Women at high HIV risk can keep using methods

Hormonal contraceptives affirmed

The Centers for Disease Control and Prevention (CDC) has updated the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) to affirm the use of hormonal contraceptives in women at risk for or living with HIV. However, a clarification has been added that notes the body of evidence concerning the association between progestin-only injectable use and HIV acquisition is inconclusive. Therefore, women at high risk for HIV infection who use progestin-only injectables should use condoms and other strategies to prevent HIV, the guidance states.1

Recent research has suggested that women using progestin-only injectables (primarily depot medroxyprogesterone acetate [DMPA]) or combined oral contraceptives might have an increased risk for HIV acquisition and transmission to noninfected partners.2

The CDC held a teleconference in March 2012 to allow reviewers with expertise in HIV infection or family planning to examine scientific evidence, as well as information on unintended pregnancy, contraceptive use, HIV infection, and maternal risk in the United States, to inform its guidance. The U.S. criteria, released in June 2012, now fall in line with similar information issued by the World Health Organization, which earlier this year clarified its original classification of DMPA use in women at high risk of HIV.

"Contraception is critically important to prevent unintended pregnancy among women at risk for HIV infection or infected with HIV and such women can continue to use all hormonal contraceptive methods without restriction," the CDC advises. "However, HIV infection preventive measures, such as voluntary testing and counseling, access and adherence to [antiretroviral] drugs, and correct and consistent use of condoms, should be strongly encouraged among all women at risk for HIV acquisition and women living with HIV infection."

Clarification extended

The new CDC guidance also addresses possible drug interactions between hormonal contraceptives and antiretroviral drugs. Because antiretroviral drugs often are indicated in patients with HIV infection without AIDS, the revised guidelines note that this warning applies to all patients with HIV infection.

The previous US guidance included a clarification for the recommendations on hormonal contraceptive methods for women with AIDS regarding the potential for drug interactions between hormonal contraceptives and antiretroviral (ARV) drugs. However, current guidance from the U.S. Department of Health and Human Services recommends that many patients with HIV infection also should take ARV drugs, including any patient with a CD4 count at or below 500 cells/mm.3 The CDC now has added a clarification regarding potential drug interactions between hormonal contraception and ARV drugs to the recommendations for women with HIV.1 (Check the drug interactions section for specific ARV drugs; go to the CDC's US MEC web site, http://1.usa.gov/chY2AV. Click on "Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use," under "CDC Resources" to see the criteria in chart form.)

Counsel on condom use

In 2010, an estimated 10,000 new HIV infections occurred among U.S. women, according to CDC estimates.1 One in 139 women will be diagnosed with HIV during her lifetime, statistics indicate.4 (Use the fact sheet for patient education.)

When talking with women about their chosen contraceptive method, explain that none of the methods of birth control outside of condoms protect against HIV or sexually transmitted infection (STIs), says Naomi Tepper, medical officer in the Division of Reproductive Health at CDC.

"It is really important that women who are using these methods for pregnancy prevention use condoms to protect against HIV and STIs if they are at risk for those infections," observes Tepper. "If they are with a partner who either is infected, or who maybe doesn't know their status, it is important that women are counseled that they need to protect against pregnancy if they don't want to become pregnant, but also need to protect against sexually transmitted infection and HIV."

References

  1. Centers for Disease Control and Prevention. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of hormonal contraception among women at high risk for HIV infection or infected with HIV. MMWR 2012; 61:449-452.
  2. Heffron R, Donnell D, Rees H, et al; Partners in Prevention HSV/HIV Transmission Study Team. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infect Dis 2012; 12(1):19-26.
  3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. P. K-26, P. K-34, K-38 Accessed at http://1.usa.gov/OuVcgl.
  4. Centers for Disease Control and Prevention. HIV among women. Fact sheet. Accessed at http://1.usa.gov/PWF9Kv.