The World Health Organization (WHO) released a statement on February 16, 2012, upholding previous guidance indicating that women with HIV or at high risk of HIV can safely use hormonal contraceptives to prevent pregnancy. However, WHO has added new clarification instructing health care providers to strongly advise women with HIV or at high risk of HIV who decide to use progestin-only injectables, in particular, to also always use male or female condoms for protection against HIV.
The statement from WHO follows a technical consultation convened between 31 January and 1 February 2012, involving 75 experts in international family planning and HIV from 18 countries. The expert group met to review the evidence base on the risk of HIV with hormonal contraceptive use. In particular, a recent study published in The Lancet Infectious Diseases suggested that use of injectables may double the risk of uninfected women acquiring HIV and of HIV-infected women transmitting the virus to their uninfected partners (read previous K4Health blog for more details about the study). The expert group convened by WHO to review this and other evidence on HIV and hormonal contraception represented a wide range of disciplines—from clinicians, epidemiologists, researchers, reproductive biologists, and pharmacologists to program managers, policy makers, guideline methodologists, and HIV and women’s health advocates.
The group considered several factors, including systematic reviews of the evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiologic evidence (GRADE is a system for grading the quality of evidence), and an analysis of the risks and benefits to country programs.
Due to serious limitations in the data, the body of evidence was given a GRADE rating of “low” on all counts—for the relationship of hormonal contraceptive use and HIV acquisition in women without the virus, transmission of the virus from HIV-positive women to HIV-negative men, and disease progression in HIV-positive women.
The group was most concerned about the risk of HIV acquisition in women using progestin-only injectables. After considering the entire evidence base, the expert group determined that current data neither established a direct cause-and-effect relationship between injectable use and HIV acquisition nor did the data definitively rule out the possibility of an effect. Thus, the group decided to uphold its previous guidance but to add clarification about using condoms with hormonal contraceptives to prevent HIV acquisition and transmission. This clarification also mentions the need for programs to expand contraceptive method mix to give women and couples access to a wide range of appropriate methods, and also the need for further research on this issue.
Register to join a global teleconference hosted by AVAC on Thursday, February 23, 2012, from 9-10 am ET to discuss WHO’s recommendations. Representatives from WHO, UNAIDS, international family planning programs, and civil society who participated in the WHO technical consultation will be on the call. Look for a summary of the teleconference afterward on the K4Health blog.