hormonal contraceptives – considerations for women with hiv and aids
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Hormonal Contraceptives
• Combined oral contraceptive pills (COCs)
• Progestin-only oral contraceptive pills (POPs)
• Injectables (Depo-Provera/DMPA)• Implants (Norplant, Jadelle, Sinoplant, Implanon)
Hormonal Contraceptive Methods:
Appropriate for Women with HIV
• Very effective
• Easy to use
• Suitable for short- or long-term use
• Reversible
• Non-contraceptive health benefits
• Serious complications extremely rare
Overview: Theoretical Concerns about Hormonal Methods
For women with HIV:
• ARVs may reduce method effectiveness or increase side effects
• Contraceptives may affect ARV efficacy
• Hormonal methods may possibly affect– infectivity
– disease progression
Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.
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Source: Leitz, 2000; Piscitelli, 1996.
How ARVs Interact with COCs
• May cause an increase or decrease of hormone levels
• Some ARVs speed up liver metabolism and could lower blood levels of contraceptive hormones, may reduce method effectiveness
• Not all ARV classes interact with contraceptive hormones (e.g., NRTIs)
Interactions between COCs and PIs
Source: WHO, 2004; Ouellet, 1998.
Protease inhibitorsProtease inhibitorsContraceptive Contraceptive
hormone levels hormone levels in bloodin blood
ARV levels ARV levels in bloodin blood
Nelfinavir Nelfinavir (NFV)(NFV) No dataNo data
Ritonavir Ritonavir (RTV)(RTV) No dataNo data
Lopinavir Lopinavir (LPV)(LPV)/ / Ritonavir Ritonavir (RTV)(RTV)
No dataNo data
Atazanavir Atazanavir (ATV)(ATV) No dataNo data
Indinavir Indinavir (IDV)(IDV) No dataNo data
Saquinavir Saquinavir (SQV)(SQV) No dataNo data No changeNo change
Interactions between COCs and NNRTIs
Non-nucleoside reverse Non-nucleoside reverse transcriptase inhibitorstranscriptase inhibitors
Contraceptive Contraceptive hormone levels hormone levels
in bloodin blood
ARV levelsARV levels in blood in blood
Nevirapine Nevirapine (NVP)(NVP) No changeNo change
Efavirenz Efavirenz (EVF or EFZ) (EVF or EFZ) No changeNo change
teratogen
Source: WHO, 2004; Cohn, 2005.
No significant interaction was found between No significant interaction was found between ARV drugs and progestin-only injectables ARV drugs and progestin-only injectables particularly DMPA.particularly DMPA.
Clinical Significance of COC/ARV Interaction Is Unknown
• Studies examining clinical outcomes are needed (i.e., pregnancy rates, ovulation indicators)
• No data on interaction between ARVs and hormonal contraceptives other than COCs and DMPA
• Ritonavir-boosted protease inhibitors reduce contraceptive hormone blood levels considerably– not generally recommended for women on oral
contraceptives or combined injectables– not part of first-line ARV regimens
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Hormonal Contraceptive Use: Increases Risk of Cervical Infection
DMPADMPA COCsCOCs
Increased risk of chlamydiaIncreased risk of chlamydia 3.13.1 2.2*2.2*
Increased risk of cervicitisIncreased risk of cervicitis 1.61.6 2.3 2.3
Source: Lavreys, 2004.
* not statistically significant when adjusted for demographic factors
Hormonal Contraceptive Use:
May Increase HIV Shedding
• HIV shedding may increase risk of HIV transmission to partner
• In one study, modest increase in cervical shedding of HIV-infected cells but no free virus
• Impact on infectivity is uncertain
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Source: Wang, 1999; Wang, 2004; John, 2001.
Relationships Require Further Research
Cervical STI Cervical STI infections may also infections may also increase cervical increase cervical shedding of HIVshedding of HIV
More HIV virus More HIV virus may increase may increase risk of transmis-risk of transmis-sion to partnersion to partner
Using hormonal Using hormonal contraceptives contraceptives may increase: may increase: • risk of acquiring risk of acquiring
cervical STIs cervical STIs • cervical shedding cervical shedding
of HIVof HIV
Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.
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Source: McClelland, 2001; Ghys, 1997.
Future research may lead to changes in clinical practices.Future research may lead to changes in clinical practices.
Hormonal Contraceptive Use:Theoretically May Affect Disease Progression
Use of hormonal contraceptives near the time of HIV acquisition is associated with: • Higher viral load set point (indicator of disease progression)
• Infection with multiple subtypes of HIV, resulting in faster CD4 decline
Source: Lavreys, 2004; Sagar, 2003.
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4Viral load increases after initial infection
Immune system’s killer cells respond
Viral load is reducedHigher set point Lower set point
Hormonal Contraceptive Use and HIV:
What Providers Should Do
• Counsel clients that certain ARV drugs reduce blood levels of contraceptive hormones which in theory may reduce method effectiveness (except DMPA)
• Encourage clients to tell providers which drugs they are taking
• When there is a choice, prescribe ARV drugs that do not interact with hormonal methods
• Encourage correct and consistent use of contraceptive method
• Keep abreast of guideline updates