Women and girls living with HIV need better advice and access to contraceptives
World Health Organization (WHO) responds to the call by national HIV programmes for clarification around contraceptive options for women and adolescent girls living with HIV.
The new implementation tool “Providing contraceptive services in the context of HIV treatment programmes” is women-focused and grounded in human rights. It outlines the best care models to reach women, effective contraceptive options with antiretroviral treatment (ART), and contraceptive considerations based on age and/or reproductive needs.
Importantly, the tool demands that all women and adolescent girls living with HIV be offered a full range of contraceptive options available in that setting, with information on each method’s features, effectiveness and safety. This includes long-acting reversible methods, such as intrauterine devices and implants, which are the most effective reversible contraceptive options.
Access to long-acting contraceptives can be beneficial to women who do not want to take daily pills, and, in the case of some long-acting methods, can reduce clinic visits. This is now especially important given that healthy people living with HIV may only need to see a health-care professional annually. Some short-acting contraception options, such as the oral contraceptive pill, vaginal rings, condoms and some injectables, require 3- or 6-monthly visits, and may be more burdensome.
The need for contraception among women living with HIV is high, despite the well-documented benefits of giving women the opportunity to decide if and when they want children, as well as how many they want. This choice promotes positive educational and economic outcomes for women, which is key for achieving gender equality, empowering women and reducing poverty. Child and maternal health outcomes are also improved.
The publication clarifies that all contraception is generally safe for women and girls living with HIV, and there are no contra-indications for any of these methods for women living with HIV or using ART. This should therefore never be a barrier to access.
The recently updated August 2019 “Medical eligibility criteria for contraceptive use” (MEC) states that women at high risk of HIV infection and women with HIV can use any form of reversible hormonal contraception without any restrictions, including progestogen-only injectables, implants, and intrauterine devices (IUDs). However, it is still noted that some non-nucleoside reverse transcriptase inhibitors (NNRTIs) may reduce the effectiveness of hormonal implants.
Depending on the stage of life, different considerations have been outlined. For example, given high rates of sexually transmitted infections particularly seen among adolescent girls in some settings, the use of a dual-method contraception including condoms should be emphasized. Similarly, in the MEC, correct and consistent condom use is also stressed to prevent HIV (and STIs) in high-burden settings, as is the offer of pre-exposure prophylaxis (PrEP) in areas where incidence of HIV exceeds 3%. Healthcare workers should provide a youth-friendly environment where adolescent girls feel comfortable discussing their sexual reproductive health needs.
In every case, it should be acknowledged that many adolescent girls and women living with HIV may be unable to negotiate condom use or choose when they become pregnant. This should be a consideration for clinicians when discussing contraceptive options with vulnerable and at-risk women.
This new tool brings together evidence and strategies from a variety of WHO publications into one document. This was prompted following the report suggesting a possible link between birth defects in babies born to mothers taking a dolutegravir-based ART regime at the time of conception. Although further data on birth defects and periconception use of dolutegravir suggests the potential risks are significantly lower than initially reported, this issue has been important to reinvigorate the conversation and increase focus on the contraceptive needs of women and adolescent girls living with HIV.
The tool calls for counselling on the risks and benefits, so that women can make an informed choice for themselves, for both family planning as well as life-saving treatment for HIV.
This story was developed by Avert and the World Health Organization (WHO) Department of HIV/AIDS and Global Hepatitis Programme.