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Hormonal contraception and HIV risk in women: more evidence but uncertainty remains
Keith Alcorn, 2012-03-07 02:40:00

Injectable hormonal contraception may raise the risk of HIV infection for women, but it does not appear to increase the risk of HIV disease progression in women with HIV, according to findings from two new studies presented at the 19th Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle.

However, the possible increased risk from injectable hormonal contraception seen in the study presented today is unlikely to be large enough to justify further changes in advice to women. Injectable hormonal contraception makes a substantial contribution to reducing the risk of death due to unintended pregnancy or complications of childbirth.

Around 14 million women in sub-Saharan Africa use a hormonal form of contraceptive and 60% of these women use an injectable, long-lasting form of hormonal contraceptive.

Concerns about injectable hormonal contraception have arisen as a result of a number of studies showing a higher risk of HIV infection in women who are using an injectable hormonal contraceptive as a method of birth control. (See research presented in 2011 here). However, not all studies have found such an increased risk.

Last month the World Health Organization convened an expert consultation to review this evidence, but decided 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 of HIV acquisi­tion, women using progestogen-only injectable contraception should be strongly ad­vised to also always use condoms, male or female, and other HIV preventive measures”. (See full technical statement here.)

The technical review noted no evidence of a significant association between oral contraceptive use and HIV acquisition in studies that were judged to have a design that was sound enough to minimise biases in the data.

The review also noted no evidence from well-designed studies of a  significant association between use of norethisterone enanthate (NET-En) as an injectable hormonal contraceptive and an increased risk of HIV acquisition.

In the case of other injectable hormonal contraceptives (such as DMPA) the evidence was mixed, with some higher-quality studies failing to show an association with an increased risk of HIV acquisition.

WHO technical review on hormonal contraception and HIV: summary recommendations

Recommendations for women at high risk of HIV infection

Women at high risk of HIV can continue to use all existing hormonal contraceptive methods without restriction. It is critically important that women at risk of HIV infection have access to and use condoms, male or female, and where appropriate, other measures to prevent and reduce their risk of HIV infection and sexually transmitted infections (STIs). Because of the inconclusive nature of the body of evidence on progestogen-only injectable contraception and risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other preventive measures. Condoms must be used consistently and correctly to prevent infection.

Recommendations for women living with HIV

Women living with HIV can continue to use all existing hormo­nal contraceptive methods without restriction. Consistent and correct use of condoms, male or female, is critical for prevention of HIV transmission to non-infected sexual partners. Voluntary use of contraception by HIV-positive women who wish to prevent pregnancy continues to be an important strat­egy for the reduction of mother-to-child HIV transmission.

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