Limitations to contraceptive choices for women with HIV on antiretroviral treatment.

• Jurisdiction: Australia
• Date: 01 September 2012
• Author: Taheny, Cara

In Australia, women represent a small proportion of the total population of people living with Human Immunodeficiency Virus (HIV) (Koelmeyer et al 2012). The average age a woman is newly diagnosed with HIV in Australia is 31 years (Cameron 2012). Therefore at least a significant proportion of women living with H IV in Australia may be of childbearing age.

Background

Part of the models of care outlined in the Sixth National HIV Strategy 2010-2013 acknowledge the need to address guidelines and standards of care for HIV positive women by supporting appropriate choices regarding fertility, family planning and antiretroviral therapy during pregnancy and birth. In an era of effective antiretroviral treatment (ART), HIV infection in women has significant implications for contraception (McCall and Vicol 2011).

It is possible working in sexual health, a woman with HIV on ART will enquire about what contraception she can use in order to control her own fertility and plan her future pregnancies. Although there are numerous options for hormonal contraception in Australia, what are the limitations for these women when on ART? Vertical transmission of HIV will be discussed and the importance of controlling fertility in order to reduce this transmission pathway. Male condoms will also be discussed as the ideal method in reducing heterosexual transmission of HIV as they are cheap and accessible, as opposed to female condoms (Beksinska et al 2011).

The focus of this clinical update is on hormonal contraception available in Australia and whether or not ART affects the efficacy of any of these contraceptives available.

Pregnancy and HIV

As of 31 December 2010, a total of 21,391 people were estimated to be living with a diagnosed infection of HIV in Australia, of whom 1,984 (9.3%) were women (Koelmeyer et al 2012).

Between 1993 and 2006 there were 2,199 diagnoses associated with heterosexual contact which equated to 18% of the total diagnoses; an increase from 15% in 1993-1999, to 20% in 2000-2006 (Guy et al 2008).

In 2009 alone, the rate of heterosexual transmission increased to 28.7% (Australia HIV and AIDS statistics 2011). In one study, 450 women infected with HIV living in London completed a questionnaire which represented about 40% of all women receiving HIV-related care at participating centres over a one-year period (Ciiffe et al 2011). Over half of the women reported their HIV diagnosis either did not affect their fertility intentions or in some cases made them want to have children sooner.

Other research (Ezeanolue et al 2010) found women with HIV on ART more frequently chose reversible forms of contraception and less frequently sterilisation. This may be as HIV is no longer a terminal illness and with ART, HIV is now considered a chronic disease (Colvin 2011).

Unplanned pregnancy in women with HIV may increase the risk of vertical transmission. Elgalib et al (2011) found the majority of pregnancies in women with HIV in their study were unplanned, with poor documentation of contraception use and advice. One quarter of women studied conceived again within 12 months of delivery.

For women on ART it is equally important to plan pregnancies as some ARTs may cause foetal toxicity, in particular Efavirenz which is a non-nucleoside reverse-transcriptase inhibitor (NNRTI) (Clayden 2009).

Barrier methods

There is no known drug interaction between antiretroviral drugs and barrier methods, according to Agboghoroma (2011). Although the use of condoms is fundamental for the prevention of HIV (Rutherford 2008), women may be unable or unwilling to persuade their partners to wear condoms (Higgins et al 2010). For some women, personal circumstances of poverty, physical abuse, helplessness and fear prevent them from insisting on condom use (Maree 2010).

As a clinician, although condom use is to be encouraged, it is pivotal to also discuss hormonal methods of contraception to increase reliability and prevent unplanned pregnancies.

Furthermore, access to safe and effective contraception is of utmost importance, where every preventable undesired pregnancy could also represent a case of avoided perinatal HIV...