Contraception and HIV

Patients living with HIV can use almost every contraceptive method. The important questions are interaction with antiretroviral therapy, immune status, risk of transmission to a partner and effect on the infection itself. Unplanned pregnancy is frequent and increases vertical transmission risk when not on suppressive therapy, so highly effective contraception is encouraged together with condoms.

Assessment. Antiretroviral regimen, adherence, CD4 count and viral load where available, clinical stage, tuberculosis treatment, other medicines, pregnancy intention, partner status and pre-exposure prophylaxis use, STI symptoms, and adolescent or postpartum status.

Condoms and dual protection. Male and female condoms are the only methods that protect against HIV and other STIs. Every patient is counselled on consistent use in addition to a primary method. PrEP can be used with any contraceptive and during breastfeeding.

HIV acquisition and DMPA. Progestin-only injectables are category 2 in women at high risk of HIV; benefits generally outweigh the uncertain risk, and condoms and PrEP limit acquisition.

Reasonable certainty of non-pregnancy. Same criteria as other patients. HIV does not change pregnancy tests.

Eligibility by method.

Interactions with antiretroviral therapy.

Method comparison. Dolutegravir-based regimens allow any method. When efavirenz or a boosted protease inhibitor is used, prefer an intrauterine device or DMPA, or an implant or pill with consistent condoms.

Special groups. Adolescents, postpartum women and breastfeeding women use the same rules. Women planning pregnancy should have viral suppression before conception and consider PrEP for the partner.

Regimen lines.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late, self-injection supported; backup 7 days if started after day 7 of bleeding; compatible with efavirenz and protease inhibitors.

• Norethisterone enanthate 200 mg intramuscularly every 8 weeks, up to 2 weeks late.

• Etonogestrel 68 mg rod (3 years) or levonorgestrel two 75 mg rods (5 years or 3 years by system): with efavirenz or ritonavir-boosted regimens add condoms throughout and for 28 days after stopping.

• Copper T 380A (up to 12 years) or levonorgestrel 52 mg device (5 years): insertion with infection screening; not affected by antiretroviral therapy.

• Combined pill (ethinylestradiol 30 micrograms with levonorgestrel 150 micrograms) or progestin-only pill: condoms advised with efavirenz, nevirapine and ritonavir regimens; no restriction with dolutegravir.

• Emergency contraception: levonorgestrel 1.5 mg within 120 hours; with efavirenz or enzyme inducers prefer the copper device, or levonorgestrel 3 mg if oral only is available.

Dual protection. Condoms at every act; PrEP for HIV-negative partners where indicated.

Follow up. Review at routine HIV clinic visits, including medicines review whenever the regimen changes, a switch to dolutegravir being the main change that removes interactions.

Integration. Provide family planning in the HIV clinic, offer HIV testing in family planning visits in high-burden settings, and give pregnancy plans and prevention of vertical transmission counselling.

Failure with interacting therapy. Pregnancy occurs more often with implants and pills on efavirenz; test early with missed bleeding, remove an implant if the pregnancy continues, and manage ectopic risk.

Pelvic infection. Patients with intrauterine devices who develop pelvic infection can continue the device during treatment; treat with antibiotics and remove if no improvement in a few days.

Bone health. DMPA lowers bone density slightly; there is no age or time limit, but tenofovir adds bone loss, so weigh other methods in older patients or those with osteoporosis risk factors.

Drug interaction changes. Review contraception when starting or switching antiretrovirals, tuberculosis treatment or antiseizure medicines.

Red flags. Pregnancy symptoms with pelvic pain, signs of immune reconstitution or opportunistic infection, jaundice.

Referral and escalation. Refer suspected ectopic pregnancy, advanced disease with complications, and pregnancy for antenatal and prevention of vertical transmission care.