Hormonal Contraceptives – Considerations for Women

with HIV and AIDS

Hormonal Contraceptives

• Combined oral contraceptive pills (COCs)

• Progestin-only oral contraceptive pills (POPs)

• Injectables (Depo-Provera/DMPA)• Implants (Norplant, Jadelle, Sinoplant, Implanon)

Hormonal Contraceptive Methods:

Appropriate for Women with HIV

• Very effective

• Easy to use

• Suitable for short- or long-term use

• Reversible

• Non-contraceptive health benefits

• Serious complications extremely rare

Overview: Theoretical Concerns about Hormonal Methods

For women with HIV:

• ARVs may reduce method effectiveness or increase side effects

• Contraceptives may affect ARV efficacy

• Hormonal methods may possibly affect– infectivity

– disease progression

Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.

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Source: Leitz, 2000; Piscitelli, 1996.

How ARVs Interact with COCs

• May cause an increase or decrease of hormone levels

• Some ARVs speed up liver metabolism and could lower blood levels of contraceptive hormones, may reduce method effectiveness

• Not all ARV classes interact with contraceptive hormones (e.g., NRTIs)

Interactions between COCs and PIs

Source: WHO, 2004; Ouellet, 1998.

Protease inhibitorsProtease inhibitorsContraceptive Contraceptive

hormone levels hormone levels in bloodin blood

ARV levels ARV levels in bloodin blood

Nelfinavir Nelfinavir (NFV)(NFV) No dataNo data

Ritonavir Ritonavir (RTV)(RTV) No dataNo data

Lopinavir Lopinavir (LPV)(LPV)/ / Ritonavir Ritonavir (RTV)(RTV)

No dataNo data

Atazanavir Atazanavir (ATV)(ATV) No dataNo data

Indinavir Indinavir (IDV)(IDV) No dataNo data

Saquinavir Saquinavir (SQV)(SQV) No dataNo data No changeNo change

Interactions between COCs and NNRTIs

Non-nucleoside reverse Non-nucleoside reverse transcriptase inhibitorstranscriptase inhibitors

Contraceptive Contraceptive hormone levels hormone levels

in bloodin blood

ARV levelsARV levels in blood in blood

Nevirapine Nevirapine (NVP)(NVP) No changeNo change

Efavirenz Efavirenz (EVF or EFZ) (EVF or EFZ) No changeNo change

teratogen

Source: WHO, 2004; Cohn, 2005.

No significant interaction was found between No significant interaction was found between ARV drugs and progestin-only injectables ARV drugs and progestin-only injectables particularly DMPA.particularly DMPA.

Clinical Significance of COC/ARV Interaction Is Unknown

• Studies examining clinical outcomes are needed (i.e., pregnancy rates, ovulation indicators)

• No data on interaction between ARVs and hormonal contraceptives other than COCs and DMPA

• Ritonavir-boosted protease inhibitors reduce contraceptive hormone blood levels considerably– not generally recommended for women on oral

contraceptives or combined injectables– not part of first-line ARV regimens

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Hormonal Contraceptive Use: Increases Risk of Cervical Infection

DMPADMPA COCsCOCs

Increased risk of chlamydiaIncreased risk of chlamydia 3.13.1 2.2*2.2*

Increased risk of cervicitisIncreased risk of cervicitis 1.61.6 2.3 2.3

Source: Lavreys, 2004.

* not statistically significant when adjusted for demographic factors

Hormonal Contraceptive Use:

May Increase HIV Shedding

• HIV shedding may increase risk of HIV transmission to partner

• In one study, modest increase in cervical shedding of HIV-infected cells but no free virus

• Impact on infectivity is uncertain

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Source: Wang, 1999; Wang, 2004; John, 2001.

Relationships Require Further Research

Cervical STI Cervical STI infections may also infections may also increase cervical increase cervical shedding of HIVshedding of HIV

More HIV virus More HIV virus may increase may increase risk of transmis-risk of transmis-sion to partnersion to partner

Using hormonal Using hormonal contraceptives contraceptives may increase: may increase: • risk of acquiring risk of acquiring

cervical STIs cervical STIs • cervical shedding cervical shedding

of HIVof HIV

Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.

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Source: McClelland, 2001; Ghys, 1997.

Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.

Hormonal Contraceptive Use:Theoretically May Affect Disease Progression

Use of hormonal contraceptives near the time of HIV acquisition is associated with: • Higher viral load set point (indicator of disease progression)

• Infection with multiple subtypes of HIV, resulting in faster CD4 decline

Source: Lavreys, 2004; Sagar, 2003.

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4Viral load increases after initial infection

Immune system’s killer cells respond

Viral load is reducedHigher set point Lower set point

Hormonal Contraceptive Use and HIV:

What Providers Should Do

• Counsel clients that certain ARV drugs reduce blood levels of contraceptive hormones which in theory may reduce method effectiveness (except DMPA)

• Encourage clients to tell providers which drugs they are taking

• When there is a choice, prescribe ARV drugs that do not interact with hormonal methods

• Encourage correct and consistent use of contraceptive method

• Keep abreast of guideline updates