Can women who are at high risk of acquiring HIV, safely use hormonal contraception?
2 March 2017
Since 1991, there has been mixed evidence as to whether using hormonal contraceptive methods increases a woman’s risk of acquiring HIV. To answer this question the World Health Organization (WHO) has continuously monitored the available evidence. In 2016, WHO commissioned an update of a 2014 systematic review of evidence to include new studies.
The updated evidence was examined in December 2016 at a consultation that included a wide range of stakeholders including global representation from clinicians with expertise in contraception and HIV, as well as representatives from affected populations, researchers and academics, epidemiologists, programme managers, policy-makers and guideline methodologists.
To guide contraceptive providers on the medical eligibility criteria (MEC) for contraceptive use, WHO uses a four category system of eligibility as described in the table below. The full MEC guidance, contains more than 2000 recommendations for 25 different contraceptive methods, addresses more than 80 medical conditions or personal characteristics, and is available online here
|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|
Note: In the “Medical eligibility criteria for contraceptive use” guideline, clarifications on eligibility are provided for a number of medical conditions or personal characteristics.
Following the consultation in December 2016, WHO issued revised guidance for women at high risk of acquiring HIV. The revised recommendation is that progestogen-only injectables (norethisterone enanthate [NET-EN] and depot medroxyprogesterone acetate [DMPA, intramuscular or subcutaneous]) can be used by women at high risk of HIV, because the advantages of these methods generally outweigh the possible, but unproven, increased risk of HIV acquisition.
FAQ on hormonal contraception and HIV
The recommendation was previously 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 is now changed to a category 2; meaning women 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. This revised guidance places greater emphasis on the importance of shared decision making and need for counselling on concerns that progestogen-only injectables may increase the risk of HIV infection.
Women at high risk of acquiring HIV can also use the following hormonal contraceptive 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). This guidance remains unchanged.