EXECUTIVE SUMMARY

The Centers for Disease Control and Prevention is revising its recommendation on the use of the progestin-only contraception injection depot medroxyprogesterone acetate (DMPA) by women at high risk for HIV from Category 1 (no restriction) to Category 2 (benefits outweigh theoretical or proven risks).

  • The guidance indicates that women at high risk for HIV should continue to have access to the contraceptive shot, but also should be counseled about a possible, but uncertain, increased risk of contracting HIV and how to reduce their risk.
  • The change follows the World Health Organization’s update of its recommendations on DMPA use in women at risk for HIV. Such action comes after the 2016 publication of a meta-analysis suggesting a possible increased risk of HIV acquisition among women using progestin-only injectables.

Women now account for 19% of the 39,513 new HIV diagnoses in the United States in 2015. Heterosexual sex accounted for 86% of these diagnoses, according to the most recent statistics.1

In an update to its U.S. Medical Eligibility Criteria for Contraceptive Use, 2016, the Centers for Disease Control and Prevention (CDC) is revising its recommendation on the use of the progestin-only contraception injection depot medroxyprogesterone acetate (DMPA) by women at high risk for HIV from Category 1 (no restriction) to Category 2 (benefits outweigh theoretical or proven risks).2

The guidance indicates that women at high risk for HIV should continue to have access to the contraceptive shot, but should be counseled about a possible, but uncertain, increased risk of contracting HIV and how to reduce their risk.

The CDC has been closely monitoring evidence on whether use of hormonal contraceptives is associated with an increased risk of HIV acquisition among non-infected women, says Naomi Tepper, MD, MPH, a CDC medical officer.

“Studies report inconsistent results on whether use of progestin-only injectables, including DMPA, is associated with an increased risk of HIV acquisition,” says Tepper. “More recent studies and a new meta-analysis suggest a possible increased risk of HIV acquisition among women using progestin-only injectables, although results varied across individual studies, and most of these studies had methodologic weaknesses.”

In light of the published meta-analysis,3 the World Health Organization (WHO) updated its guidance, changing its classification of long-acting injectable contraceptives like DMPA from “use without restriction” to “benefits outweigh theoretical or proven risks.”4

“In order to keep its guidance for providers up to date, CDC considered the entire body of evidence, recently updated WHO guidance on this issue, other factors such as potential biological mechanisms and the context of family planning in the U.S., and individual input from external experts in HIV or family planning,” says Tepper. “The agency determined that the updated WHO recommendations were applicable to the United States and decided to adopt the WHO recommendations.”

An accompanying clarification to the U.S. guidance notes that there is evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. It goes on to state that it is not clear whether the effect is due to methodological issues with the evidence or a real biological effect. All women at risk for HIV infection, regardless of contraceptive choice, should be counseled about how to reduce their risk, the guidance states.2

Scientists now are involved with the ECHO Study (Evidence for Contraceptive Options and HIV Outcomes), launched in December 2015. It is the first randomized clinical trial designed to assess the risk of HIV acquisition by women using one of three contraceptives: DMPA, the levonorgestrel implant Jadelle, and the copper IUD. The study, spread across 12 research sites in Kenya, South Africa, Swaziland, and Zambia, also is designed to evaluate the performance of these methods in relation to pregnancy rates, side effects, and women’s patterns of use. More than half of the intended 7,800 voluntary participants have been enrolled. Initial results are expected in early 2019.

Women who are at high risk of unintended pregnancy and HIV have multiple concerns — HIV infection is associated with adverse pregnancy outcomes for both the mother and child, including increased morbidity during pregnancy and perinatal HIV transmission.5

The most recent statistics on U.S. contraceptive trends indicate that while overall use of DMPA in the United States is low (4.5%), among current contraceptive users during 2011-2013, use was higher among black women (10%), women ages 15-24 (8.5%), those who had income of less than 150% of the federal poverty level (7.3%), and women who had less than a high school education (10.1%).6 While the rate of unintended pregnancy is declining, the latest data indicate that 45% of pregnancies in the United States were unintended in 2011, with higher percentages among women ages 15-19 (75%) and black women (64%).7

Women at high risk for HIV have many options available when it comes to contraception. Recommendations for other hormonal contraceptive methods, including combined hormonal methods, implants, and progestin-only pills, have no restriction on their use (U.S. MEC category 1). No change was made in their use in this update. For both the copper-T and the levonorgestrel intrauterine devices, the U.S. MEC classifies use as Category 2 — the benefits outweigh theoretical or proven risks.8 

REFERENCES

  1. Centers for Disease Control and Prevention. HIV Among Women. Fact sheet. Available at: http://bit.ly/2hFqFRN. Accessed Oct. 16, 2017.
  2. Tepper NK, Krashin JW, Curtis KM, et al. Update to CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Revised recommendations for the use of hormonal contracep-tion among women at high risk for HIV infection. MMWR Morb Mortal Wkly Rep 2017;66:990-994.
  3. Polis CB, Curtis KM, Hannaford PC, et al. An updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition in women. AIDS 2016;30:2665-2683.
  4. World Health Organization. Hormonal Contraceptive Eligibility for Women at High Risk of HIV. Available at: http://bit.ly/2xDhj3M. Accessed Oct. 16, 2017.
  5. Ewing AC, Datwani HM, Flowers LM, et al. Trends in hospitalizations of pregnant HIV-infected women in the United States: 2004 through 2011. Am J Obstet Gynecol 2016;215:499.e1-8.
  6. Daniels K, Daugherty J, Jones J, et al. Current contraceptive use and variation by selected characteristics among women aged 15–44: United States. 2011–2013. Nat Health Stat Rep 2015;86:1-18.
  7. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med 2016;374:843-852.
  8. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-103.