Practice Uncertainties Page

Should women with HIV, or at high risk of contracting HIV, use progestogen-containing contraception?

BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6695 (Published 14 November 2013) Cite this as: BMJ 2013;347:f6695
  1. Sarah Louise Giles, GP locum and overseas volunteer doctor at Kitovu Hospital, Masaka, Uganda1,
  2. Felicia Lester, assistant professor2
  1. 1c/o Uganda River of Life Ministries, PO Box 985, Masaka, Uganda
  2. 2University of California, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, USA
  1. Correspondence to: S L Giles sarahgiles35{at}yahoo.co.uk

Nearly 150 million women worldwide use hormonal methods of contraception, predominantly oral contraceptives taken daily (both combined hormonal pills and progestogen-only pills for the purpose of this article) and long acting injectables such as depot medroxyprogesterone acetate and norethisterone enantate.1 When used correctly, these are highly effective in preventing pregnancy and are reversible. Side effects of medroxyprogesterone are similar in those who are seropositive for HIV and those who are HIV negative,2 and antiretroviral therapy does not reduce its effectiveness.3 However, antiretroviral therapy can make oral contraceptives less effective at preventing pregnancy, and oral contraceptives can increase antiretroviral drugs’ toxicity.3

Concerns have been raised about possible harmful effects of hormonal contraception in patients infected with HIV and those at high risk of contracting HIV. These effects can be considered in three main categories: HIV acquisition, HIV infectivity, and rate of progression of HIV. Several biologically plausible mechanisms have been proposed for these effects, including effects on genital HIV viral shedding, vaginal epithelial thickness, degree of cervical ectopy, or local and systemic immune responses.4 However, there is little consistent evidence.

Any potential for harm is important given that in sub-Saharan Africa, women of childbearing age are disproportionately affected by HIV. It is essential to offer women the opportunity to prevent HIV acquisition, not only for their own health but to prevent mother to child transmission. The most upstream means of primary prevention for HIV is preventing unintended pregnancy in the first place. Disease progression puts the woman at risk of opportunistic infections and increases the risk of transmitting the disease to an uninfected partner.

However, it is equally important to avoid denying access to contraceptives without adequate evidence, since those areas where unintended pregnancy poses the greatest threat to women’s lives are often the same areas …

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