The ideal contraceptive for an HIV-positive woman prevents pregnancy as well as transmission of HIV and STDs.  Dual contraception using condoms plus an additional contraceptive appears to be the best strategy.

CLINICAL ACTIONS:

The following represent good contraceptive choices in addition to condoms:

• Combined hormonal contraception (pill, patch and ring) and progestin-only pills may decrease hormone levels in women taking some antiretroviral therapies, but are still considered safe (MEC cat. 2)
  • If the patient is on fosamprenavir, avoid hormonal contraception; it may reduce efficacy of the antiretroviral
• Contraceptive implants are highly effective and benefits outweigh risks in HIV positive women (MEC cat. 2)
  • Theoretical interactions between multiple antiretrovirals and implants may reduce effectiveness
• Injectable depot medroxyprogesterone acetate (DMPA) is safe and effective (MEC cat. 1) and does not appear to have interactions with antiretrovirals
• Intrauterine devices, both copper containing and levonorgestrel-releasing, are safe (MEC cat. 1) for women with HIV, with no known drug interactions with antiretrovirals
  • Limited data suggest a low risk of pelvic inflammatory disease and no changes in genital shedding of HIV RNA

SYNOPSIS:

Condoms effectively reduce transmission of HIV between discordant partners but do not represent optimal contraception, with an annual pregnancy rate of over 15% per year. Dual contraception with any of the above options are safe in HIV positive women, assuming they meet the usual health criteria for use.  Counseling should emphasize that use of any contraception does not take the place of condom use for prevention of transmission.

KEY POINTS:

• HIV infection does not pose a barrier to sterilization, which remains an appropriate contraceptive option
• Emergency contraception including hormone based (progestin-only pills, ulipristal acetate, combined oral contraceptives) and the copper IUD should be offered to HIV positive women whenever appropriate
• Spermicides and diaphragms with spermicide are not recommended
  • Nonoxynol-9, the active ingredient in most formulations, may increase the likelihood of HIV transmission to a partner
• Diagnosis codes:
  • HIV infection: Z21
  • Encounter for contraception management: Z30.09

Learn More – Primary Sources:

ACOG Practice Bulletin 167: Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus

CDC United States medical eligibility criteria for contraceptive use, 2016

Contraception: Contraceptive failure in the United States

Related ObG Topics:

Cervical Cytology and HPV Screening in the HIV Positive Woman

Screening & Treatment of Gynecologic infections in the HIV-Positive Woman

Ulcerative Genital Conditions in the HIV-Positive Woman