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 existing 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 Prevent Pregnancy and Protect against HIV

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. Do not use condoms with these lubricants.
  • 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.

Hormone-Based Methods That Prevent Pregnancy but Do Not Protect against HIV

Hormone-based contraceptives are available in progesterone-only or combined estrogen and progesterone options. 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-based 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.

Interactions with HIV Treatment

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. The two hormone-based methods least likely to be affected by your HIV treatment are DMPA and hormonal IUDs.

In 2014, researchers in one study found that the NNRTI Sustiva (efavirenz) reduced the effectiveness of a commonly-used progesterone contraceptive implant among women living with HIV in Uganda. Sustiva is used widely in resource-limited areas, and is one of the World Health Organization's recommended first-line HIV drugs for adults. Therefore it is important that women and their providers be aware of Sustiva's effect on the performance of progesterone-containing contraceptive implants.

After reviewing the scientific data, the World Health Organization (WHO) recommended in June 2014 that HIV+ women and women at high risk for HIV can continue to use hormonal contraceptives safely. The WHO further recommended that special consideration be given to women taking efavirenz or nevirapine (Viramune)-containing HIV treatment regimens.

Effects on HIV Transmission

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. 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. Therefore, if you are using DMPA to prevent pregnancy, it is advisable to also use condoms to protect against HIV. You may also want to consider treatment for the partner living with HIV (treatment as prevention), or pre-exposure prophylaxis (PrEP) if you are HIV-negative.

Long-Acting Reversible Contraceptives (LARCs)

According to the American Congress of Obstetricians and Gynecologists (ACOG), IUDs and implants are by far the most effective forms of birth control – 20 times more effective than patches, rings, or birth control pills. In the first year of typical use of an IUD or an implant, fewer than one in 100 women will become pregnant.

IUDs (intrauterine devices)

An IUD is a small, T-shaped device put into the uterus (womb) by a health care provider. It releases a substance that helps to prevent pregnancy. There are several types of IUDs currently available. Mirena, Skyla, and Liletta are IUDs that contain levonorgestrel, a hormone similar to those found in birth control pills. Mirena lasts for five years, while Skyla and Liletta each last for three. ParaGard is a non-hormonal IUD that contains copper and lasts for ten years. At any time during their use, any of these IUDs can be removed if you want to switch birth control methods or become pregnant.

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 or condom failure) if inserted within five 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)

Implants

Birth control implants are thin, flexible plastic rods that are inserted under the skin of the upper arm. An implant is about the size of a matchstick, and contains a form of the female sex hormone progesterone. They can last up to three years. Common implants include Implanon and Nexplanon.

Benefits:

  • Very effective (fewer than 1 out of 100 women get pregnant while using an implant)
  • Long-lasting and inexpensive (over time)
  • You do not need to do anything right before sex
  • Cannot be felt by either partner
  • Can be used while breastfeeding
  • Some women have less painful menstrual periods when they have an implant
  • Can be removed at any time if you decide to switch methods or become pregnant

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • Irritation, pain, and/or scarring are possible at the implant site
  • The most common side effect is irregular menstrual bleeding, which occurs most often during the first six to 12 months
  • Other side effects include depression, weight gain, nausea, headache, and/or sore breasts

Note: It is important for women living with HIV to know that the effectiveness of their implant may be reduced if they are taking Sustiva (efavirenz) as part of their HIV treatment regimen.

Shots (Injections)

Birth control shots are injections of a form of the female sex hormone progesterone. The shots last for up to three months. The most common shot is Depo-Provera, or DMPA (depot medroxyprogesterone acetate). Because researchers are unclear if using DMPA increases women's risk of getting HIV, it is especially important to use additional methods to prevent the spread of HIV. These include condoms, treatment of the partner living with HIV (treatment as prevention), and pre-exposure prophylaxis (PrEP) if you are HIV-negative.

