Sexual and reproductive health

Hormonal contraceptive eligibility for women at high risk of HIV

February 2017

Frequently asked questions

1. Why is WHO issuing a new statement on hormonal contraceptive eligibility for women at high risk of HIV now?

On 1 June 2015, WHO released the fifth edition of the Medical eligibility criteria for contraceptive use (MEC). This guidance contains more than 2000 recommendations for 25 different contraceptive methods and addresses more than 80 medical conditions or personal characteristics. WHO carefully monitors the publication of new research evidence to keep this guideline up to date with the state of knowledge in the field. Guidance is updated as new evidence emerges, and a body of existing evidence is maintained.

The goal of the MEC is to improve access to, and quality of, family planning services by providing policy-makers, decision-makers and the scientific community with recommendations that can be used for developing or revising national guidelines on medical eligibility criteria used in the provision of all methods of contraception. These recommendations do not indicate a single “best” method but rather provide an overview of all methods that could be used safely by people with certain health conditions or characteristics.

Since 1991, there has been mixed evidence as to whether the use of hormonal contraceptive methods is associated with an increased risk of a woman acquiring HIV. In response to continued questions as to whether the use of hormonal contraception increases the risk of HIV acquisition, WHO commissioned an update of a 2014 systematic review, to include new data. Based on this update, WHO convened a consultation to determine whether a revision of the guidance was needed.

The consultation considered new scientific evidence from recently published studies and concluded that the cumulative body of scientific evidence available to date continued to indicate an association with an increased risk of acquiring HIV among progestogen-only injectable users (DMPA and NET-EN). The consultation concluded that it was unknown whether the associations seen in observational studies were due to a true biological effect, or because of limitations of the observational studies, such as bias or confounding.

2. What is the new guidance on hormonal contraceptive eligibility for women at high risk of HIV?

The new guidance is that women at high risk of acquiring HIV can use progestogen-only injectables but should be advised about concerns that these methods may increase risk of HIV acquisition, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV (MEC category 2). Previously the recommendation was a category 1 with a clarification, meaning there was no restriction for the use of the contraceptive method but women should be informed that progestogen-only injectables may or may not increase risk of HIV acquisition. This revised guidance places greater emphasis on the importance of shared decision making and the need for counselling on concerns that progestogen-only injectables may increase the risk of HIV infection.

Guidance on use other hormonal contraceptive methods by women at high risk of HIV infection remains unchanged. They can use the following methods without restriction: combined oral contraceptive pills (COCs), combined injectable contraceptives (CICs), combined contraceptive patches and rings, progestogen-only pills (POPs), and levonorgestrel (LNG) and etonogestrel (ETG) implants (MEC category 1).

Category Condition
1 A condition for which there is no restriction for the use of the contraceptive method
2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method
4 A condition which represents an unacceptable health risk if the contraceptive method is used

3. Why has WHO made this new recommendation?

WHO has made this new recommendation to prioritise the needs and rights of women wanting to prevent pregnancy, who are at a high risk of acquiring HIV, – as well as to safeguard the value of contraceptive choice. A category 2 recommendation addresses women’s preference to be fully informed in decision-making regarding contraception choices and is more feasible to implement than the previous category 1 with a clarification. A category 2 recommendation means, therefore, that women at high risk of HIV should not be denied the use of progestogen-only injectables if this is their preferred method but they must be counselled on the concerns regarding possible increased risk of HIV acquisition.

4. What else do contraceptive service providers need to know?

Informed decision-making is a fundamental principle when providing any contraceptive information and service. A shared decision-making approach to contraceptive use should be taken with all individuals, but special attention should be paid to vulnerable populations, such as women at high risk of acquiring HIV. Counselling should be provided free of stigma, discrimination or coercion, and must respect the human rights of women and girls. Counselling tools and guidelines should be updated to align with the new guidance.

5. Why is this new recommendation important for policy-makers and programme managers?

This new WHO recommendation is critically important for women's health, particularly in sub-Saharan Africa, where high rates of HIV coincide with high use of injectable contraception. Hormonal contraception protects against unintended pregnancy, but not HIV or other sexually transmitted infections (STIs). All individuals at high risk of HIV or other STIs need ready access to infection prevention strategies such as condoms and, where appropriate, pre-exposure prophylaxis.

Many regions with high HIV prevalence also have high rates of unmet need for contraception. The United Nations estimates that 225 million women in developing countries would like to delay or stop childbearing but, for a variety of reasons, are not using any method of contraception. A lack of access to contraception for women and couples, may lead to unintended pregnancy, and subsequent maternal mortality and morbidity, as well as other poor sexual and reproductive health outcomes.

According to current evidence and the revised guidance, contraceptive programmes delivering services to women at high risk of HIV infection can continue to offer all methods of contraception. Updated comprehensive contraceptive and HIV information and counselling services should be made available equally and freely to everyone, free of discrimination, coercion or violence. Countries are encouraged to expand the range of available family planning/contraceptive method options in national programmes, so that women and girls have a wide of range of contraceptive choices.

