|
Research |
||
|
|
||
|
By Kim Best, Senior Science Editor, and Kathleen Henry Shears, Principal Research Writer, Family Health International, Research Triangle Park, NC, USA Women with HIV have a right to decide whether they want to become pregnant and bear children. But if an HIV-infected woman chooses not to have children, or wants to space her family, she should be able to make informed, voluntary decisions about contraception and then receive her method of choice. Such use of contraception by HIV-infected women is an important way to reduce HIV-positive births. In addition, HIV-infected women using antiretroviral (ARV) therapy may want to use family planning until the effects of these drugs on maternal and child health are better understood.* Numerous studies suggest that contraceptive use by HIV-infected women can be surprisingly low. One reason is that some infected women may very much want to have children. The increasing availability of ARV drugs -- which can restore fertility in infected women -- may also make pregnancy more appealing, since treatment offers hope for better health, better quality of life, and survival.1 However, many women on ARV drugs are experiencing unintended pregnancies, with disastrous consequences for some.2 One factor that deters some HIV-infected women from using contraception is fear of its possible health effects. However, HIV-infected women can use most contraceptive methods safely. Hormonal methods Further research is needed about the effects of hormonal contraception on a woman's HIV infectiousness and disease progression, and about the consequences of interactions between these methods and ARV drugs. (For example, there is some concern that use of certain ARVs can alter the metabolism of oral contraceptives, and therefore might require an adjustment in contraceptive dosage or change to another contraceptive method.) However, the World Health Organization (WHO) recommends that HIV-infected women can safely use hormonal contraceptives -- including combined oral contraceptives (COCs), the injectables depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), and implants such as Norplant. Intrauterine devices A highly effective yet reversible nonhormonal contraceptive method became more available to HIV-infected women in 2004, when WHO removed most of its previously recommended restrictions on use of the intrauterine device (IUD) by women with HIV. Those restrictions, based on theoretical concerns about increased risk of pelvic inflammatory disease and HIV infectivity, were lifted after studies demonstrated that complications of IUD use are no more common among HIV-infected IUD users than they are among uninfected IUD users3 and that IUD use does not appear to increase HIV infectivity.4 These findings suggest that appropriately selected HIV-infected women with regular access to medical services can use IUDs safely. Under the revised WHO guidelines, most HIV-infected women generally can initiate and use IUDs and the levonorgestrel-releasing intrauterine system, and IUD users who become infected with HIV may continue using the device. The only exceptions are for insertions among women who have developed AIDS and are not receiving ARV drugs or women with AIDS who are not responding well to ARV treatment. IUD initiation is not recommended for such women because their suppressed immune systems can make them more vulnerable at the time of IUD insertion to infections that could lead to pelvic inflammatory disease. However, HIV-infected IUD users who develop AIDS may generally continue using the device.5 Sterilisation For HIV-infected women who have decided to forgo or end childbearing, female sterilisation is a good option because it is a safe, highly effective, and permanent method of contraception. If a woman has an AIDS-related illness, however, female sterilisation should be postponed until her condition improves.6 Condoms When used consistently and correctly at each act of sexual intercourse, male and female condoms are the only contraceptive methods that can prevent the transmission of sexually transmitted infections (STIs), including HIV. Consistent condom use can protect an already HIV-infected woman against re-infection with another strain of HIV or from acquiring STIs such as gonorrhea and chlamydial infection. It can also reduce the risk of an HIV-infected woman transmitting the virus to an uninfected partner. Even when a woman is unlikely to infect others with HIV because her own infection is controlled by ARV therapy, she should be encouraged to use condoms because treatment may not completely eliminate her risk of infecting others. Since condoms as they are typically used are not as effective in preventing pregnancy as are many other contraceptive methods, HIV-infected women who do not want to become pregnant should consider using a more effective form of contraception while using condoms for STI protection. Another dual protection option is the consistent use of condoms alone, with access to emergency contraception as a backup method of contraception.
Other methods Barrier methods other than condoms offer only modest protection against pregnancy and are generally not recommended for women with HIV.7 Frequent use of spermicides containing nonoxynol-9 (N-9) may increase the risk of re-infection with other strains of HIV because N-9 can disrupt the lining of the vagina, making it more vulnerable to infection.8 Diaphragms and cervical caps are not recommended for women with HIV or AIDS and women at high risk of HIV infection because they are usually used with spermicides containing N-9. Fertility awareness-based (natural family planning) methods require abstaining from sex or using barrier methods only during the fertile days of the menstrual cycle in order to prevent pregnancy.9 But protected sex throughout the menstrual cycle -- even during non-fertile periods -- is necessary to prevent HIV transmission to a partner. Therefore, sexually active HIV-infected women and their partners should use male or female condoms consistently throughout the woman's menstrual cycle. References
* Certain ARV drugs may be toxic for pregnant women and fetuses. The drug efavirenz (EFZ), for example, is believed to be a potent early teratogen, and recent World Health Organization (WHO) draft guidelines state that 'EFZ should not be given to women of childbearing potential unless effective contraception can be assured.' Other concerns have been raised about whether a woman's use of nucleoside reverse transcriptase inhibitors (such as zidovudine and lamivudine) could affect the mitochondrial or nuclear DNA of her child, potentially causing such side-effects as lactic acidosis and anemia and increasing susceptibility to cancer.
This article was reproduced with permission of the Mera journal, the leading publication of continuing medical education for health professionals in the English-speaking countries of Africa (info@fsg.co.uk, www.fsg.co.uk). |
|||
 |
|||
