Transcript Slide 1

Contraceptive Options for
Women and Couples with HIV
Implants, POPs and
Emergency Contraception
Subdermal Implants
• Progestin-filled rods or capsules
that are inserted under the skin
• Norplant: 6-capsule system,
effective for 5 years
• Second generation implants
– Jadelle and Sinoplant: 2-rod system,
effective for 5 years
– Implanon: 1-rod system,
effective for 3 years
• Mechanism of action similar to
injectables
Implants – Characteristics
Advantages
Disadvantages
• Safe, 99.95% effective,
easy to use, reversible
• Have common side
effects
• Can be used by
breastfeeding women
• Cannot be initiated/
discontinued without
provider’s help
• Offer health benefits,
such as reducing risk
of symptomatic PID
and anemia
• Provide no protection
from STIs/HIV
Source: Hatcher, 2007; WHO, 2004, updated 2008; CCP and WHO, 2007.
Implants – Side Effects
• First several months:
light bleeding/spotting, prolonged irregular bleeding,
infrequent bleeding, amenorrhea
• After one year:
light bleeding for fewer days, irregular bleeding,
infrequent bleeding, amenorrhea
• Other side effects: nausea, headaches, breast
tenderness, weight change, abdominal pain
– less common than with progestin-only injectables
– diminish after the first few months
Source: Shoupe, 1991; CCP and WHO, 2007.
Category 1 and 2 Examples (not inclusive):
Who Can Use Implants
WHO
Category
Conditions
Category 1 breastfeeding after 6 weeks postpartum, heavy
smokers, complicated valvular heart disease,
endometriosis, endometrial or ovarian cancer,
thyroid disorders
Category 2 blood pressure ≥160/100, history of DVT/PE,
diabetes with vascular complications, heavy or
prolonged vaginal bleeding patterns, multiple
risk factors for CVD
Source: WHO, 2004; updated 2008.
Category 3 and 4
Who Should Not Use Implants
WHO
Category
Conditions
Category 3 breastfeeding before 6 weeks postpartum, acute
DVT/PE, unexplained vaginal bleeding, history of
breast cancer, severe liver disease and most
liver tumors, systemic lupus disease
continuation only: ischemic heart disease,
stroke, migraine with aura
Category 4 current breast cancer
Source: WHO, 2004; updated 2008.
Implant Use by Women with HIV
WHO Eligibility Criteria
Condition Category
HIV1
infected
AIDS
1
ARV
therapy
2
• Women with HIV or AIDS can
use without restrictions
• Some ARV drugs reduce
blood progestin level
• Efficacy is not affected
because implants provide
consistent dose of hormone
over time
• Dual method use should be
encouraged
Source: WHO, 2004, updated 2008; Mildvan, 2002.
Progestin-Only Pills (POPs)
• Contain no estrogen
• Less progestin than COCs
• All pills in pack are active
• Progestin amount same throughout
• 28-35 pills per pack
• Eligibility criteria is similar to those of implants
POPs are especially suitable for breastfeeding women
and others who should not use estrogen.
Source: WHO, 2004; updated 2008.
Progestin-Only Pills (POPs)
continued …
• Mechanism of action:
– partial suppression of ovulation (more pronounced in
breastfeeding women)
– thickening of cervical mucus
• Have no known adverse effects
• Side effects are similar to those of implants
– irregular or prolonged bleeding is not common in
breastfeeding women
• Require stricter pill-taking schedule than COCs
– 1 pill each day within 3 hours of same time
– no breaks between packs
Source: CCP and WHO, 2008 update.
* within 12 hours for POPs
containing desogestrel 75μg
POPs – Missed Pills
• Take most recent missed pill as soon as possible
• Abstain or use backup method for 48 hours
• Take next pill at regular time
• Consider use of emergency contraception if
appropriate
• No backup method or emergency contraception
needed if pills are missed by a woman who is
still protected by LAM
Source: CCP and WHO, 2008 update.
POP Use by Women with HIV
Category
• Women with HIV or AIDS can
use without restrictions
HIV-infected
1
• Women on ARVs other than
ritonavir can use POPs safely
AIDS
1
• Should not be used by
women who take ritonavir
2
• Dual method use should be
encouraged
WHO Eligibility Criteria
Condition
ARV therapy
(which does not
contain ritonavir)
Ritonavir/
ritonavirboosted PIs
3
(as part of ARV
regimen)
Source: WHO, 2004, updated 2008; Sekar, 2008.
• Breastfeeding status provides
additional protection from
pregnancy
ECP Use by Women with HIV
• Use to prevent pregnancy after unprotected
intercourse
– progestin-only and combined estrogen-progestin regimens
– start as soon as possible; counsel to adopt regular method
• Use if regular method was used incorrectly,
failed, or was not used
• Safe for all women (including women with HIV/AIDS and
taking ARV drugs)
There is no evidence to justify changes to emergency
contraceptive pill regimens for ARV clients.
Source: Hatcher, 2007; WHO, 2004, updated 2008.
ECP Pill Regimens:
Progestin-Only Oral Contraceptives
Start within 120 hours (5 days) after unprotected intercourse
pills formulated
as emergency
contraception
regular progestinonly pills
1.5 mg levonorgestrel or
3 mg norgestrel;
take all at once or in
two doses 12 hours apart
Source: CCP and WHO, 2007; WHO Task Force on Postovulatory Methods
of Fertility Regulation, 1998; Piaggio, 1999; von Hertzen, 2002.
ECP Pill Regimens:
Combined Oral Contraceptives
Start within 120 hours (5 days) after unprotected intercourse
low-dose pills*
12 hours
Each dose should
contain at least:
0.1 mg ethinyl
estradiol and
0.5 mg
levonorgestrel
high-dose pills
repeat dose
12 hours
repeat dose
Known as
Yuzpe regimen
*or
5 pills for each dose, if each pill
contains 0.02 mg of ethinyl estradiol
Most effective when used early.
Source: WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; CCP and WHO, 2007.
ECPs – Key Counseling Messages
• Use and effectiveness
• More effective the sooner they are begun
• Side effects (nausea and vomiting) may occur;
less common with progestin-only regimen
• Next menses may come a week early or late
• Do not provide pregnancy protection for future
intercourse or protection from STIs/HIV
• After using, regular method should be considered