1. Hormonal Contraception and HIV: Implications for Contraceptive Guidance
Michael Lowe, PhD, MSPH
Division of Reproductive Health
Centers for Disease Control and Prevention
This presentation was created and previously presented by Naomi K. Tepper, MD, MPH, FACOG (CDC employee)
May 13, 2013
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health

2. Disclosures
No conflicts of interest

3. Objectives
To discuss the evidence for hormonal contraception and HIV acquisition, transmission and progression
To discuss competing risks for women at risk for HIV or infected with HIV/AIDS
To discuss CDC’s updated guidance on use of hormonal contraceptives among women at risk for HIV or infected with HIV/AIDS

4. Effectiveness of Reversible Contraceptives
More
Effective
Less
IUD
Implant
Depo
Pill
Patch
Ring
Diaphragm
Condoms
Withdrawal
Spermicide

5. Effectiveness of Reversible Contraceptives
More
Effective
Less
Less User
Dependent
More User
IUD
Implant
Depo
Pill
Patch
Ring
Diaphragm
Condoms
Withdrawal
Spermicide

6. WHO Global Contraceptive Guidance

7. WHO Global Contraceptive Guidance
To base family planning practices on the best available evidence
To address misconceptions regarding who can safely use contraception
To reduce medical barriers
To improve access and quality of care in family planning

8. WHO Medical Eligibility Criteria for Contraceptive Use (MEC)
Purpose:
who can use contraceptive methods
WHO MEC, 4th edition, 2009,

9. MEC categories No restriction for use of the contraceptive method
Advantages of using the method generally outweigh theoretical or proven risks
Theoretical or proven risks usually outweigh advantages of using the method
Unacceptable health risk if the contraceptive method is used

10. WHO MEC HIV/AIDS recommendations
Condition
CHC
POP
DMPA, NET-EN
Implants
High risk for HIV 1
HIV infection
AIDS 1*
* Clarification: Drug interactions may occur between hormonal contraceptives and ARV therapy; refer to the section on drug interactions.

11. WHO Intent for MEC
“The guidance in this document is intended for interpretation at country and programme levels in a manner that reflects the diversity of situations and settings in which contraceptives are provided.”
WHO MEC, 4th edition, 2009,

12. Same recommendations as WHO for women at risk for HIV and with HIV/AIDS

14. Source: fhi360

15. Hormonal Contraception and HIV: Evidence

16. Hormonal Contraception and HIV
Does hormonal contraceptive use increase risk for:
HIV acquisition among non-infected women?
HIV transmission to non-infected male partners?
HIV disease progression?
interaction with antiretroviral therapy?

17. Hormonal Contraception and HIV: Acquisition

18. Prospective, observational studies of OC pills & HIV acquisition (including studies that did not meet minimum quality criteria) Adjusted OR, IRR, or HR (log scale) and 95% CI
* includes MSM and Cox estimates
Source: Polis, USAID

19. Prospective, observational studies of injectables & HIV acquisition (including studies that did not meet minimum quality criteria) Adjusted OR, IRR, or HR (log scale) and 95% CI
* includes MSM and Cox estimates
Source: Polis, USAID

20. Biological mechanisms for acquisition
HC may induce changes in vagina/cervix
Cervical ectopy
Thinning of vaginal epithelium
Reduction of lactobacilli
Immunologic changes
Viral diversity or virulence
Other STIs
Animal studies

21. Hormonal Contraception and HIV: Transmission

22. HC and HIV transmission from women to men
Hormonal contraceptive
Hazard Ratio*
(95% CI)
Number of men infected
Injectable
2.0 ( ) 15
Oral
2.1 ( ) 4
* Compared with no hormonal contraceptive use
Heffron, Lancet Infect Dis 2012;12:19-26.

23. HC and HIV transmission: indirect evidence
16 studies
Outcomes: genital viral shedding or plasma viral load
Genital shedding evidence mixed
Plasma viral load no effect
Limitations
Viral shedding is proxy
No measurement consensus

24. Hormonal Contraception and HIV: Disease Progression

25. HC and HIV progression 12 studies
Outcomes: mortality or progression to AIDS
7 observational studies no difference
1 RCT- increased risk with OC and injectables (high levels of switching and loss to follow up)
Outcomes: change in CD4 count or viral load
5 observational studies
No differences

26. Summary of evidence HIV acquisition HIV transmission
OCs and Net-EN: no increased risk
DMPA: data inconsistent, possibility of increased risk not ruled out
HIV transmission
Direct evidence: 1 study showed increased risk with DMPA
Indirect evidence: mixed for changes in genital shedding, no effect on plasma viral load
HIV disease progression
Most studies showed no progression, 1 RCT showed increased risk

27. Limitations Objective of study Limited power
Measurement of exposure, outcome and key variables
Behavioral differences
Comparison group
Confounding
Follow up

28. Putting Evidence into Context: Balancing Competing Health Risks

29. Competing risks HIV infection Unintended pregnancy
Pregnancy and HIV transmission
Maternal mortality and morbidity

30. Number of women with HIV/AIDS, 2009
16 million women HIV-infected globally
76% of HIV-infected women in sub-Saharan Africa

31. 350,000 women die of pregnancy-related causes every year
1 in 30 in sub-Saharan Africa
For every maternal mortality, women suffer maternal morbidity

32. HIV diagnoses among females (N=10,168) U.S., 2010
CDC, HIV surveillance report 2010,

33. HIV diagnoses, women ages >13 U.S., 2009
CDC, NCHHSTP Atlas,

34. Unintended pregnancy U.S., 2006
Finer, Contraception, 2011;84:478.

35. Maternal mortality ratio, 2008

36. Pregnancy-related mortality U.S., 1998-2005
Berg, Obstet Gynecol, 2010;116:1302.

37. Maternal mortality, by race/ethnicity U.S., 2007
NCHS,

38. Maternal morbidity U.S.,2001-2005
Type of morbidity
Percent Number
Obstetric complications
28.6
1,091,200
1,141,100
Preexisting medical conditions
4.1
155,300
4.9
194,100
Berg, Obstet Gynecol, 2009;113:1075.

40. CDC consultation March 2012 teleconference
Reviewed evidence and WHO recommendation
Discussed whether any changes needed to be made for US recommendations

41. CDC updated guidance
CDC. MMWR 2012;61:

42. MEC HIV/AIDS recommendations
Condition
CHC
POP
DMPA
Implants
High risk for HIV 1 1†
HIV infection 1*
AIDS
* Clarification: Drug interactions might exist between hormonal contraceptives and antiretroviral drugs; refer to the section on drug interactions.
† Clarification: See next slide.
CDC. MMWR 2012;61:

43. Clarification for progestin-only injectables among women at high risk of HIV
Some studies suggest that women using progestin-only injectable contraception might be at increased risk for HIV acquisition; other studies do not show this association. CDC reviewed all available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk for HIV acquisition, women using progestin-only injectable contraception should be strongly advised to also always use condoms (male or female) and take other HIV preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection are essential. These recommendations will be continually reviewed in light of new evidence.

44. Conclusions Evidence mixed on hormonal contraceptives and HIV risk
Consider health risks of HIV, unintended pregnancy and maternal mortality/morbidity
Counseling about dual protection critical

46. Thank you
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA
Telephone: CDC-INFO ( )/TTY:
Web:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health