Information on hormonal contraceptive methods, their impact on HIV risk in HIV-negative women, and their use in women living with HIV, is constantly evolving. We encourage you to supplement this basic factsheet with a visit to www.avac.org/hc-hiv for the most recent information. For more basic fact sheets in this series on emerging HIV prevention tools visit www.avac.org/intro.
What are the available data about hormonal contraceptive use and risk of HIV infection?
There are mixed data. Some studies suggest that use of certain hormonal contraceptives—particularly injectable progestogen-only methods like Depo- Provera (DMPA)—increase women’s risk of HIV infection. Other studies do not. The available information is primarily observational data. This means it was derived from trials or studies designed primarily to answer other questions. This type of information is hard to analyze since there are many variables that could have influenced or biased the outcome. There has not been a randomized controlled trial (RCT) of HIV acquisition in women using hormonal contraceptives or other methods.
What conclusions can be drawn from the data that exist right now?
Nothing definite. But there is concern about DMPA and impact on the risk of HIV in HIV-negative women. Even with this concern and uncertainty, DMPA remains an important option, including for women living with HIV.
As of July, 2016, a WHO-commissioned systematic review of available data has found “increased concern” regarding the impact of Depo-Provera (DMPA) on HIV-negative women’s risk of HIV acquisition.
A “systematic review” involves gathering all available evidence on an issue, evaluating the quality of that evidence and summarizing it to provide a reliable overview of knowledge on a topic. Such reviews are often conducted by teams of independent researchers who agree on search terms and criteria for identifying quality evidence. This was the approach used in the recently published paper.
Two previous systematic reviews concluded that there was uncertainty about the relationship between DMPA and HIV risk. This latest review indicates concern but does not draw a firm conclusion. The key findings from this review are summarized below:
- Data on oral contraceptive pills, the injectable NET-EN and levonorgestrel implants do not suggest an association with HIV acquisition, though data on implants are limited. Right now, there’s no evidence that other hormonal methods (ones that do not rely on DMPA) impact HIV risk. But for implants there’s just not a lot of information available.
- New, higher-quality observational data on DMPA, added to previous information, increase concerns about DMPA and HIV acquisition in women. The cumulative data strengthen concerns that DMPA might be increasing women’s HIV risk. It’s not definite, but it’s looking more likely than it did the last time the data were reviewed.
- The study states that, “Recent analyses contradict the hypothesis that differential over-reporting of condom use by HC users explains observed associations between HC use and HIV infection in some studies. The argument that women who use DMPA also use fewer condoms than women who choose other methods has been suggested to explain previous data. It’s important to note that this review directly addresses this argument and supports research suggesting that it is not valid.
What’s the difference between hormonal contraceptive methods?
All hormonal contraceptive methods contain synthetic versions of the hormones that orchestrate women’s menstrual cycles. These synthetic hormones change the normal cycle in ways that prevent pregnancy. Hormonal contraceptives differ by type of synthetic hormone(s), level of dosage or frequency of dosage, and they include pills, injections and implants. There are also non-hormonal methods like the copper intrauterine device, diaphragms, male and female condoms and others. Right now, concern is focused only on hormonal methods because they affect the lining of the genital tract as well as the the immune environment. Non-hormonal methods like the copper intrauterine device (IUD) and male and female condoms do not have the same effects on the genital tract.
Is the current discussion about all hormonal contraceptives?
When it comes to concern about impact on HIV risk, the main focus is on DMPA. Extensive data on the oral contraceptive pill offers no indication of increased HIV risk. This doesn't mean that other hormonal methods do not affect HIV risk—there just isn’t as much information about rates of HIV in women who use them. This is because the oral pill and DMPA are among the most widely used contraceptive methods in sub-Saharan Africa. According to the WHO-commissioned systematic review, the limited data to date do not suggest concern about the injectable known as NET-EN (an injection every two months that relies synthetic hormones other than progestogin, the hormone in DMPA. But there are many gaps in the data. For example, there are no data on the Sayana Press method, which uses the same hormone found in DMPA but at a lower dose.