6. What process was followed to determine whether a change in the guidance was required?

WHO commissioned an update of a 2014 systematic review to include new evidence and determine whether revised guidance was needed. Based upon the review’s findings, a technical consultation was held in December 2016 that brought together a wide range of stakeholders and experts to review the evidence and existing guidance and provide recommendations on whether current guidance should be revised.

7. Who was involved in this technical consultation?

A wide range of stakeholders were present at this meeting including not only global representation from clinicians with expertise in contraception and HIV, but also representatives from affected populations, researchers and academics, epidemiologists, programme managers, policy-makers and guideline methodologists.

8. How were the scientific findings on hormonal contraception and HIV evaluated by WHO during the technical consultation?

The recommendations were prepared according to the standards and requirements specified in the WHO handbook for guideline development with due attention to human rights standards and principles, as well as consideration for the balance of benefits and harms of contraceptive use and values and preferences of end-users. In summary, the process included determining critical questions and outcomes, retrieving evidence, synthesizing and assessing the quality of the evidence, presenting the evidence using a structured approach, and formulating the recommendations.

9. What about future research?

WHO will continue to monitor the publication of new research evidence on the issue of hormonal contraception and HIV. It will convene additional consultations, should new evidence necessitate reconsideration of existing recommendations. WHO encourages research to address key unresolved issues related to establishing medical eligibility criteria for contraceptive use.

During the consultation views on whether the available data support the conclusion that DMPA itself has an impact on HIV risk were shared and discussed. While views varied among members, the group agreed that further observational data are unlikely to reduce the uncertainty. The group endorsed the need for randomized clinical trials to provide more information about possible causality although there was no consensus as to whether these will provide a definitive answer. There is also a need for research that clearly elucidates women’s preferences and values in contraceptive decision-making are needed.

More about hormonal contraception and HIV

10. Do hormonal contraceptives protect against HIV infection?

No. Hormonal contraceptives do not protect against HIV or other sexually transmitted infections. Currently there are no contraceptives, with the exception of condoms (male and female), that help protect against HIV or STIs. To protect themselves, women using hormonal contraceptives must also use a condom or take other preventive measures to protect themselves against HIV infection.

11. Does using hormonal contraceptives increase the risk of contracting HIV?

Hormonal contraceptives do not protect against HIV, but equally do not cause one to get HIV unless exposed to the virus. Available data are currently unclear as to whether women using progestogen-only injectables have a higher risk of HIV infection if exposed to the virus. All individuals at high risk of HIV or other sexually transmitted infections need ready access to prevention strategies, such as condoms and, where appropriate, pre-exposure prophylaxis.

12. What is dual protection?

Dual protection means taking steps to protect against unintended pregnancy, as well as sexually transmitted infections including HIV. This can be achieved either by using condoms (male and female), or with using condoms or pre-exposure prophylaxis plus another method of contraception, such as an intrauterine device (IUD), implants, the birth control pill or injectables.

Abstaining from sex and abstaining from penetrative sex also offer “dual protection” against pregnancy and STIs, including HIV, but the term “dual protection” usually refers to condom use plus another contraceptive.

Condoms are the only proven contraceptive method that also protects against STI transmission including HIV. Male and female condoms only protect if they are used consistently and correctly.

13. What can be done to increase the ability of women and girls to practice dual protection?

Counselling about HIV prevention and contraception should be provided to all women, girls and their partners, especially those who are sexually active. This should be provided by health workers at sexual and reproductive health clinics, by trainers in sexuality education programmes, and by HIV-related health service providers. Information and support from peers through peer outreach programmes should complement messages from health workers about dual protection. Peer counsellors can also promote male responsibility and engagement on condom use.

14. Can women living with HIV use hormonal contraceptives?

Yes, they can. To protect uninfected sexual partners from HIV, or infected partners from reinfection, however, condoms (male and female) or other HIV prevention measures must be used. Women living with HIV can talk to their healthcare provider for a full range of HIV prevention and contraceptive options.

15. Who should decide on what option is best for women and girls?

All sexually active women and girls should be given the necessary information and the means to decide freely about contraception, HIV prevention and matters related to their sexuality. To help sexually active women and girls make informed decisions, health workers should provide them with counselling as well as accurate and complete information about their options, the benefits, risks and side effects of each method. Sexual partners of women and girls should also be provided information on contraception and HIV prevention methods such as condoms and, where appropriate, pre-exposure prophylaxis.

16. Are the current options available for HIV prevention and contraception enough?

While a range of contraceptives protect against unintended pregnancies, only condoms, male and female, provide dual protection by stopping HIV transmission and preventing unintended pregnancies. The lack of methods of HIV prevention that are controlled by women and girls, along with low levels of condom use place women and girls at increased vulnerability to HIV infection. Women need safe contraceptive and HIV prevention options that they can own and manage. New investments into research for female-controlled technologies that allow women to prevent both HIV and pregnancy are essential.