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Intrauterine Device Appears Safe for Some Women with HIV -- April 17, 2000

Some women infected with the human immunodeficiency virus (HIV) may be able to safely use the intrauterine device (IUD) for family planning, according to a recent scientific study conducted in Nairobi, Kenya.

Researchers at Family Health International (FHI) and the University of Nairobi found that HIV-infected women who used the IUD had no more complications than women who used the IUD but were not HIV-infected. This was true for women who used the device for as long as two years.

"These are encouraging results," said Dr. Charles Morrison of Family Health International, a U.S- based research organization. "One of the concerns with IUD use has been that it could result in more complications among women with HIV. Another concern is that IUDs could result in an increased risk of HIV infection for women's partners. These studies show that may not be the case."

In the study, researchers examined the health of two groups of women: 156 HIV-infected women who received the IUD and 493 women who received the IUD but were not infected with HIV. Researchers looked for problems after insertion, such as IUD removal due to infection, bleeding and pain; expulsion of the IUD; pregnancy; and pelvic inflammatory disease (PID), an infectious disease that can cause severe pain, infertility, or even death. Research results were highlighted in a recent issue of Network, FHI's quarterly science bulletin.

The percentage of women reporting overall complications after IUD insertion was almost identical for the two groups — 14.7 among HIV-positive women and 14.8 among HIV-negative women. The percentage of women reporting problems related to some type of infection — including pelvic tenderness and IUD removal for infection or pain — was 10.7 among those who were HIV-positive, and 8.8 percent among those who were HIV-negative. While HIV-positive women tended to have slightly more problems related to infection, such problems were rare.

In addition to these results, researchers found that the partners of HIV-positive women using IUDs were likely not to be at increased risk of infection. Because IUDs can cause heavier menstrual bleeding, some researchers have expressed concern that IUD use by HIV-infected women could increase men's risk of acquiring HIV, due to increased shedding of HIV-infected cells from the woman's genital area.

The new study found that there was no increase in HIV cervical shedding among HIV-infected women using IUDs. "The data … suggest that IUD use by HIV-infected women does not appear to make them more infectious to their partners," said Dr. Morrison.

Currently, the World Health Organization (WHO) recommends that women with HIV use another form of contraception if available. WHO also says that women who currently have sexually transmitted infections (STIs), such as gonorrhea or chlamydia, not use IUDs until the STI has been treated. And WHO says IUDs are not recommended for women who are at high risk for contracting STIs or whose partners are at high risk for STIs.

There are several reasons for these recommendations. First, there is a concern that HIV-positive women whose immune systems are weakened may not be able to fight off further infections caused by the virus. Also, health experts believe that if a woman has an STI, the process of inserting the IUD can introduce bacteria from the cervix into the womb or the fallopian tubes, leading to PID.

Experts recommend that health workers screen prospective IUD users for STIs through laboratory tests, physical examinations and personal medical histories. Although PID can be treated with antibiotics, women in developing countries may lack access to these drugs, so screening is critical.

If a woman has an undiagnosed STI or another type of cervical infection and she receives an IUD, the chances of her acquiring PID appear to be greatest during the first 20 days following insertion. A study of more than 23,000 women, conducted by WHO, found that women's risk of developing PID dropped dramatically after the 20-day period and remained low for up to eight years.¹ Other studies, including some by FHI, have shown that about 95 percent of women with cervical infections at the time of IUD insertion did not develop PID in the months following.² However, screening women for cervical infections or identifying women at risk of cervical infections is important, since PID risk is higher for this group of women. PID risks among women who do not use the IUD varies, depending on the prevalence of STIs in their area.

While current international medical guidelines discourage IUD use for HIV-infected women, researchers say the findings from the FHI study may eventually offer another option for family planning. Fourteen million women worldwide are HIV-infected, many of whom have a critical need for safe, effective contraception.

"Study findings suggest that the IUD may be a safe contraceptive method for women who have been screened for STIs and who have ongoing access to medical services," says Dr. Morrison. "Use of an IUD by HIV-infected women does not appear to compromise their health."

References:

• Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1991; 339(8796): 785-88.
• Sinei SK, Schulz KF, Lamptey PR, et al. Preventing IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion. B J Obset Gynaecol 1990; 97(5): 412-19. Morrison CS, Sekadde-Kigondu C, Miller WC, et al. Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates. Contraception 1999; 59(2): 97-106. Faúndes A, Telles E, Cristofoletti ML, et al. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998; 58(2): 105-09.

Editor's note: For more information about FHI's research on IUDs see: Sinei SK, Morrison CS, Sekadde-Kigondu C, et al. "Complications of use of intrauterine devices among HIV-1 infected women". Lancet 1998;351(9111):1238-41.