Birth Control and HIV

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Women Living with HIV and Birth Control

All women who have sex with men and have not yet completed menopause (have not yet had 12 months without any periods) or had surgery that prevents pregnancy need to make decisions about which birth control method is best for them. If you are a woman living with HIV (HIV+), it is also important to consider the possibility of passing your virus to a partner. This is true if your partner(s) is HIV+ or HIV-negative.

When both partners are HIV+, you do not need to worry about one getting infected with HIV. However, one partner could re-infect (also called super-infect) the other with a strain of HIV that is resistant to the HIV drugs being taken. Also, other sexually transmitted diseases (STDs) could be passed from one partner to the other. The only forms of birth control that will provide protection against HIV and other STDs are abstinence (not having sex) or using condoms while having sex.

Not all HIV+ women will want to, or be able to have their partners use condoms, whether their partners are HIV+ or HIV-negative. For more information on male and female condom use, see our article on Talking with Your Partner about Condoms.

For HIV+ women who do not use condoms and do not want to get pregnant, there are a number of other choices available. These other methods of birth control offer protection against pregnancy, but do not protect against HIV or other STDs. Some health care providers suggest "dual (double) protection" – condoms to prevent HIV transmission, and another method to prevent pregnancy.

Methods That Protect against HIV Infection

Condoms

Condoms (rubbers) are thin latex or plastic barriers. The male condom is worn on the penis. The female condom is put in the vagina or anus.

Benefits:

  • Female and male condoms are the most effective ways to prevent many STDs (including HIV)
  • If used correctly, male condoms are up to 98 percent effective at preventing pregnancy; if not always used correctly, male condoms are only 85 percent effective. If used correctly, female condoms are up to 95 percent effective at preventing pregnancy; if not always used correctly, female condoms are only 79 percent effective.
  • The female condom is the only female-controlled method of birth control that also provides protection from STDs
  • The female condom can be inserted several hours to immediately before sex
  • Male condoms are inexpensive
  • Condoms do not require a prescription

Drawbacks:

  • Male condom requires cooperation of the male partner
  • Male condoms may break if not put on correctly or if used with oil-based lubricants like baby oil or Vaseline
  • Male condoms must be put on during sex while the male partner is erect
  • Female condoms can be expensive and are not available everywhere

The male condom is available in lubricated and unlubricated (dry) forms. Unlubricated condoms are often the condoms of choice for oral sex. For vaginal sex, you can use either a lubricated or unlubricated condom. For anal sex, lubricated condoms are suggested. You can choose to add lubricant (lube) any time you use a condom. Remember, however, to use only water-based lubes (like Astroglide, KY Jelly) with latex condoms. Oil-based lubricants like mineral oil, cold cream, Vaseline (petroleum jelly), and vegetable oils will damage latex and make the condom ineffective at preventing infections or pregnancy.

Condoms lubricated with the spermicide Nonoxynol-9 (N-9) are no longer recommended. They have a shorter shelf life, do not decrease pregnancy more than other lubricated condoms, and may increase HIV risk by causing irritation of the vagina or rectum.

Methods That Do Not Protect against HIV Infection

Hormone Methods

Hormone-based contraceptives are available in combined estrogen and progesterone (ethinyl estradiol/norethindrone) or progesterone-only formulations. Hormone methods are available in many different forms including pills, shots, implants, vaginal rings, patches, sponges, and IUDs.

Depending on which you choose, you will need to use hormone methods daily, weekly, monthly, or every few months or years. You need a prescription for hormonal methods and in some cases a health care provider must administer them on a regular basis.

Benefits:

  • Very effective (97 to 99 percent) in preventing pregnancy
  • You do not need to do anything right before sex to prevent pregnancy
  • May reduce risk of ovarian and endometrial (lining of the uterus, or womb) cancers, pelvic inflammatory disease, non-cancerous growths of the breasts, ovarian cysts, and osteoporosis (thinning of the bones)

Drawbacks:

  • Not effective against STDs (including HIV)
  • Many possible side effects
  • May increase risk for blood clots, heart attack, and stroke (especially among smokers age 35 and older)

Some hormone-based birth control methods can interact with HIV drugs, changing the level of one or more drugs in the blood stream. Some HIV drugs decrease the levels of hormone-based birth control, increasing the chances of an unwanted pregnancy. Some HIV drugs increase the levels of hormone-based birth control methods. It is not clear what effect this will have. It is important to talk with your health care provider to see if or how your HIV drugs interact with your preferred method of birth control. Your provider should know how to adjust doses of your HIV drugs and/or hormone-based birth control methods.

In the past few years, there has been some debate about the effect of hormonal contraceptives like the pill or injectable Depo-Provera (DMPA) on HIV transmission. Some studies have reported that women using hormonal contraceptives were more likely to become infected with HIV and to infect their partners with HIV than women who were not using hormonal contraceptives. Other studies have shown no difference in the risk of getting or spreading HIV between these groups. It appears fairly clear from available data that oral hormonal contraceptives (birth control pills) do not increase women's risk of getting HIV. However, the picture concerning DMPA and its ability to increase women's chances of getting HIV remains unclear.

