Hormonal Contraception for Women at Risk of HIV Infection

Does hormonal contraception use increase the risk of HIV acquisition among women at high risk of HIV infection?

Use of hormonal contraception, including medroxyprogesterone depot injection and levonorgestrel implant, for up to 18 months in women who are at risk of HIV infection results in little to no difference in HIV acquisition rates compared with a nonhormonal method (ie, copper intrauterine device [IUD]).¹ (Strength of Recommendation: B, consistent, moderate-quality, patient-oriented evidence.)

Hormonal contraception is a widely used family planning method, with more than 140 million users worldwide. In the United States, one in four women of reproductive age relies on hormonal contraception.² Because HIV remains a leading cause of global morbidity and mortality, it is essential for clinicians to understand how hormonal contraceptive use impacts HIV risk. This Cochrane review assessed whether hormonal contraception use increased the risk of HIV acquisition among women in settings with high HIV prevalence.

The review included four randomized controlled trials involving 9,726 HIV-negative females (HIV status of sex partners not defined), ranging in age from 15 to 45 years, in four countries with high HIV prevalence.¹ Three studies were parallel-group randomized controlled trials, and one smaller trial was a crossover study. Three hormonal contraception options were examined: medroxyprogesterone depot injection, levonorgestrel implant (not available in the United States), and norethisterone enanthate injection (not available in the United States). The medroxyprogesterone injection and levonorgestrel implant were compared with a nonhormonal contraception method (ie, copper IUD). In addition, the three hormonal contraception methods were compared with each other. The primary outcome was incidence of HIV acquisition. Pregnancy rates and adverse effects were secondary outcomes.

There was little to no difference in HIV acquisition rates in patients using hormonal contraception vs copper IUD contraception.¹ The authors concluded that using medroxyprogesterone injection slightly increased risk of HIV infection compared with levonorgestrel implant (56 per 1,000 vs 45 per 1,000, respectively), but the results were not statistically significant (risk ratio [RR] = 1.25; 95% CI, 0.98–1.58; P = .007). HIV acquisition rates for medroxyprogesterone injection compared with norethisterone enanthate injection are uncertain.

Secondary outcomes favored hormonal contraception for preventing pregnancy.¹ Women using medroxyprogesterone injections were less likely to become pregnant (RR = 0.53; 95% CI, 0.39–0.71), discontinue the method (RR = 0.50; 95% CI, 0.40–0.62), or experience adverse effects (RR = 0.53; 95% CI, 0.38–0.75) compared with women using the copper IUD (high-certainty evidence).Similarly, women using levonorgestrel implants were less likely to become pregnant than those using the copper IUD (RR = 0.67; 95% CI, 0.51–0.89; moderate-quality evidence). Women using medroxyprogesterone injections were less likely than those using levonorgestrel implants to discontinue the method (RR = 0.48; 95% CI, 0.39–0.60) or report adverse events (RR = 0.63; 95% CI, 0.44–0.90).

There are several limitations to the studies in this review.¹ Population-specific HIV incidence during the study time-frames were not included. None of the trials compared use of these contraception methods with no contraception or barrier methods, meaning baseline risks of HIV acquisition are unknown. In addition, the trials only looked at a few specific hormonal contraceptive methods; many commonly used formulations were not included. Cost and accessibility data were not reported. These factors limit the generalizability of findings to all contraception types or contraceptive users. As noted, it is not clear whether the patients in these studies were in sero-discordant relationships or using preexposure or postexposure prophylaxis.

According to World Health Organization and Centers for Disease Control and Prevention guidelines, women at risk of contracting HIV may safely use any reversible contraceptive method.^3,4 Hormonal contraception remains a safe, effective option for preventing pregnancy, and counseling should focus on integrating HIV prevention rather than limiting contraceptive choice based on HIV risk alone.

The practice recommendations in this activity are available at https://www.cochrane.org/CD015701.