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Hormonal Contraceptive Methods for Women at High Risk of HIV and Living with HIV: 2014 Guidance Statement. Geneva: World Health Organization; 2014.
| If there is risk of STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms (male or female) is recommended, either alone or with another contraceptive method. | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| CONDITION | CATEGORY1 | CLARIFICATIONS | |||||||
| COC | P/R | CIC | POP | DMPA | NET-EN | LNG/ETG | LNG-IUD | ||
| HIGH RISK OF HIV | 1 | 1 | 1 | 1 | 1a | 1a | 1 | 2 | a 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 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. |
Category 1: A condition for which there is no restriction for the use of the contraceptive method; Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks; Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method; Category 4: A condition which represents an unacceptable health risk if the contraceptive method is used.
CIC: combined injectable contraceptives; COC: combined oral contraceptives; DMPA: depot medroxyprogesterone acetate; IUD: intrauterine device; LNG/ETG: levonorgestrel and etonogestrel implants; LNG-IUD: levonorgestrel-releasing IUD (20 μg/24 hours); MEC: Medical eligibility criteria for contraceptive use (WHO publication); NET-EN: norethisterone enantate (NET-EN); P: combined contraceptive patch; POP: progestogen-only pills; R: combined contraceptive vaginal ring; STI: sexually transmitted infection.
| If there is risk of STI/HIV (including during pregnancy or postpartum), the correct and consistent use of condoms is recommended, either alone or with another contraceptive method. | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| CONDITION | CATEGORY I = initiation, C = continuation | CLARIFICATIONS | ||||||||
| COC | P/R | CIC | POP | DMPA | NET-EN | LNG/ETG | LNG-IUD | |||
| I | C | |||||||||
| ASYMPTOMATIC OR MILD HIV CLINICAL DISEASE (WHO STAGE 1 OR 2) | 1b | 1 b | 1 b | 1 b | 1 b | 1 b | 1 b | 2 | 2 | b Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the section on drug interactions. |
| SEVERE OR ADVANCED HIV CLINICAL DISEASE (WHO STAGE 3 OR 4) | 1 b | 1 b | 1 b | 1 b | 1 b | 1 b | 1 b | 3 | 2 | b Because there may be drug interactions between hormonal contraceptives and ARV therapy, refer to the section on drug interactions. |
| ANTIRETROVIRAL DRUGS | ||||||||||
| NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIs) | I | C | ||||||||
| ABACAVIR (ABC) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | c There is no known interaction between antiretroviral therapy and IUD use. However, severe or advanced HIV clinical disease (WHO stage 3 or 4) as a condition is classified as Category 3 for insertion and Category 2 for continuation. Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) is classified as Category 2 for both insertion and continuation. |
| TENOFOVIR (TDF) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| ZIDOVUDINE (AZT) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| LAMIVUDINE (3TC) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| DIDANOSINE (DDI) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| EMTRICITABINE (FTC) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| STAVUDINE (D4T) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs) | I | C | ||||||||
| EFAVIRENZ (EFV) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | d Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted protease inhibitors) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. c There is no known interaction between antiretroviral therapy and IUD use. However, severe or advanced HIV clinical disease (WHO Stage 3 or 4) as a condition is classified as Category 3 for insertion and Category 2 for continuation. Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) is classified as Category 2 for both insertion and continuation. |
| ETRAVIRINE (ETR) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| NEVIRAPINE (NVP) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | |
| RILPIVIRINE (RPV) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3c | 2c | |
| PROTEASE INHIBITORS (PIs) | I | C | ||||||||
| RITONAVIR-BOOSTED ATAZANAVIR (ATV/r) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | d Antiretroviral drugs have the potential to either decrease or increase the levels of steroid hormones in women using hormonal contraceptives. Pharmacokinetic data suggest potential drug interactions between some antiretroviral drugs (particularly some NNRTIs and ritonavir-boosted protease inhibitors) and some hormonal contraceptives. These interactions may reduce the effectiveness of the hormonal contraceptive. c There is no known interaction between antiretroviral therapy and IUD use. However, severe or advanced HIV clinical disease (WHO stage 3 or 4) as a condition is classified as Category 3 for insertion and Category 2 for continuation. Asymptomatic or mild HIV clinical disease (WHO stage 1 or 2) is classified as Category 2 for both insertion and continuation. |
| RITONAVIR-BOOSTED LOOPINAVIR (LPV/r) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | |
| RITONAVIR-BOOSTED DARUNAVIR (DRV/r) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | |
| RITONAVIR (RTV) | 2 d | 2 d | 2 d | 2 d | 1 | 2 d | 2 d | 2/3c | 2c | |
| INTEGRASE INHIBITORS | I | C | ||||||||
| RALTEGRAVIR (RAL) | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 2/3 | 2 | |
CIC: combined injectable contraceptives; COC: combined oral contraceptives; DMPA: depot medroxyprogesterone acetate; IUD: intrauterine device; LNG/ETG: levonorgestrel and etonogestrel implants; LNG-IUD: levonorgestrel-releasing IUD (20 μg/24 hours); MEC: Medical eligibility criteria for contraceptive use (WHO publication); NET-EN: norethisterone enantate (NET-EN); P: combined contraceptive patch; POP: progestogen-only pills; R: combined contraceptive vaginal ring; STI: sexually transmitted infection.
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