Contraceptives and HIV

Can barrier methods help reduce the risk of both pregnancy and HIV infection?

If used consistently and correctly, male latex condoms provide protection against HIV, gonorrhea, and unintended pregnancy. Depending on the meta-analysis or model used to study condom effectiveness, consistent use reduces HIV incidence by at least 80 percent and perhaps as much as 97 percent. For protection against unintended pregnancy, male latex condoms are 86 percent to 97 percent effective, depending on whether use is typical or ideal, respectively. Scientific evidence to support these conclusions is not complete, but it is strong and consistent enough to produce the solid public health recommendation that condoms work. Most HIV and other sexually transmitted infections (STIs) or unplanned pregnancies likely occur because of condom non-use or inconsistent use, so the challenge is to increase the consistency of male condom use during risky sexual contacts.

As is true of the male latex condom, the female condom has been found to be impermeable to various STIs, including HIV, in the laboratory. In theory, the device should protect against STIs in people as well, but more research is needed to confirm its effectiveness.

Most other female barrier methods – such as the diaphragm, cervical cap, or contraceptive sponge – involve use of a spermicidal product, commonly containing nonoxynol-9 (N-9). Spermicides containing N-9 remain – in themselves – a moderately effective contraceptive option. But based on extensive research, technical experts convened in 2002 by the World Health Organization and the U.S.-based CONRAD Program have concluded that N-9 spermicides increase the risk of HIV infection when used frequently by women at high risk of infection. Thus, they should not be used in this way. Using a male condom lubricated with N-9 is better than using none at all. But the technical experts recommended against promoting condoms lubricated with N-9 since there is no evidence that such condoms are more effective in preventing pregnancy or infection than condoms lubricated with silicone.

Whether N-9 adds contraceptive protection to barrier methods other than condoms is still unknown; still, spermicide use with the diaphragm continues to be recommended. The contraceptive sponge, which re-entered the market in 2003 on a limited basis, protects against pregnancy by blocking sperm from entering the cervix and by releasing N-9. But, again, potential users of the sponge should be aware that N-9 increases the risk of HIV infection when used frequently by women at high risk of infection.

The hypothesis that diaphragms alone might offer women some protection against STIs, including HIV, will soon be tested in several randomized controlled trials. Also to be tested soon is the hypothesis that diaphragms and microbicides may be most effective if used together. (More than 50 agents are being studied for their microbicide potential, and about one-third are in clinical trials.)

What about "non-barrier" methods---like pills, injectables, and IUDs?

Whether hormonal contraceptive use affects acquisition or transmission of STIs, including HIV, remains an important research question.

Two thorough reviews of numerous studies of the risk of HIV acquisition among women who use hormonal contraceptives have been conducted. One found a relationship between use of oral contraceptives (OCs) and HIV acquisition, while the other did not. (Authors of the reviews observed that the quality of such studies was generally poor and their results inconsistent.) Of note, few studies of hormonal contraceptive use and HIV acquisition have been prospective. However, a large prospective study of the relationship between the use of combined OC or depot-medroxyprogesterone acetate (DMPA) injectable and HIV acquisition is being conducted by FHI researchers and collaborating institutions, and should yield results in 2004. The study, funded by NICHD, is being conducted in Uganda, Thailand, and Zimbabwe.

A theoretical concern exists that hormonal contraceptive use by HIV-infected women might increase shedding of HIV and thus increase transmission to uninfected partners. Research findings are inconsistent. To further clarify the matter, FHI researchers are conducting a prospective study in Zimbabwe and Uganda, funded by NICHD, of the effect of combined OC or DMPA use on HIV genital shedding among 140 women with acute or early HIV infection. Preliminary results are expected in 2004.

Insertion of a copper IUD in an HIV-infected woman or one who is at high risk of infection is not usually recommended, according to the World Health Organization's medical eligibility criteria for safe use of contraceptives. However, recent research conducted by FHI and colleagues in Kenya suggests that the IUD may be a safe contraceptive method for carefully selected HIV-infected women with continuing access to medical services.


So, what are the family planning guidelines?

Current knowledge of a potential relationship between use of hormonal methods of contraception and HIV infection is insufficient to change family planning practices. However, neither hormonal contraceptives nor IUDs appear to protect against HIV or other STIs. Thus, while continuing to promote hormonal contraception and IUDs for family planning when appropriate, providers should counsel such contraceptive users who are also at high risk of HIV/STIs to use a condom during each act of intercourse.

In summary, of all available contraceptives, only male latex condoms have been shown to help protect against HIV/STIs, as well as unplanned pregnancy. Condoms may not be suitable for all users, but consistent and correct use of these methods can give excellent protection against both pregnancy and disease.