WHO Affirms That Women at Risk for HIV Should Continue To Use Injectable Contraceptives

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The World Health Organization (WHO) has affirmed its 2009 policy that women living with or at risk for HIV should continue to use hormonal contraception, despite conflicting results from recent studies suggesting that oral or injectable hormones may increase the risk of HIV infection.

In one of the recent studies, published in the January 2012 issue of Lancet Infectious Diseases, investigators with the Partners in Prevention HSV/HIV Transmission Study Team showed that hormonal contraceptives -- especially the injectable depot medroxyprogesterone acetate (DMPA, better known as Depo Provera) -- was associated with nearly 2-fold risk of acquiring HIV for both women and their male partners in a large African trial.

Another study by Charles Morrison from FHI and colleagues, described in the February 20, 2012, issue of AIDS, did not find an increased likelihood of HIV infection associated with oral or injectable contraceptives in a study of more than 5500 women in South Africa. However, this study did see "modest evidence" of an increased risk of HIV acquisition among young women using DMPA.

A third study by Handan Wand and Gita Ramjee (published in the January 28, 2012, issue of AIDS), which looked at more than 2200 women in South Africa, found that use of injectable hormonal contraception was significantly associated with increased risk for HIV infection, and that women using such methods were less likely to also use condoms for disease prevention.

"This study reinforces the importance of comprehensive contraceptive counseling to women about the importance of dual protection, such as male condoms and hormonal contraceptives use," the study authors concluded.

A WHO advisory committee of 75 experts and stakeholders from 18 countries met in late January to discuss relevant scientific evidence about hormonal contraceptives and whether it supports a policy change. The panel decided to retain the existing recommendation for injectable contraceptives, which are widely used in resource-limited settings, but said that condoms are the most reliable way to prevent both pregnancy and HIV infection.

Not everyone agrees with the committee's decision, however. While the Population Council called the WHO announcement "a responsible step forward," the International Community of Women Living with HIV expressed concern about the conflicting data, calling for more research and increased communication to explain the potential risks to women using or considering hormonal contraception.

Below is an edited excerpt from a recent WHO press announcement describing the recent meeting and policy decision. A WHO Technical Statement providing more detailed information is available online at http://www.who.int/reproductivehealth/topics/family_planning/Hormonal_contraception_and_HIV.pdf.

Who Upholds Guidance on Hormonal Contraceptive Use and HIV

Women living with HIV or at high risk of HIV can safely continue to use hormonal contraceptives to prevent pregnancy

February 16, 2012 -- Geneva --WHO has concluded, on the advice of its Guidelines Review Committee, that women living with HIV or at high risk of HIV can safely continue to use hormonal contraceptives to prevent pregnancy. The recommendation follows a thorough review of evidence about links between hormonal contraceptive use and HIV acquisition.

Current WHO recommendations in the Medical eligibility criteria for contraceptive use(2009 edition) therefore remain: there are no restrictions on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. Couples seeking to prevent both unintended pregnancy and HIV should be strongly advised to use dual protection – condoms and another effective contraceptive method, such as hormonal contraceptives.

A study published in Lancet Infectious Diseases in October 2011 suggested that hormonal contraceptives, such as the pill or injectable contraceptives, may increase a woman's risk of HIV infection. It also found that women living with HIV and using hormonal contraception may be more likely to transmit the virus to their partner than women who did not use hormonal contraception.

WHO convened a technical consultation from 31 January-1 February 2012 to review findings from all recent epidemiological studies on the issue. The meeting brought together 75 experts from 18 countries to review existing WHO recommendations in the light of these findings.

The experts recommended that women living with HIV, or at high risk of HIV, continue to use hormonal contraceptives to prevent pregnancy, but emphasized the need to also use condoms to prevent HIV acquisition and transmission. They also stressed the need for further research on the issue and the importance of offering a wider choice of contraceptive options.

On 15 February 2012 WHO's Guidelines Review Committee upheld the recommendations. The Guidelines Review Committee is the body responsible for ensuring that all WHO recommendations are based on the best available scientific evidence and have been developed in a transparent, unbiased and clearly reported manner.

3/2/12

Sources

World Health Organization. WHO Upholds Guidance on Hormonal Contraceptive Use and HIV. Press release. February 16, 2012.

UNAIDS. Women Need Access to Dual Protection -- Effective Contraceptives and HIV Prevention Options. Press statement. February 16, 2012.

World Health Organization. Hormonal Contraception and HIV. Technical Statement. http://www.who.int/reproductivehealth/topics/family_planning/Hormonal_contraception_and_HIV.pdf.

Population Council. WHO Announcement on Injectable Contraception and HIV a Responsible Step Forward. Press release. February 16, 2012.

M Mazzotta. Community group cautions WHO on communication of its guidance on hormonal contraceptives and HIV. Science Speaks: HIV & TB News blog. February 28, 2012.

References

R Heffron, D Donnell, H Rees, J Baeten, et al (Partners in Prevention HSV/HIV Transmission Study Team). Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infectious Diseases 12(1):19-26. January 2012.

CS Morrison, S Skoler-Karpoff, C Kwok, et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS 26(4):497-504. February 20, 2012.

H Wand and G Ramjee. The effects of injectable hormonal contraceptives on HIV seroconversion and on sexually transmitted infections. AIDS 26(3):375-380. January 28, 2012.