Hormonal contraception and HIV
Following new findings from recently published epidemiological studies, WHO convened a technical consultation regarding hormonal contraception and HIV acquisition, progression and transmission. It was recognized that this issue was likely to be of particular concern in countries where women have a high lifetime risk of acquiring HIV, where hormonal contraceptives (especially progestogen-only injectable methods) constitute a large proportion of all modern methods used and where maternal mortality rates remain high. The meeting was held in Geneva between 31 January and 1 February 2012, and involved 75 individuals representing a wide range of stakeholders. Specifically, the group considered whether the guideline Medical eligibility criteria for contraceptive use, Fourth edition 2009 (MEC) should be changed in light of the accumulating evidence.
After detailed, prolonged deliberation, informed by systematic reviews of the available evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiological evidence, and analysis of risks and benefits to country programmes, the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, the group recommended that a new clarification (under Category 1) be added to the MEC for women using progestogen-only injectable contraception at high risk of HIV as follows:
Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not show this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures.
Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in light of new evidence.
The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits. The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male or female, as hormonal contraceptives are not protective against HIV transmission or acquisition.
All evidence was reviewed carefully, and there was extensive discussion of the interpretation and implications of the results. The group considered the strength of the epidemiological and biological data, possible implications for country programmes, taking into account the need for HIV prevention, and the risk of unintended pregnancy on maternal mortality and pregnancy-related morbidity. Most concern focused on the relationship between progestogen-only injectable contraception and risk of HIV acquisition in women. In considering the totality of available evidence, the group determined that currently available data neither establish a clear causal association with injectables and HIV acquisition, nor definitively rule out the possibility of an effect.
The group agreed that use of hormonal contraceptives should remain unrestricted if a strong clarification was added to the MEC, which reflected the difficulties the group had with the data, the need for an enhanced message about condom use, for both male and female condoms, and other HIV prevention measures, and the need for couples to have access to as wide a range of contraceptive methods as possible. A clear recommendation was also made on the need for further research on this issue and an undertaking to keep emerging evidence under close review.
Thus, the expert group determined that women at high risk of HIV or living with HIV, can continue to use all existing hormonal contraceptive methods (Category 1) (oral contraceptive pills, contraceptive injectables, patches, rings, and implants), but that a strong clarification (as detailed above) relating to the use of progestogen-only injectables be added for women at high risk of HIV.
Overall, women should receive correct and full information from their health-care providers so that they are in a position to make informed choices.
Recommendations for women at high risk of HIV infection
- Women at high risk of HIV can continue to use all existing hormonal contraceptive methods without restriction.
- It is critically important that women at risk of HIV infection have access to and use condoms, male or female, and where appropriate, other measures to prevent and reduce their risk of HIV infection and sexually transmitted infections (STIs).
- Because of the inconclusive nature of the body of evidence on progestogen-only injectable contraception and risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other preventive measures. Condoms must be used consistently and correctly to prevent infection.
Recommendations for women living with HIV infection
- Women living with HIV can continue to use all existing hormonal contraceptive methods without restriction.
- Consistent and correct use of condoms, male or female, is critical for prevention of HIV transmission to non-infected sexual partners.
- Voluntary use of contraception by HIV-positive women who wish to prevent pregnancy continues to be an important strategy for the reduction of mother-to-child HIV transmission.