WHO releases revised recommendations for hormonal contraceptive use for women at high risk of HIV and women living with HIV
During the AIDS 2014 conference in Melbourne, the World Health Organization announced that following a review of existing epidemiological evidence, including new studies published since 2012, no changes to the Medical eligibility criteria for contraceptive use (MEC) recommendations for initiating or continuing hormonal contraceptives among women at high risk of HIV or living with HIV were warranted. Also, the revised guideline adds recommendations across classes of antiretroviral medications and the individual medications themselves.
WHO 2014 guidance statement
The World Health Organization convened a Guideline Development Group (GDG) meeting in March 2014. The GDG comprising of 52 individuals from 24 countries representing a wide range of stakeholders, reviewed, and where appropriate, revised WHO’s Medical eligibility criteria for contraceptive use, fourth edition (MEC) guidance.
The use of hormonal contraceptive methods by women at high risk of HIV and women living with HIV were among the many topics reviewed at this meeting. The GDG, following deliberations and analysis on the strength of the available evidence concluded that WHO should recommend:
- No restriction (MEC Category 1) on the use of combined hormonal contraceptives (combined oral contraceptive pills, combined contraceptive patches, combined contraceptive vaginal rings, or combined injectable contraceptives).
- No restriction (MEC Category 1) on the use of progestogen-only pills, progestogen-only injectables (DMPA and NET-EN), and levonorgestrel (LNG) and etonogestrel (ETG) implants.
- Given the unresolved questions surrounding the interaction between progestogen-only injectables and risk of HIV acquisition, the following clarification applies for women using progestogen-only injectable contraception who are at high risk of HIV: Available studies on the association between progestogen-only injectable contraception and HIV acquisition have important methodological limitations hindering their interpretation. Some studies suggest that women using progestogen- only injectable contraception may be at increased risk of HIV acquisition; other studies have not found this association. The public health impact of any such association would depend upon the local context, including rates of injectable contraceptive use, maternal mortality, and HIV prevalence. This must be considered when adapting guidelines to local contexts. WHO expert groups continue to actively monitor any emerging evidence. At the meeting in 2014, as at the 2012 technical consultation, it was agreed that the epidemiological data did not warrant a change to the Medical eligibility criteria for contraceptive use (MEC). Given the importance of this issue, women at high risk of HIV infection should be informed that progestogen-only injectables may or may not increase their risk of HIV acquisition. Women and couples at high risk of HIV acquisition considering progestogen-only injectables should also be informed about and have access to HIV preventive measures, including male and female condoms.
- No restriction (MEC Category 1) on the use of the levonorgestrel-releasing intrauterine device (LNG-IUD) for women at high risk of HIV.
- Women living with HIV who have asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) may generally use the LNG-IUD (MEC Category 2). Women living with HIV who have severe or advanced HIV clinical disease (WHO stage 3 or 4) should generally not initiate use of the LNG-IUD (MEC Category 3 for initiation) until their illness has improved to asymptomatic or mild HIV clinical disease. However, women who already have an LNG-IUD inserted and who develop severe or advanced HIV clinical disease need not have their LNG-IUD removed (MEC Category 2 for continuation). LNG-IUD users with severe or advanced HIV clinical disease should be closely monitored for pelvic infection.
- In general, women taking antiretroviral therapy are eligible for all hormonal contraceptive methods, but special consideration (MEC Category 2) may be necessary for women using some hormonal methods (i.e. combined hormonal methods, progestogen-only pills, or LNG and ETG implants) with certain antiretroviral therapy (ART) regimens (specifically those containing efavirenz or neviripine, as well as some protease inhibitors).
At the recommendation of the GDG, the hormonal contraceptive eligibility guidance for women at high risk of HIV and women living with HIV is being released in advance of the entire MEC guideline’s fifth edition expected to be completed in 2015.