Benefits:

  • Very effective
  • Long-lasting and inexpensive (over time)
  • You do not need to do anything right before sex
  • Cannot be felt by either partner
  • Can be used while breastfeeding
  • Some women have less painful menstrual periods when they get birth control shots
  • One of the methods least affected by interactions with HIV drugs

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • Irritation and pain are possible at the injection site
  • The most common side effect is irregular menstrual bleeding, which occurs most often during the first weeks
  • Other side effects include depression, weight gain, nausea, headache, and/or sore breasts
  • It can take a while to get pregnant since the shot is long-lasting and cannot be reversed or removed

Patches and Rings

Birth control patches are thin plastic flexible squares that stick to the skin and release forms of the female sex hormones progesterone and estrogen. They are good for one week each, and are applied for three consecutive weeks followed by a week off. The patch is known by the names Ortho Evra or Evra.

Birth control rings are small, flexible rings that women insert deep into their vagina. One ring is good for three weeks, after which there is a week without a ring. Commonly known as NuvaRing, the ring contains forms of the female sex hormones estrogen and progesterone.

Benefits:

  • Very effective
  • You do not need to do anything right before sex
  • Cannot be felt by either partner (on rare occasions when the ring can be felt, it can be taken out for as long as four hours at a time)
  • Some women have less painful menstrual periods when they use a patch or ring
  • Your ability to become pregnant returns quickly after stopping use

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • The most common side effects are irregular menstrual bleeding, nausea, and sore breasts
  • The ring may also cause vaginal discharge or irritation
  • Because patches and rings contain estrogen, there are certain medical conditions that may make these methods a less good choice for you

Oral Contraceptive Pills (Birth Control Pills)

Birth control pills (or "the pill") are a type of medication women can take by mouth to prevent pregnancy. They contain either progesterone only, or a combination of estrogen and progesterone. Combination pills come in 21-day or 28-day packs, and each type of pack contains 21 pills with active hormone (28-day packs also come with 7 days of placebo pills). With combination pills, you take 21 consecutive days of pill containing hormone, then take 7 days off. Progesterone-only pills come in packs of 28 active pills that you take every day (no days off).

Benefits:

  • Very effective, when taken daily and at the same time every day
  • You do not need to do anything right before sex
  • Cannot be felt by either partner
  • Some women have less painful menstrual periods when they are on the pill
  • Your ability to become pregnant returns quickly after stopping use

Drawbacks:

  • Does not offer protection against STDs (including HIV)
  • You have to take a pill every day, and at the same time every day
  • The most common side effects are irregular menstrual bleeding, nausea, and sore breasts
  • Because some pills contain estrogen, there are certain medical conditions that may make combination pills a less good choice for you

Other Methods That Prevent Pregnancy but Do Not Protect against HIV

Emergency Contraception

There are two methods to help prevent pregnancy after unprotected sex or condom failure: emergency "morning-after" pills and emergency IUD insertion.

While these methods can be effective in reducing the risk of pregnancy if started within a few days after sex, it is important to note that they offer no protection against STDs (including HIV). An IUD can be up to 99 percent effective in preventing pregnancy if it is inserted within five to seven days after sex. It works by stopping the implantation of a fertilized egg in the uterus (womb).

There are several types of "morning after" pills. The first is a pill containing a synthetic (man-made) version of the female sex hormone progesterone. This pill has several names, including Plan B One-Step in the US, Levonelle in the UK, Escapelle in South Africa, and Unwanted 72 or i-Pill in India. These pills should be taken as soon as possible, since their effectiveness depends on how soon you take them. If taken within 72 hours of sex, they can reduce the chance of pregnancy by close to 90 percent. Researchers are unsure if taking HIV drugs reduces the effectiveness of "morning after" pills; therefore, it is best to continue taking your HIV drugs as directed if you use "morning after" pills.

The second type of "morning after" pill is called Ella (in the US, or EllaOne in the European Union). It contains ulipristal, which is not a female sex hormone. Ella needs to be taken within five days of sex.

For more information, visit the Emergency Contraception website at not-2-late.com.

Spermicides

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

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. If you are HIV-negative, you may want to explore other options for birth control.

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

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 spermicidal cream, jelly, or foam. If you are considering using a diaphragm or cervical cap, it is important to know that:

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. If you are HIV-negative, you may want to explore other options for birth control.

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

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).

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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