IUDs)
COCs + Worse prognostic disease in
higher risk groups (SWs).
Worse disease progression?
(from RCT with IUDs)
IUDs - IUD use appears safe in HIV+ve
women.

67. Thank you