1. Hormonal Contraceptives – Considerations for Women with HIV and AIDS

2. Hormonal Contraceptives Combined oral contraceptive pills (COCs) Progestin-only oral contraceptive pills (POPs) Injectables (Depo-Provera/DMPA) Implants (Norplant, Jadelle, Sinoplant, Implanon)

3. Hormonal Contraceptive Methods: Appropriate for Women with HIV Very effective Easy to use Suitable for short- or long-term use Reversible Non-contraceptive health benefits Serious complications extremely rare

4. Overview: Theoretical Concerns about Hormonal Methods For women with HIV: ARVs may reduce method effectiveness or increase side effects Contraceptives may affect ARV efficacy Hormonal methods may possibly affect –infectivity –disease progression Future research may lead to changes in clinical practices. ? ? ? ? ? 4 Source: Leitz, 2000; Piscitelli, 1996.

5. How ARVs Interact with COCs May cause an increase or decrease of hormone levels Some ARVs speed up liver metabolism and could lower blood levels of contraceptive hormones, may reduce method effectiveness Not all ARV classes interact with contraceptive hormones (e.g., NRTIs)

6. Interactions between COCs and PIs Source: WHO, 2004; Ouellet, 1998. Protease inhibitors Contraceptive hormone levels in blood ARV levels in blood Nelfinavir (NFV)  No data Ritonavir (RTV)  No data Lopinavir (LPV) / Ritonavir (RTV)  No data Atazanavir (ATV)  No data Indinavir (IDV)  No data Saquinavir (SQV) No data No change

7. Interactions between COCs and NNRTIs Non-nucleoside reverse transcriptase inhibitors Contraceptive hormone levels in blood ARV levels in blood Nevirapine (NVP)  No change Efavirenz (EVF or EFZ)  No change teratogen Source: WHO, 2004; Cohn, 2005. No significant interaction was found between ARV drugs and progestin-only injectables particularly DMPA.

8. Clinical Significance of COC/ARV Interaction Is Unknown Studies examining clinical outcomes are needed (i.e., pregnancy rates, ovulation indicators) No data on interaction between ARVs and hormonal contraceptives other than COCs and DMPA Ritonavir-boosted protease inhibitors reduce contraceptive hormone blood levels considerably –not generally recommended for women on oral contraceptives or combined injectables –not part of first-line ARV regimens ? ? ? ? ? 4

9. Hormonal Contraceptive Use: Increases Risk of Cervical Infection DMPACOCs Increased risk of chlamydia 3.1 2.2* 2.2* Increased risk of cervicitis 1.62.3 Source: Lavreys, 2004. * not statistically significant when adjusted for demographic factors

10. Hormonal Contraceptive Use: May Increase HIV Shedding HIV shedding may increase risk of HIV transmission to partner In one study, modest increase in cervical shedding of HIV-infected cells but no free virus Impact on infectivity is uncertain ? ? ? ? ? 4 Source: Wang, 1999; Wang, 2004; John, 2001.

11. Relationships Require Further Research Cervical STI infections may also increase cervical shedding of HIV More HIV virus may increase risk of transmis- sion to partner Using hormonal contraceptives may increase: risk of acquiring cervical STIsrisk of acquiring cervical STIs cervical shedding of HIVcervical shedding of HIV Future research may lead to changes in clinical practices. ? ? ? ? ? 4 Source: McClelland, 2001; Ghys, 1997.

12. Future research may lead to changes in clinical practices. Hormonal Contraceptive Use: Theoretically May Affect Disease Progression Use of hormonal contraceptives near the time of HIV acquisition is associated with: Higher viral load set point (indicator of disease progression) Infection with multiple subtypes of HIV, resulting in faster CD4 decline Source: Lavreys, 2004; Sagar, 2003. ? ? ? ? ? 4 Viral load increases after initial infection Immune system’s killer cells respond Viral load is reduced Higher set pointLower set point

13. Hormonal Contraceptive Use and HIV: What Providers Should Do Counsel clients that certain ARV drugs reduce blood levels of contraceptive hormones which in theory may reduce method effectiveness (except DMPA) Encourage clients to tell providers which drugs they are taking When there is a choice, prescribe ARV drugs that do not interact with hormonal methods Encourage correct and consistent use of contraceptive method Keep abreast of guideline updates