The World Health Organization (WHO) has revised its recommendations for the use of hormonal contraceptives among women at high risk of HIV infection.
Background Information:
The World Health Organization (WHO) convened a Guideline Development Group (GDG) meeting from 29 to 31 July 2019 to review global guidance on contraceptive eligibility for women at high risk of HIV acquisition to and determine whether revisions to the fifth edition of the Medical eligibility criteria for contraceptive use (MEC) were needed.
The issue was deemed critical, particularly for sub-Saharan Africa, given the high lifetime risk of acquiring HIV alongside the importance of hormonal contraception in offering women and adolescent girls’ choice and in reducing their risk of unintended pregnancy, a common threat to the health, well-being and lives of women and adolescent girls.
The GDG considered the following factors when formulating recommendations for each contraceptive method:
- quality of the evidence (i.e. GRADE profile)
- values and preferences of contraceptive users
- balance of benefits and harms
- priority of the problem
- equity and human rights
- feasibility.
In formulating these recommendations, the GDG kept at the centre of their deliberations the individuals most affected by the recommendations – that is, those women wanting to prevent pregnancy who are at a high risk of HIV acquisition.
Key Messages:
Women at a high risk of HIV infection are eligible to use all progestogen-only contraceptive methods (POCs) without restriction (MEC Category 1), including progestogen-only pill (POPs), intramuscular and subcutaneous depot medroxyprogesterone acetate (DMPA-IM and DMPA-SC), norethisterone enanthate (NET-EN), levonorgestrel (LNG) implants and etonogestrel (ETG) implants.
Women at a high risk of HIV infection are eligible to use copper-bearing intrauterine devices (Cu-IUDs) and LNGIUDs without restriction (MEC Category 1). In considering the use of IUDs, many women at a high risk of HIV are also at risk of other sexually transmitted infections (STIs); for these women, providers should refer to the MEC recommendation on women at an increased risk of STIs, and the Selected practice recommendations for contraceptive use: third edition on STI screening before IUD insertion.
Women at a high risk of HIV infection are eligible to use all combined hormonal contraceptive methods without restriction (MEC Category 1), including combined oral
contraceptives (COCs), combined injectable contraceptives (CICs), combined contraceptive patches and combined vaginal rings.
These revisions mean that women at a high risk of HIV can use all methods of contraception without restriction.
However, the guidance document does state that each of the three contraceptive methods mentioned above “do not protect against sexually transmitted infections (STIs), including HIV. If there is a risk of STI/HIV, the correct and consistent use of condoms is recommended. When used correctly and consistently, condoms offer one of the most effective methods of protection against STIs, including HIV. Female condoms are effective and safe, but are not used as widely as male condoms by national programmes.”
There are several key messages from this guidance for policymakers, programme managers and health-care providers:
- A woman’s risk of HIV does not restrict her contraceptive choice.
- Efforts to expand contraceptive method options and ensure full and equitable access to family planning services must continue.
- A renewed emphasis on HIV/STI testing and prevention services is urgently needed, including the integration of family planning and HIV/STI services as appropriate, along with sexual and reproductive health packages.
Useful Links:
Link to the WHO news release:
Link to the guidance document:
Link to Medical Eligibility Criteria for contraceptive use 5th Edition:
https://www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/
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