Contraceptive Options for Women and Couples with HIV

Intrauterine Device(IUD or IUCD)

Copper T-380A

Types of IUDs

• Most common: – T-shaped, copper bands on plastic stem/arms

• Inserted in uterus through vagina and cervical opening

• Strings: – assure IUD is in place; facilitate removal

• Most common copper IUD: TCu-380A

• Less common: hormonal IUDs

Copper T-380A

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

Mechanism of Action of Copper IUDs

Prevents fertilization by:

• Impairing the viability of the sperm

• Interfering with sperm movement

Source: Ortiz, 1996.

Characteristics of Copper IUDs:

Advantages

• Highly effective and very safe

• Does not interfere with intercourse

• Easy to use

• Long lasting

• Easily reversible

• Quick return to fertility

• No systemic effects

• Complications are rare

Source: CCP and WHO, 2007.

Characteristics of Copper IUDs:

Disadvantages

• Side effects, including cramping and increased or prolonged bleeding

• Rare complications include perforation and pelvic inflammatory disease

• Method failure can lead to ectopic pregnancy (extremely rare)

• Insertion and removal require trained provider

• No STI/HIV protection

Source: CCP and WHO, 2007.

Copper IUDs – Common Side Effects

• Cramping and increased or prolonged menstrual bleeding

• Possible bleeding between menstrual periods

Side effects are most common during the Side effects are most common during the first 3 months.first 3 months.

Source: CCP and WHO, 2007; Larsson, 1993; DeMaeyer, 1989; WHO, 2004, updated 2008; WHO Special Programme of Research Development and Research Training in Human Reproduction, 1997.

IUDs – Pelvic Inflammatory Disease (PID)

Risk of PID in IUD users:• Low overall

– risk of PID attributable to IUD is 0.15% to 0.30%

• Higher during first 20 days after insertion• Due mostly to presence of gonorrhea or

chlamydia at time of insertion• Similar to risk of PID in women with gonorrhea

and chlamydia who are not using IUD

Source: Shelton, 2001.

PID is an infection of a woman’s upper genital tract.PID is an infection of a woman’s upper genital tract.

IUDs – Reducing the Risk of PID

• Do not insert IUD if:– at high individual risk of STIs, or– clinical symptoms and signs of an STI are present

• Counsel about risk of PID

• Follow infection prevention procedures during insertion

• Recommend follow-up visit at 3 to 6 weeks to check for infection– return immediately if any symptoms of PID develop

Source: WHO, 2004; updated 2008.

IUDs – Perforations

Risk:

• Linked to skill and experience of provider

• Reduced through supervised training

• Greater for postpartum insertions performed between 48 hours and 4 weeks after delivery

Very rare: 1 in 1,000 insertions

Source: WHO, 1987.

IUDs – Expulsions

Factors contributing to expulsion:

• Provider’s skill placing IUD at top of uterine cavity

• Age and parity of woman

• Time since insertion

• Timing of insertion

Partial or unnoticed expulsion may result inirregular bleeding or pregnancy

Source: Anteby, 1993; O’Hanley, 1992; Zhang, 1992; Petersen, 1991; Sivin, 1992.

IUDs Safe for Women with HIV

Source: Morrison, 2001.

Percentage of women in Kenyan study

Little difference in complications between IUD acceptors with and without HIV.

IUD Use Does Not Increase HIV Transmission

Theoretical concern: • IUD use by women with HIV may increase risk of transmission to partner

Research has found:• No postinsertion increase in cervical shedding • No increased risk of partner exposure to higher dose of virus

Source: Richardson, 1999.

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IUD Use by Women with HIV

• Safe for majority of women with HIV

• Initiation not recommended if woman has AIDS and is not on ARV therapy

• Dual method use should be encouraged

WHO Eligibility Criteria

ConditionCategory

Initiate Continue

HIV-infected 2 2

AIDS(without ARVs) 3 2

ARV therapy(clinically well) 2 2

Source: WHO, 2004; updated 2008.

Category 1 and 2 Examples (not inclusive):

Who Can Use Copper IUDs

menarche to <20 years, nulliparous, heavy or prolonged bleeding, severe dysmenorrhea, endometriosis, anemia, high risk of HIV

Category 2

≥20 years, hypertension, deep venous thrombosis, ischemic heart disease, migraine headaches, cervical ectopy, breast disease (including breast cancer)

Category 1

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

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

pregnancy; postpartum/postabortion sepsis; unexplained vaginal bleeding (prior to eval.); uterine fibroids with cavity distortion; current PID; purulent cervicitis; endometrial cancer, cervical cancer, or pelvic TB/if initiating use

Category 4

48 hours to <4 weeks postpartum, ovarian cancer/if initiating use, high individual risk of STIs, AIDS (no ARV treatment or not well on ARVs)

Category 3

ConditionsWHO

Category

Source: WHO, 2004; updated 2008.

Timing of IUD Insertion

Interval insertion• Anytime during menstrual cycle if woman is not

pregnant

Postpartum insertion• Immediately after vaginal or cesarean delivery if

no infection or bleeding (within 48 hours or delay at least 4 weeks)

Postabortion insertion • Immediately if no infection

Source: WHO, 2004; updated 2008.

IUD Counseling Topics

• Characteristics of IUDs

• Effectiveness and how IUDs work

• Common side effects

• Client’s risk of STIs

• Insertion and removal procedures

• Instructions for use and follow-up visit (including signs of complications that require immediate return to the clinic)

Counseling about IUD Side Effects: What to Expect

During Insertion:• Some pain and cramping

First few days:• Light bleeding and mild cramping

First few months:• Heavier and/or prolonged menstrual bleeding• Menstrual cramping• Spotting between periodsSource: CCP and WHO, 2007.

IUD Use and Follow-up

• Teach client how to check for strings:– with clean fingers – after each menses

(expulsion most likely in first 6 months)

• Schedule follow-up visit at: – 3 to 6 weeks

• Counsel to return immediately if any signs of complications

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

Signs of Possible IUD Complications

Advise to return immediately if experiencing:

• Bleeding and severe abdominal cramping 3 to 5 days postinsertion perforation

• Irregular bleeding or pain every cycle partial expulsion, perforation

• Fever, unusual vaginal discharge, low abdominal pain infection

• Missing IUD strings, missed period expulsion, pregnancy

Source: CCP and WHO, 2007.

Dispelling IUD Myths

IUDs:

• Are not abortifacients

• Do not cause infertility

• Do not cause discomfort for the male partner

• Do not travel to distant parts of the body

• Are not too large for small women

Source: CCP and WHO, 2007; Farr, 1994.

IUDs – Summary

IUDs are:• Safe, effective, convenient, reversible,

long lasting, cost-effective, easy to use, appropriate for the majority of women

Providers can ensure safety by:• Informative counseling• Careful screening• Appropriate infection prevention

practices• Proper follow-up