In February 2012, after reviewing the scientific data, the World Health Organization (WHO) concluded that HIV+ women and women at high risk for HIV can continue to use hormonal contraceptives safely. In June 2012, the US Centers for Disease Control and Prevention (CDC) issued a report in agreement with the WHO's statement.  The CDC added that, because the evidence about the progestin-only injectables (like Depo-Provera) and potentially increased risk of HIV transmission is unclear, women using these contraceptives who are at high risk of HIV infection are strongly encouraged to use condoms. The WHO is scheduled to review the data and issue another recommendation in 2014.

Diaphragms and Cervical Caps

The diaphragm and cervical cap fit over the cervix. Both need to be fitted by a health care provider and used with a spermicide cream or jelly.

Benefits:

  • Up to 94 percent effective in preventing pregnancy if used correctly
  • Can be inserted ahead of time, so as not to interrupt sex
  • There are usually no side effects
  • Cannot usually be felt by either partner

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • May be difficult to insert

IUDs (intrauterine devices)

An IUD is a small, T-shaped device put into the uterus (womb) by a health care provider. There are two types of IUDs currently available. The first is called ParaGard. It contains copper and lasts for up to ten years. The second is called Mirena. It releases small amounts of the hormone progestin and lasts five years.

Benefits:

  • Very effective (fewer than 1 out of 100 women get pregnant while using an IUD)
  • Long-lasting and inexpensive (over time)
  • You do not need to do anything right before sex
  • Cannot be felt by either partner
  • The ParaGard IUD does not change your hormone levels
  • Can be used during breastfeeding
  • Can be used as emergency contraception (after unprotected sex) if inserted within 5 days of intercourse

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • Some cramping and pain may occur when the IUD is first put into the uterus
  • For the first three to six months you may have:
    • spotting between periods
    • irregular periods with Mirena
    • worse menstrual cramps or heavier periods with ParaGard
  • You need to check occasionally to make sure it is still in place by feeling for the string with your fingers inside the vagina (birth canal)
  • Some risk of ectopic pregnancy (when a fertilized egg grows outside the uterus) and pelvic inflammatory disease; in very rare cases, the IUD pushes through the wall of the uterus (uterine perforation)

Spermicides

Spermicides are available in a variety of forms such as film, foam, jelly, cream and suppository.

Benefits:

  • Inexpensive
  • Does not require prescription
  • Can be inserted ahead of time, so as not to interrupt sex
  • Cannot usually be felt by either partner

Drawbacks:

  • Not very effective when used alone as birth control
  • Offer no protection against STDs (including HIV)
  • May cause increased risk for transmission of HIV due to irritation of the vagina

Warning: The spermicide Nonoxynol-9 (N-9) can actually increase HIV risk by irritating the skin in the vagina and rectum. Condoms with nonoxynol-9 are no longer recommended for this reason.

Other Methods That Do Not Protect against HIV Infection

Permanent Birth Control (Sterilization)

Sterilization is a surgical procedure that can be performed on a woman (tubal ligation) or a man (vasectomy). It is almost 100 percent effective against pregnancy; however it is not effective against STDs (including HIV).

"Natural" Birth Control

This includes abstinence, withdrawal, and fertility awareness-based methods (Rhythm Method). The effectiveness of natural birth control options at preventing pregnancy ranges from 100 percent (abstinence) to 73 percent (withdrawal method). Except for abstinence, natural methods are not effective for preventing STDs (including HIV).

Emergency Contraception

There are two methods to help prevent pregnancy after unprotected sex: emergency "morning-after" pills and emergency IUD insertion. These methods can be effective in reducing the risk of pregnancy if started within a few days after unprotected sex. They offer no protection against STDs (including HIV). The morning after pill may interact with your HIV drugs, so ask your provider in advance if this interaction will occur with your HIV drugs.  For more information, visit the Emergency Contraception website at not-2-late.com

How to Choose

For HIV+ women, drug interactions and the need to reduce the risk of disease transmission can complicate choosing a method of birth control. Work closely with your health care provider or a family planning counselor to decide on the contraceptive that is best for you.

It is important to get accurate and up-to-date information on any birth control method you choose. You may want to ask the following questions about different methods:

  • Does it provide protection from sexually transmitted diseases (STDs) including HIV?
  • Does it interact with my HIV drugs or other drugs I am taking?
  • How well will it fit into my lifestyle?
  • How convenient will it be? 
  • How effective is it?
  • How safe is it?
  • Will I like it?
  • How affordable is it?
  • How will it impact my chances of getting pregnant in the future if I choose to?

The Future: Multipurpose Prevention Technologies

Multipurpose Prevention Technologies (MPTs) provide ways of preventing more than one thing in one device. For example, MPTs may prevent pregnancy and HIV, or they may prevent HIV and several other STDs.  Having methods that combine prevention of pregnancy and STDs (including HIV) would be more convenient and likely lead to more consistent and therefore more effective use. 

Researchers are studying several methods for combining prevention technologies, including a vaginal ring containing both a hormonal contraceptive (to prevent pregnancy) and an HIV drug (to prevent HIV; a form of Pre-Exposure Prophylaxis, or PrEP). It can be inserted well before sex, stay there for up to three months, and is not usually felt by either partner. Early studies have shown that the ring appears effective in preventing monkeys from getting HIV and from getting pregnant. The next step is for the ring to be tested in women in clinical research trials.

Additional Resources

Select the links below for additional material related to birth control.

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