Contraception for Women Taking Antiretroviral Medications (ARVs): An Update

· Women with HIV/AIDS, including those who are taking ARVs, can start and use almost all family planning methods safely and effectively.

· Women on ARVs need access to contraception for compelling reasons.

· To successfully reach ARV recipients, contraceptive services need to be integrated with HIV care from the start.

ARV Basics. ARVs are powerful drugs that reduce the amount of virus in a person’s body. ARVs are not recommended for all people with HIV—only those in late stages of infection. To maintain good health over time, people receiving ARVs must take them for life, usually without any break in treatment.

The World Health Organization (WHO) recommends a combination of three ARV medications to maximally suppress the virus and stop the progression of HIV disease (known as “first-line” therapy). The therapy generally consists of two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTI). (Another class of ARVs—protease inhibitors (PIs)—are not included in first-line regimens.)

Programmatic Synergies. Reaching potential ARV recipients in resource-poor settings may require using a variety of service delivery "entry points," such as maternal-child health services or family planning services. Such entry points might either provide ARVs directly or refer clients to other sites. Offering multiple services at one location is more likely to attract larger numbers of potential ARV clients, help overcome stigma, and support treatment adherence and follow-up.

Why is Access to Family Planning Important for Women on ARVs?

· Women of reproductive age are the majority of potential ARV recipients in sub-Saharan Africa.

· Unmet need for contraception is high—approximately 25% in sub-Saharan Africa, according to Demographic and Health Surveys.

· Preventing unintended pregnancy in women with HIV can prevent mother-to-child transmission of HIV. It will also reduce the number of abortions and the number of children orphaned by AIDS.

· Women on ARVs already have serious stresses in their lives without the additional stress of unintended pregnancy.

· HIV infection increases the risk of poor pregnancy outcomes, such as low birth weight, preterm delivery, and miscarriage.

· Some ARV medications have significant potential drug toxicities that can harm a fetus. For example, women using the ARV efavirenz should not get pregnant.

· Programmatic synergies can result from providing family planning and ARV services together.

Women on ARVs Can Use Most Contraceptive Methods

Drug Interactions Only of Theoretical Concern:Limited evidence suggests that certain ARVs could alter blood levels of contraceptive hormones in women using low dose hormonal contraceptives. The extent to which this interaction actually reduces contraceptive effectiveness is not clear. Consistent condom use can help to compensate for any potential decrease in effectiveness. Hormonal contraceptives do not appear to reduce the effectiveness of most ARV medications.

IUDs: WHO advises that women with HIV, including those on ARVs and those who have progressed to clinically-defined AIDS, can generally start using an intrauterine device (IUD) if they are clinically well. A woman who has clinically-defined AIDS and is not using ARVs should not have an IUD inserted, nor should a woman with AIDS who is being treated but is not clinically well. An IUD already in place does not need to be removed if a woman becomes infected with HIV or other STIs, or she develops AIDS.

Oral Contraceptives (OCs): The concern about low-dose OCs is that some ARVs could speed up liver metabolism of contraceptive hormones, possibly lowering blood levels of the hormones. Despite this concern, women taking ARVs still generally can use OCs. If a woman using ARVs wants to use OCs, she can be given a formulation with at least 30 mcg of estrogen, counseled about the importance of taking OCs every day (without missing pills), and counseled about consistent condom use.

Emergency Contraceptive Pills (ECPs): ECPs are an important option for all women, including women with HIV. ARVs likely do not reduce the effectiveness of ECPs because ECPs contain higher doses of hormones than daily OCs. There is currently no evidence to justify increasing the ECP dosage for women on ARVs.

Injectables and Implants:There is little concern that ARVs could reduce the effectiveness of implants and progestin-only injectables such as DMPA. Progestin-only injectables provide high hormone levels and, with both methods, the hormones are absorbed into the blood before they are metabolized by the liver. The few studies available find that ARVs have little or no effect on hormone levels in DMPA users with HIV¹. If there is any reduced effectiveness, it is likely to be at the end of the three-month period, when blood levels of progestin decrease. Although repeat DMPA injections can normally be given as much as two weeks late, striving to provide the next injection by the end of three months appears prudent for a woman on ARVs.

Male and Female Condoms: Condoms are the only method that help protect against both pregnancy and sexually transmitted infections. They must be used correctly with every act of sex to be fully effective. As typically used, however, condoms provide less protection against pregnancy than hormonal methods or IUDs typically provide.

Other Methods: Women taking ARVs can generally use other hormonal methods such as the patch and the ring. Although there is little known about interactions between ARVs and these methods, such interactions are less of a concern because these methods deliver a continuous dose of contraceptive hormones. Women with HIV, including those with AIDS, who want a permanent method of contraception can safely undergo female sterilization. Fertility awareness methods can also be used, although for most people, they are less effective than are other modern methods of contraception.

CHU, J.H., GANGE, S.J., ANASTOS, K., MINKOFF, H., CEJTIN, H., BACON, M., LEVINE, A., and GREENBLATT, R.M. Hormonal contraceptive use and the effectiveness of highly active antiretroviral therapy. American Journal of Epidemiology 161(9): 881–890. May 1, 2005.

COHN, S.E., PARK, J.G., WATTS, D.H., STEK, A., HITTI, J., CLAX, P.A., YU, S., and LERTORA, J.J. Depo-medroxyprogesterone in women on antiretroviral therapy: Effective contraception and lack of clinically significant interactions. Clinical Pharmacology and Therapeutics 81(2): 222–227. Feb. 2007.

Other technical briefs can be found at: http://www.maqweb.org

Last Revised: 11/16/07

Produced in association with The Maximizing Access and Quality Initiative

Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs


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