Do all hormonal contraceptives have the same effects on the genital tract?
No. Different contraceptive methods contain different synthetic hormones and/or different doses of the same synthetic hormones.
What are the primary concerns for women living with HIV?
Drug interactions are an issue for women living with HIV. Do ART regimens undermine contraceptive efficacy or vice versa. These are important questions. There is some evidence that implants containing the synthetic hormone called etonogestrol can be adversely impacted by antiretroviral treatments containing efavirenz. There may be more method failure—increased pregnancy rates—in women taking etonogestol and efavirenz. This is one of many reasons why DMPA and a full range of options needs to be available for all women. At this time, no evidence suggests any contraceptive method increases women’s risk of transmitting HIV.
Who is most impacted by the concern about DMPA and HIV risk?
All women have the right to a complete, informed choice of a range of family planning methods and HIV prevention tools. If women stopped using DMPA and did not switch to another method, they would be at greater risk of unplanned pregnancy, maternal morbidity and mortality. This issue is of greatest relevance in East and Southern African countries where rates of HIV are high and where injectable hormonal contraceptives like DMPA are widely used.
Will questions about contraception and HIV risk in HIV-negative women be resolved?
Maybe. We hope so. There is an ongoing trial known as ECHO that is currently or soon-to-be enrolling women in Kenya, South Africa, Swaziland and Zambia to learn more about how three different contraceptive methods impact risk of HIV. The three methods are DMPA, the Jadelle implant and the copper IUD. Women in the trial are randomly assigned to one of these three methods (though all participants have the right to refuse randomization). All receive a package of HIV prevention. Researchers are measuring rates of HIV in each group of women. At the conclusion of the trial, there could be clarity about how all three methods impact HIV risk—and how they compare to each other. It’s also possible that the trial won’t provide a definitive answer. Right now, enrollment is going well and the vast majority of women are agreeing to randomization.
What if uncertainty persists—or if DMPA is proven to increase risk?
Whatever happens, advocates working on this issue want three key things:
- Programs, policies and messages that reflect women’s right to know all available information regarding the contraceptive method(s) they are being offered. Women weigh risks and benefits all the time. If properly delivered, information about DMPA and HIV risk should not cause women to abandon contraception or DMPA itself, if that is their method of choice.
- Proactive investment in the expansion of the range of methods that women can choose from. In the contraceptive field, this is known as method mix. In most of East and Southern Africa, DMPA is the only invisible, long-acting method available for women. Saying that women “prefer DMPA” when it is their only option other than a daily pill (which requires adherence, keeping pills at home, et cetera) is not accurate. The way to learn about preference is to increase method mix, provider training and engagement with women as experts on their own lives.
- Ongoing engagement with women affected by these issues. Their perspectives and experiences must guide policy, programs and messaging.
Do hormonal contraceptives protect against HIV infection?
No. Hormonal contraceptives do not protect against HIV or other sexually transmitted infections (STI). Currently, there are no contraceptives, with the exception of condoms (male and female), that protect against HIV. Women using hormonal contraceptives must also use a condom or take other measures to protect themselves against HIV.
What is current World Health Organization guidance regarding hormonal contraceptive use and HIV risk?
In early 2012, the World Health Organization issued a “technical statement” on hormonal contraceptives and HIV risk that stated: “The World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV”. However, the statement recommended that a new clarification (under Category 1) be added:
Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not show this association.[...] However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male or female, and other HIV preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in light of new evidence.
In 2014, WHO updated this technical statement with the additional recommendation that women at risk of HIV selecting DMPA be informed of the mixed data regarding that method’s impact on risk of HIV acquisition.
What are other key developments?
Based on the new systematic review, WHO is convening an expert stakeholder consultation to review its current guidance on DMPA. This is expected to be completed by the end of 2016.
Last updated September 2016.