Contraceptive Options for Women and Couples with HIV

Injectable Contraceptives

Types of Injectable Contraceptives

Cyclofem,

Mesigyna

DMPA,

NET-EN

Type

1 month3 months,2 months

Duration of effect

progestin +estrogen

progestinHormones

CombinedProgestin-only

Effectiveness

Source: CCP and WHO, 2007.

Oral contraceptives

Percentage of women pregnant in first year of use

Rate during typical use

Rate during perfect use

Female condom

Female sterilization

Implants

DMPA

Spermicides

Standard Days Method

Male condom

IUD (TCu-380A)

0 10 15 20 255 30

DMPA – Mechanism of Action

Thickens cervical mucus to block sperm

Suppresseshormonesresponsible forovulation

DMPA – Most Widely Used Injectable

• Best known as Depo-Provera

• Used by more than 14 million women worldwide

• Administered by deep intramuscular injection

• 150 mg every 3 months

• Injection site: upper arm or buttocks

Characteristics of DMPA:

Advantages

• Safe

• Highly effective

• Easy to use

• Long acting

• Reversible

• Can be discontinuedwithout provider’s help

• Can be provided outside of clinics

• Requires no action at time of intercourse

• Use can be private

• Has no effect on lactation

• Has non-contraceptive health benefits

Characteristics DMPA:

Non-contraceptive Health Benefits

DMPA use may reduce:

• Risk of endometrial cancer

• Risk of ectopic pregnancy

• Risk of symptomatic pelvic inflammatory disease

• Uterine fibroids

• Frequency and severity of sickle cell crises

• Symptoms of endometriosisSource: CCP and WHO, 2007.

Characteristics DMPA:

Disadvantages

• Causes side effects, particularly menstrual changes

• Action cannot be stopped immediately

• Causes delay in return to fertility

• Provides no protection against STIs/HIV

DMPA – Common Side Effects

• Menstrual changes– prolonged or heavy bleeding – irregular bleeding or spotting – amenorrhea (absence of menses)

• Weight gain

• Headaches, dizziness, changes in mood and sex drive

One third of users discontinue during One third of users discontinue during the first year because of side effects.the first year because of side effects.

Source: WHO, 1983.

DMPA – Return to Fertility

• Does not permanently reduce fertility

• Length of time DMPA was used makes no difference

• Return to fertility depends on how fast woman fully metabolizes DMPA– on average, it takes 9 to 10 months for

women to become pregnant after their last injection

Source: Pardthaisong, 1984; Schwallie, 1974.

Infant Exposure to DMPAthrough Breastfeeding

• DMPA has no effect on: – onset or duration of lactation – quantity or quality of breast milk – health and development of infant

• When to initiate: – after child is 6 weeks old (preferred)

Source: Koetsawang, 1987; WHO Task Force for Epidemiological Research on Reproductive Health, 1994; WHO, 2004; updated 2008.

Effect of DMPA on Bone Density

• DMPA users have lower bone density than non-users

• Women initiating use as adults regain most lost bone

• Long-term effect in adolescents unknown – concern that osteoporosis may develop later – long-term studies are needed – generally acceptable to use

Source: Cromer, 1996; Cundy, 1994; WHO, 2004; updated 2008.

Category 1 and 2 Examples (not inclusive): Who Can Use DMPA

≤18 years, adequately controlled hypertension, uncomplicated diabetes, gall-bladder disease

Category 2

heavy smokers, breastfeeding after six weeks postpartum, thyroid disorders, severe dysmenorrhea, uterine fibroids, STIs/PID, use of rifampicin or rifabutin, anticonvulsants, or any type of ARV drug

Category 1

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

Category 3 and 4 Examples (not inclusive): Who Should Not Use DMPA

current breast cancerCategory 4

breastfeeding before 6 weeks postpartum, severe hypertension (≥160/≥100), vascular disease, acute DVT/PE, current or history of ischemic heart disease or stroke, complicated diabetes, severe liver disease and most liver tumors

Category 3

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

DMPA Use by Women with HIV

• Women with HIV or AIDS can use without restrictions

• Nevirapine reduces blood progestin level by ~20%

• DMPA dose provides wide margin of effectiveness

• On-time injections emphasized

• Dual method use should be encouraged

WHO Eligibility CriteriaWHO Eligibility Criteria

Condition Category

HIV-infected 1

AIDS 1

ARV therapy 1

Source: WHO, 2004, updated 2008; Mildvan, 2002; Said, 1986.

How to Take DMPA: When to Initiate

• Anytime during menstrual cycle if provider is reasonably sure woman is not pregnant – backup recommended if given after day 7

• Postpartum: – not breastfeeding: immediately – breastfeeding: delay 6 weeks

• Postabortion: immediately

Source: WHO, 2004; updated 2008.

How to Take DMPA: Injection Schedule

• Injection every 3 months or 13 weeks

• Can be up to 2 weeks early or 4 weeks late

Source: WHO, 2004; updated 2008.

Management of DMPA Side Effects:

Counseling about Bleeding

• Before first injection, counsel that bleeding changes are normal and expected

• Provide ongoing counseling and reassurance

• If client is concerned or bleeding is severe, treatment or discontinuation may be necessary

Counseling is the most important tool Counseling is the most important tool for managing bleeding irregularities.for managing bleeding irregularities.

Management of DMPA Side Effects:

Treatment of Bleeding

• Treatment options

– ibuprofen (800 mg three times/day for 5 days)

– combined oral contraceptives (COCs) for 21 days

– with very heavy bleeding, rule out pregnancy or gynecological problems (uterine evacuation not indicated)

Iron supplements can help prevent anemia.Iron supplements can help prevent anemia.

Source: CCP and WHO, 2007; WHO, 2004; updated 2008.

Management of DMPA Side Effects:

Amenorrhea

• Medical treatment not required

• If no reason to suspect pregnancy, counsel and reassure that amenorrhea is normal

• Pregnancy may need to be ruled out in some cases

Sterile Injection Procedures

• Wash hands

• Clean injection site

• Use sterile needle and syringe

• Dispose of waste correctly

• Needles and syringes: – single-use must be disposed of safely– reusable must be sterilized

Counseling about DMPA

Factors for clients to consider:

• Other available contraceptive options

• Characteristics (advantages and disadvantages)

• Side effects, including menstrual changes

• Timing of return to fertility

• Need for regular, timely injections

Counseling about DMPA

continued ...

Messages after choosing DMPA:

• Do not massage injection site

• Expect bleeding 12–15 days after injection

• Return with problems or concerns

• No protection from STIs/HIV

Counseling Reduces DMPA Discontinuation

• Menstrual changes most common reason for discontinuation

• Women receiving appropriate counseling more likely to continue using injectables

Source: Lei, 1996.

DMPA – Summary

• Safe, effective, easy to use

• Nonclinical provision possible

• Appropriate counseling essential