TABLE. Recommendations for contraceptive use by women who are at high risk for human immunodeficiency virus (HIV) infection.
| Condition | Category |
Clarifications/Evidence | |||
|---|---|---|---|---|---|
| Implants | DMPA | POP | CHCs | ||
| High risk for HIV | 1 | 2 | 1 | 1 |
Clarification (DMPA): There continues to be evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. Uncertainty exists about whether this is due to methodological issues with the evidence or a real biological effect. In many settings, unintended pregnancies and/or pregnancy-related morbidity and mortality are common, and progestin-only injectables are among the few types of methods widely available. Women should not be denied the use of progestin-only injectables because of concerns about the possible increased risk. Women considering progestin-only injectables should be advised about these concerns, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV. Evidence (Implants, DMPA, POP): Evidence from 13 observational studies of DMPA, NET-EN or nonspecified progestin-only injectables, which were considered to be “informative but with important limitations,” continues to show some association between use of progestin-only injectables and risk of HIV acquisition, but it remains unclear whether this results from a causal relationship or methodological limitations.* One additional randomized pilot feasibility trial, published subsequently to the systematic review, found no statistically significant difference in risk of HIV acquisition between progestin-only injectable users (DMPA or NET-EN) and copper IUD users; this study had several limitations including lack of power to assess differences in HIV acquisition rates, and problems with ascertainment of hormonal contraception exposure and HIV acquisition outcomes.† Two small studies assessing levonorgestrel implants, which were considered to be “informative but with important limitations,” did not suggest an elevated risk, although the risk estimates were imprecise.* One study reported no association between use of progestin-only pills and HIV acquisition.* Evidence (CHCs): Eleven studies, deemed “informative but with important limitations,” assessed the use of OCs. Ten of these studies found no statistically significant association between use of OCs and HIV acquisition, while one study reported a marginally significant increased risk. No studies of patch, ring or combined injectable contraception were identified.* |
Abbreviations: CHC = combined hormonal contraceptive; DMPA = depot medroxyprogesterone acetate; HIV = human immunodeficiency virus; IUD = intrauterine device; NET-EN = norethisterone enanthate; OC = oral contraceptive; POP = progestin-only pills.
* Polis CB, Curtis KM, Hannaford PC, Phillips SJ, Chipato T, Kiarie JN, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016;30:2665–83. http://journals.lww.com/aidsonline/fulltext/2016/11130/An_updated_systematic_review_of_epidemiological.13.aspx.
† Hofmeyr GJ, Singata-Madliki M, Lawrie TA, Bergel E, Temmerman M. Effects of injectable progestogen contraception versus the copper intrauterine device on HIV acquisition: sub-study of a pragmatic randomised controlled trial. J Fam Plann Reprod Health Care 2017;43:175–80. http://jfprhc.bmj.com/content/familyplanning/early/2017/04/05/jfprhc-2016-101607.full.pdf.