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Hormonal Contraception and HIVHormonal contraceptive users need not switch to another contraceptive method. |
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By Willard Cates, Jr., MD, MPH Charles Morrison, PhD Hormonal contraceptive methods, among the most effective means of preventing pregnancy, have greatly improved the well-being of women and their families alike. However, as the HIV/AIDS pandemic continues unabated, scientists seeking to identify factors that could contribute to the spread of HIV have raised the possibility of an association between hormonal contraceptive use and HIV acquisition. Research on the topic has been conflicting and inconclusive. However, new data from the largest prospective study ever conducted specifically on this topic help clarify this issue. The FHI-led investigation, conducted among family planning clients in Uganda, Zimbabwe, and Thailand, has found no overall association between the use of combined oral contraceptive (COC) pills or depot-medroxyprogesterone acetate (DMPA) and HIV acquisition. In sum, on the basis of current knowledge about HIV acquisition risks, hormonal contraceptive users who are HIV-negative need not switch to another contraceptive method. Despite its sophistication and power, this study — funded by the U.S. National Institute of Child Health and Human Development — raised an interesting and unexpected question (see Hormonal Contraception and HIV Acquisition): Does the absence of previous genital herpes infection influence the impact, if any, of hormonal contraception on HIV acquisition? Further analyses of the rich data from this study may help provide answers. Meanwhile, hormonal contraceptive use by HIV-infected women continues to be an important topic for researchers. More women worldwide are learning that they are infected with HIV and many of them do not wish to become pregnant. Uncertainty exists about whether the use of hormonal contraception by HIV-positive women affects their infectivity to male partners or disease progression to AIDS. Research about the infectiousness of HIV-positive hormonal contraceptive users has been limited and inconclusive. As a result, the topic continues to be investigated. Likewise, some evidence indicates that disease progression may be more rapid if hormonal contraception is used at the time of HIV infection than if it is not used then, but this observation must be confirmed. Further research will also help determine whether hormonal contraceptive use during the later, chronic stage of HIV infection alters the progression to AIDS and the need for antiretroviral (ARV) drug therapy. Finally, clarity about interactions between hormonal contraception and ARV therapy (or other medications used to treat AIDS-related opportunistic infections) is needed. HIV treatment programs are currently scaling up in countries with high HIV prevalence among women, so we need this knowledge as soon as possible. While hormonal contraception is highly effective against pregnancy, it does not protect against HIV. Thus, HIV-negative hormonal contraceptive users at any risk of infection should, if possible, reduce their number of sex partners and also use condoms consistently and correctly. This long-accepted recommendation remains unchanged regardless of the method of contraception a woman uses. If further research confirms that hormonal contraceptive use at the time of HIV infection speeds disease progression, then women at risk for HIV who continue to use hormonal contraception for protection against pregnancy may have even more incentive to use condoms to protect against infection. Meanwhile, the possible reproductive health consequences of changing contraceptive methods should be carefully considered. Other than condoms, no contraceptive methods protect against HIV infection. However, some methods provide more protection against pregnancy than others. Women switching to a less effective contraceptive method may be at greater risk for a pregnancy that is both unintended and may have serious health consequences. Pregnancy can result in serious maternal harm or death, especially in some resource-poor settings where childbirth is unsafe or abortion is illegal. In sub-Saharan Africa, for example, as many as one woman in every 16 faces the risk of maternal death in the course of her lifetime.1 Furthermore, pregnancy itself may increase risk of HIV acquisition. In the three-country, FHI-led study of hormonal contraceptive use and HIV acquisition, pregnancy did not appear to alter the risk of HIV acquisition.2 But in a study conducted in Rakai, Uganda, pregnant women were more than twice as likely as non-pregnant, non-lactating women to acquire HIV. Hypothesized reasons for this possible increased risk include the hormonal changes a woman experiences during pregnancy that might affect her immune system or vagina.3 Again, this finding will need to be confirmed by additional research. Hormonal contraceptive users who are already HIV-positive and who — in light of limited data about infectivity, disease progression, and drug interactions — wish to continue hormonal contraceptive use can be counseled to do so. Meanwhile, HIV-positive women using hormonal contraception who wish to switch methods should be counseled about other highly effective contraceptive options, such as intrauterine devices and sterilization. Such counseling is especially important because use of contraception by HIV-positive women plays a critical role in preventing mother-to-child transmission of HIV. References
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