Contraceptive Options for Women and Couples with HIV

Implants, POPs and Emergency Contraception

Subdermal Implants

• Progestin-filled rods or capsules that are inserted under the skin

• Norplant: 6-capsule system, effective for 5 years

• Second generation implants– Jadelle and Sinoplant: 2-rod system,

effective for 5 years– Implanon: 1-rod system,

effective for 3 years

• Mechanism of action similar to injectables

Implants – Characteristics

Disadvantages

• Have common side effects

• Cannot be initiated/ discontinued without provider’s help

• Provide no protection from STIs/HIV

Source: Hatcher, 2007; WHO, 2004, updated 2008; CCP and WHO, 2007.

Advantages

• Safe, 99.95% effective, easy to use, reversible

• Can be used by breastfeeding women

• Offer health benefits, such as reducing risk of symptomatic PID and anemia

Implants – Side Effects

• First several months:light bleeding/spotting, prolonged irregular bleeding, infrequent bleeding, amenorrhea

• After one year:light bleeding for fewer days, irregular bleeding, infrequent bleeding, amenorrhea

• Other side effects: nausea, headaches, breast tenderness, weight change, abdominal pain– less common than with progestin-only injectables

– diminish after the first few months

Source: Shoupe, 1991; CCP and WHO, 2007.

Category 1 and 2 Examples (not inclusive):

Who Can Use Implants

blood pressure ≥160/100, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD

Category 2

breastfeeding after 6 weeks postpartum, heavy smokers, complicated valvular heart disease, endometriosis, endometrial or ovarian cancer, thyroid disorders

Category 1

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

Category 3 and 4 Who Should Not Use Implants

current breast cancerCategory 4

breastfeeding before 6 weeks postpartum, acute DVT/PE, unexplained vaginal bleeding, history of breast cancer, severe liver disease and most liver tumors, systemic lupus disease

continuation only: ischemic heart disease, stroke, migraine with aura

Category 3

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

Implant Use by Women with HIV

• Women with HIV or AIDS can use without restrictions

• Some ARV drugs reduce blood progestin level

• Efficacy is not affected because implants provide consistent dose of hormone over time

• Dual method use should be encouraged

WHO Eligibility CriteriaWHO Eligibility Criteria

Condition Category

HIV-infected 1

AIDS 1

ARV therapy 2

Source: WHO, 2004, updated 2008; Mildvan, 2002.

Progestin-Only Pills (POPs)

• Contain no estrogen

• Less progestin than COCs

• All pills in pack are active

• Progestin amount same throughout

• 28-35 pills per pack

• Eligibility criteria is similar to those of implants

POPs are especially suitable for breastfeeding women POPs are especially suitable for breastfeeding women and others who should not use estrogen.and others who should not use estrogen.

Source: WHO, 2004; updated 2008.

Progestin-Only Pills (POPs)

continued …

• Mechanism of action:– partial suppression of ovulation (more pronounced in

breastfeeding women)– thickening of cervical mucus

• Have no known adverse effects• Side effects are similar to those of implants

– irregular or prolonged bleeding is not common in breastfeeding women

• Require stricter pill-taking schedule than COCs– 1 pill each day within 3 hours of same time– no breaks between packs

Source: CCP and WHO, 2008 update.* within 12 hours for POPs

containing desogestrel 75μg

POPs – Missed Pills

• Take most recent missed pill as soon as possible

• Abstain or use backup method for 48 hours

• Take next pill at regular time

• Consider use of emergency contraception if appropriate

• No backup method or emergency contraception needed if pills are missed by a woman who is still protected by LAM

Source: CCP and WHO, 2008 update.

POP Use by Women with HIV

• Women with HIV or AIDS can use without restrictions

• Women on ARVs other than ritonavir can use POPs safely

• Should not be used by women who take ritonavir

• Dual method use should be encouraged

• Breastfeeding status provides additional protection from pregnancy

Source: WHO, 2004, updated 2008; Sekar, 2008.

WHO Eligibility CriteriaWHO Eligibility Criteria

Condition Category

HIV-infected 1

AIDS 1ARV therapy(which does not contain ritonavir)

2

Ritonavir/ ritonavir-boosted PIs (as part of ARV regimen)

3

ECP Use by Women with HIV

• Use to prevent pregnancy after unprotected intercourse – progestin-only and combined estrogen-progestin regimens

– start as soon as possible; counsel to adopt regular method

• Use if regular method was used incorrectly, failed, or was not used

• Safe for all women (including women with HIV/AIDS and taking ARV drugs)

There is no evidence to justify changes to emergency There is no evidence to justify changes to emergency contraceptive pill regimens for ARV clients.contraceptive pill regimens for ARV clients.

Source: Hatcher, 2007; WHO, 2004, updated 2008.

Start within 120 hours (5 days) after unprotected intercourse

ECP Pill Regimens:

Progestin-Only Oral Contraceptives

More effective than COC regimen;

More effective than COC regimen;

most effective when used early.

most effective when used early.

pills formulated pills formulated as emergency as emergency contraceptioncontraception

regular progestin-regular progestin-only pillsonly pills

1.5 mg levonorgestrel or 3 mg norgestrel;

take all at once or in two doses 12 hours apart

Source: CCP and WHO, 2007; WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; Piaggio, 1999; von Hertzen, 2002.

Start within 120 hours (5 days) after unprotected intercourse

ECP Pill Regimens:

Combined Oral Contraceptives

Most effective when used early.Most effective when used early.

high-dose pillshigh-dose pills

repeat doserepeat dose

12 hours12 hours

Each dose should contain at least:

0.1 mg ethinyl estradiol and

0.5 mg levonorgestrel

Known as Yuzpe regimen

low-dose pillslow-dose pills**

repeat doserepeat dose

12 hours12 hours

Source: WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; CCP and WHO, 2007.

*or 5 pills for each dose, if each pill contains 0.02 mg of ethinyl estradiol

ECPs – Key Counseling Messages

• Use and effectiveness

• More effective the sooner they are begun

• Side effects (nausea and vomiting) may occur; less common with progestin-only regimen

• Next menses may come a week early or late

• Do not provide pregnancy protection for future intercourse or protection from STIs/HIV

• After using, regular method should be considered