Hormonal Contraception and HIV Technical Update

The revised guidance classifies progestogen-only injectables as Category 2 for women at high risk of HIV acquisition, indicating that the advantages of using these methods generally outweigh the possible, but unproven, increased risk of HIV acquisition. The revised guidance is based on an update to the 2014 systematic review of the epidemiological evidence on hormonal contraceptive methods and risk of HIV acquisition in women. The review included ten additional observational studies, five of which were considered to be of higher quality. Among the studies included in the review that involved women who used depot medroxyprogesterone acetate (DMPA), some studies found a significant association between DMPA use and increased HIV acquisition, while other studies did not. When data from the higher quality new and previous studies were combined, the hazard ratio for HIV acquisition with use of DMPA compared with non-hormonal or no contraceptive use was 1.40 (95 percent CI 1.23–1.59), indicating a significant association between use of DMPA and HIV acquisition among women. However, due to methodological limitations within all of the studies included in the review, establishing a causal relationship between the use of DMPA and any increase in HIV acquisition based upon the currently available results is not possible. Several biological mechanisms by which individual methods of hormonal contraception could theoretically increase the risk of HIV acquisition have been postulated, but it is unclear which (if any) are clinically relevant. Data for oral contraceptive pills, more limited data for norethisterone enanthate (NET-EN), and progestin-only implants, generally do not suggest an association between use of these methods and increased risk of HIV acquisition. The revised guidance means that women at high risk of HIV should not be restricted from using progestogen-only injectables. All women who are medically eligible to use injectable contraceptives, including progestogen-only injectables (DMPA-IM, DMPA-SC, and NET-EN), should have the option to do so. Women at high risk of HIV should not be denied access to injectables, if they chose to use them. All women who choose to use progestogen-only injectables should be advised on the potential increased risk of HIV acquisition. Informed decision-making is a fundamental principle when providing any contraceptive information and service. The U.S. Agency for International Development (USAID) is committed to ensuring access to high-quality, evidence-based information and services in family planning and HIV prevention, care, and treatment activities. Progestogen-only injectable contraceptives are very popular in many countries and may be the predominant contraceptive method in some countries, including countries with high HIV prevalence. In these settings, expanding contraceptive availability so that women have a broad range of contraceptive options should be a priority. The USAID Strategic Communication Framework for Hormonal Contraceptive Methods and Potential HIV-Related Risks provides suggestions for health providers on discussing hormonal contraception options for women at high risk of HIV. The framework offers guidance on the adaptation and dissemination of information pertaining to hormonal contraception and potential HIV-related risks. The WHO Frequently Asked Questions on hormonal contraceptive eligibility for women at high risk of HIV is a companion resource to the Technical Statement, providing additional information on the new guidance on hormonal contraceptive eligibility for women at high risk of HIV. The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and USAID will continue to work with WHO, Ministries of Health, U.N. agencies, U.S. Government agencies, and non-governmental organization partners to develop and disseminate programmatic resources on the issue of HC-HIV acquisition. PEPFAR and USAID will collaborate with field missions and host country partners to ensure that essential information on this topic is widely disseminated and integrated into family planning and HIV service delivery programs.