MOH Brief 6 A Contraceptive Option for HIV-Positive Clients

Publication date: 2003

Recommendations for use An HIV-positive woman who wants to avoid pregnancy has the same need for safe and effective contraception as any other woman. According to the 2004 revised World Health Organization’s medical eligibility criteria, HIV and high risk of HIV are “Category 2” conditions for IUCD use. For Category 2 conditions, the method can generally be used, but careful follow-up may be required. Considering its effectiveness and long-term contraceptive protection, the IUCD can be an appropriate choice for HIV-positive women, provided they have continuing access to medical services and follow-up. A large study conducted in Kenya in the late 1990s considered several important outcomes related to IUCD use in HIV-positive women. Results of this study, which included some 150 HIV-positive and nearly 500 HIV-negative users, provide evidence that the IUCD may be used safely in HIV-positive women. No greater risk of IUCD-related complications in HIV-positive users Evidence from the Kenyan study suggests that HIV-positive users of the IUCD have no greater risk than do HIV-negative users of developing IUCD-related complications — such as pelvic inflammatory disease, IUCD expulsion, pregnancy, or removal of the IUCD due to infection, pain, or bleeding — up to two years following insertion. The study also suggests that complication rates in HIV-positive IUCD users do not differ according to whether their immune systems are severely, moderately, or mildly compromised. Thus, the results suggest that the IUCD does not increase the risk of IUCD-related complications in even the most severely immunocompromised HIV-positive users. No evidence of increased risk of HIV transmission by HIV-positive users No evidence exists that IUCD use increases an HIV-positive woman’s risk of transmitting her virus to an uninfected sexual partner. But to guard against transmission, sexually active HIV-positive clients should use condoms, regardless of what other contraceptive methods they are using. Blood represents a potential route for HIV transmission, and some women IUCD Method Brief No. 6 A Contraceptive Option for HIV-Positive Clients KEY POINTS FOR PROVIDERS: n Providers should present a range of contraceptive options to clients so they can make informed choices after assessing the risks and benefits of each method. n Inserting an IUCD in an HIV-positive woman will not endanger her health, provided medical services and careful follow-up are available. KEY POINTS FOR CLIENTS: n HIV-positive clients need to be informed of a range of contraceptive options and understand the risks and benefits of each. n A client’s HIV status should not prevent her from choosing an IUCD. n As long as she has no other contraindications to IUCD use, an HIV-positive woman should be counselled that evidence suggests she will not be at increased health risk if she uses the IUCD and maintains careful medical follow-up. KEY POINTS FOR POLICY-MAKERS: n Preliminary research indicates that the IUCD may be a safe option for HIV- positive women. n Research into the medical care and treatment of HIV- positive men and women, including meeting their contraceptive needs, must continue. experience heavy bleeding during the first few months of IUCD use. Unfortunately, no studies have been conducted to determine if HIV-positive IUCD users who experience increased menstrual flow are more likely to transmit the virus to their sexual partners. Another potential route for HIV transmission is shedding of HIV-infected cells from the genital tract, which includes the cervix. Insertion of the IUCD causes non-specific inflammation, and theoretical concerns exist that this could increase cervical shedding of HIV, thus increasing the dose of virus to which a woman’s sexual partner is exposed. In the Kenyan study, researchers calculated rates of cervical shedding of HIV-infected cells before IUCD insertion and four months after insertion. Results showed no significant differences in cervical shedding from HIV- positive women before and after insertion. In other words, the evidence suggests that the IUCD does not increase the risk of HIV transmission via this route. No greater risk of HIV acquisition by HIV-negative users Evidence from a study evaluating the risk of HIV acquisition in IUCD users — conducted from 1992 to 1995 amongst more than 2,000 HIV- negative users in Tanzania — suggests that IUCD users are not at an increased risk of HIV acquisition. For any sexually active woman, the best way to prevent HIV and other sexually transmitted infections (STIs) is to be in a mutually monogamous relationship with an uninfected partner, or to use condoms consistently and correctly. Summary Because of the health risks associated with pregnancy, it is safer for HIV-positive women to use the IUCD than to use no contraceptive method at all. And current evidence suggests that the IUCD can be used safely amongst HIV-positive women and in resource-poor settings. Recent revisions to the World Health Organization’s Medical Eligibility Criteria reflect this evidence. However, HIV-positive users and those at high risk of HIV acquisition must also be counselled to use condoms consistently and correctly to avoid transmitting or acquiring HIV and other STIs. These briefs were produced by the Kenya Ministry of Health and its collaborating partners. This work is supported by the U.S. Agency for International Development (USAID). The contents do not necessarily reflect USAID policy. For more information or additional copies, please contact: Head, Division of Reproductive Health, Kenya Ministry of Health Old Mbagathi Road, P.O. Box 43319, Nairobi, Kenya Telephone: 254-020-2725105 Fax: 254-020-2716814 or Regional Director, Population and Reproductive Health Programs Family Health International, The Chancery, 2nd Floor, Valley Road P.O. Box 38835, Nairobi, Kenya E-mail: iucdbriefs@fhi.or.ke Telephone: 254-020-2713913-6 Fax: 254-020-2726130 If a client acquires HIV during IUCD use, the IUCD need not be removed, given the evidence that HIV- positive IUCD users are not at increased risk of IUCD-related complications or of HIV transmission via cervical shedding.

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