Contraceptive Options for Women with HIV

What can an HIV-infected woman use for birth control?

Anything she wants to (almost)……

•Women with HIV have similar childbearing wishes and patterns and similar contraceptive practices to women without HIV. Ask, "Do you currently want to become pregnant?" to start the discussion.

•Combine any contraceptive with condoms to prevent HIV and STD transmission.

•Contraception works best if the woman likes it and it makes practical sense for her.

Hormonal Methods

For HIV-positive women not on antiretroviral therapy (ART), all contraception methods are suitable

For HIV-positive women on ART:

•Some hormonal methods are not recommended because of potential drug interactions

–Discuss all options

–Identify potential drug interactions

–Explain concept of reduced contraceptive efficacy

Drug interactions between ART and combined oral contraceptives:2

•The pharmacokinetics: cytochrome P-450 isoenzyme pathway is used in drug metabolism

•Two or more drugs using this pathway will interact

–Potential for increased or decreased drug concentration of either agent

–Potential for change in drug potency and effectiveness

–Potential need for dose adjustment

•An issue for certain HIV meds:

–PIs (protease inhibitors)

–NNRTIs (non-nucleoside reverse transcriptor inhibitors)

–Meds that combine two or three of these into one trade-name brand

•Oral contraceptives containing less than 25 mcg of ethinyl estradiol or progestins other than norethindrone or norgestimate have not been studied.

Interactions between HIV Medications and Oral Contraceptives

Antiretroviral Drug
(Generic, Trade) / Effect of Interaction with OCs / Contraceptive Recommendation
NNRTI (Non-Nucleoside Reverse Transcriptase Inhibitor)
Efavirenz (Sustiva, Atripla) / EE*: no effect
Levonorgestrel AUC ↓ 83%
Norelgestromin AIC ↓ 64% / Use alternative or additional methods; norelgestromin and levonorgestrel are active metabolites of norgestimate
Levonorgestrel (Plan B) AUC↓58% / Effectiveness of emergency postcoital contraception may be diminished
↓Etonogestrel (Implanon) / Interaction has not been studied. Decreased exposure of etonogestrel may be expected.
Etravirine (Intelence) / EE AUC ↑22%
Norethindrone: no significant effect / No dose adjustment needed
Nevirapine (Viramune) / EE AUC ↓ 20%
Norethindrone AUC ↓ 19% / Use alternative or additional methods
Depomedroxyprogesterone acetate: no significant change / No dosage adjustment needed
Rilpivirine (Endurant, Complera) / EE AUC ↑ 14%
Norethindrone: no significant change / No dosage adjustment needed
PIs (Protease Inhibitor) and RTV-boosted PIs (Ritonavir-boosted designated with /r)
ATV/r: Atazanavir/r (Reyataz + Norvir) / ↓ EE
↑ Norgestimate / OC should contain at least 35 mcg of EE. OCs containing progestins other than norethindrone or norgestimate have not been studied.
DRV/r: Darunavir/r (Prezista + Norvir) / EE AUC ↓ 44%
Norethindrone AUC ↓ 14% / Use alternative or additional method
FPV/r: Fosamprenavir/r (Lexiva + Norvir) / EE AUC ↓ 37%
Norethindrone AUC ↓ 34% / Use alternative or additional method
LPV/r: Lopinavir/r (Kaletra) / EE AUC ↓ 42%
Norethindrone AUC ↓ 17% / Use alternative or additional method
SQV/r: Saquinavir/r (Invirase + Norvir) / ↓ EE / Use alternative or additional method
TPV/r: Tipranavir/r (Aptivus +
Norvir) / EE AUC ↓ 48%
Norethindrone: no significant change / Use alternative or additional method
ATV: Atazanavir (Reyataz) / EE AUC ↑ 48%
Norethindrone AUC ↑ 110% / OC should contain no more than 30 mcg of EE, or use alternate method.
OCs containing <25 mcg of EE or progestins other than norethindrone or norgestimate have not been studied.
FPV: Fosamprenavir (Lexiva) / With Amprenavir: ↑ EE and
↑ norethindrone; ↓ APV 20% / Use alternative method
CCR5 Antagonist and Integrase Inhibitor
MVC: Maraviroc (Selzentry) / No significant effect on EE or levonorgestrel / Safe to use in combination
RAL: Raltegravir (Isentress) / No clinically significant effect / Safe to use in combination

* EE = ethinyl estradiol Table references: Panel on Antiretroviral Guidelines in Adults and Adolescents, Oct. 2011

•Efavirenz (Sustiva) is not recommended for women with childbearing potential unless two effective methods of contraception are used together2

•Fosamprenavir (Lexiva)is not recommended in combination with hormonal contraceptives2

Drug interactions change concentrations of both agents

•Medroxyprogesteroneacetate (Depo-provera) injection

–Concerns about bone density

•HIV disease itself and some ART may also cause decreased bone density1

•Calcium supplementation recommended

•Combined contraceptive transdermal patch (Ortho Evra) and vaginal ring (NuvaRing)

–Drug interactions with ART not studied to date

–May have similar drug interactions as combined oral contraceptives

Other Contraceptives

•Spermicides are not recommended for use with or without condoms1

–N-9 (Nonoxynol-9) does not protect against HIV

•Mucosal irritation, inflammation, damage

•Reduces vaginal lactobacilli

•Barriers: Diaphragm and cervical cap are less effective methods

•Female condom4

Testing in vitro (in the laboratory) demonstrated barrier qualities

Many errors in usage, due to ring slippage; first year failure rate is 12.4% (typical use)

Second-generation product, FC2 Female Condom, was approved by FDA March 2009

•IUD (Intrauterine device)1

–No difference in complications between HIV-positive and HIV-negative women

–No associationbetween IUD and HIV transmission

–Levonorgestrel-containing IUD

•No data to assess hormone blood levels when combined with ART

WHO recommendations for IUD use in HIV-positive women3,4

–With immune reconstitution on ART:

•benefits outweigh risks for insertion and continuation of IUD: method can be used

–With advanced immunosuppression (CD4 <200 and not on ART):

•Risks outweigh benefits for insertion of IUD; NOT recommended

•Benefits outweigh risks for continuation of IUD; method can be maintained

Additional Considerations

•In counseling, be sensitive to cultural and religious beliefs

•Examine patterns of adherence to appointments, antiretroviral therapy, and other medications: What can we predict about success with a particular contraceptive method based on these patterns?

Key References

1.U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau.

Guide for HIV/AIDS Clinical Care. January 2011.

2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents

In HIV-1 Infected Adults and Adolescents. Department of Health and Human Services. October 14, 2011; 1-167. Available at: Accessed November 18, 2011.

3. World Health Organization. Medical Eligibility Criteria for Contraceptive Use, Fourth Edition, 2009. WHO;

26 September 2010.

4. Trussell J. Contraceptive Efficacy.In: Hatcher, R et al. Contraceptive Technology 20th rev. ed.

Ardent Media; 2011.

Written by Susan Richardson MN, MPH, CFNP. Reviewed by Felicia Guest MPH, and Willard Cates, Jr. MD, MPH

Updated November 2011

Southeast AIDS Training and Education Center (SEATEC)

• 404-727-2929 • November 2011

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