Optimizing Contraception for the HIV-positive Woman

The ideal contraceptive for an HIV-positive woman prevents pregnancy as well as transmission of HIV and STDs. Dual contraception using condoms plus an additional contraceptive is the best strategy. Preexposure (PrEP) and postexposure (PEP) prophylaxis should be available to partners regardless of contraceptive method used.

There does not appear to be an association between the use of non-injectable hormonal contraception and risk of HIV acquisition. Studies regarding the risk of HIV acquisition with the use of progestin only DMPA injectable are conflicting, and the CDC continues to recommend it.

SUMMARY:

Combined hormonal contraception (pill, patch and ring) and progestin-only pills
- Considered MEC cat. 1 for patient who are not on antiretrovirals or are not clinically well
- For patients who are taking antiretrovirals, can decrease hormone levels but are still considered safe (either cat. 1 or 2 depending on which antiretroviral is being used)
- Protease inhibitors, pharmacologic boosters, and efavirenz can cause decreased effectiveness of hormonal contraception
- Fostemsavir: can cause increased levels of ethinyl estradiol and raise risk of thromboembolic events. Dosing of ethinyl estradiol should not be higher than 30 mcg daily.
Contraceptive implants are highly effective and benefits outweigh risks in HIV positive women (MEC cat. 1)
Injectable depot medroxyprogesterone acetate (DMPA) is safe and effective (MEC cat. 1) and does not appear to have interactions with antiretrovirals
- Studies regarding increased risk of HIV transmission and acquisition are conflicting.
Intrauterine devices, both copper containing and levonorgestrel-releasing
- MEC cat. 1 for women with HIV who are clinically well and on antiretrovirals, with no known drug interactions with antiretrovirals
- For women with HIV who are not clinically well or not on antiretrovirals, initiation of IUD is considered MEC cat. 2, but continuation for an already placed IUD is cat.1
- Limited data suggest a low risk of pelvic inflammatory disease and no changes in genital shedding of HIV RNA
Condoms reduce transmission of HIV between discordant partners but are not represent optimal contraception, with an annual pregnancy rate of over 15% per year. Should be used concurrently with another contraceptive method
Spermicides: not recommended due to potential of causing genital lesions
- Nonoxynol-9, the active ingredient in most formulations, can cause genital lesions and may increase the likelihood of HIV transmission to a partner

KEY POINTS:

HIV infection does not pose a barrier to sterilization, which remains an appropriate contraceptive option
Emergency contraception including hormone based (progestin-only pills, ulipristal acetate, combined oral contraceptives) and the copper IUD should be offered to HIV positive women whenever appropriate
Spermicides and are not recommended