Women who use a hormonal contraceptive have double the risk of becoming infected with HIV-1, and are also twice as likely to pass the infection on to their sexual partner, researchers from the University of Washington, Seattle, reported in The Lancet Infectious Diseases. The raised risk is especially notable among those using injectables. The authors informed that over 140 million adult females around the world use hormonal contraception, including long-acting injectables or oral pills.

Co-author, Jared Baeten said:

“These findings have important implications for family planning and HIV-1 prevention programmes, especially in settings with high HIV-1 prevalence.”

Lead author, Renee Heffron said:

“Recommendations regarding contraceptive use, particularly emphasising the importance of dual protection with condoms and the use of non-hormonal and low-dose hormonal methods for women with or at risk for HIV-1, are urgently needed.”

A significant number of females in sub-Saharan Africa who are HIV positive use hormonal contraception. HIV susceptibility linked to hormonal contraction had been studied before, but with inconsistent and inconclusive results, the authors wrote.

The aim of this study was to determine whether using hormonal contraception raises a woman’s risk of HIV infection and transmitting it to male sexual partners. It involved 3,790 couples, with one partner infected with HIV-1 and the other not (serodiscordant couples); they were all heterosexual. The individuals came from Zimbabwe, Uganda, Tanzania, South Africa, Rwanda, Kenya and Botswana.

The study found that:

  • A woman’s risk of becoming infected with HIV-1 doubled if she was on hormonal contraception
  • There was a more significant risk for those taking an injectable hormone contraceptive (DMPA)
  • Those on injectable contraceptives were twice as likely to transmit their HIV-1 infection to their male sexual partners, compared to women not on hormonal contraception

The authors wrote:

“To our knowledge, ours is the first prospective study to show increased HIV-1 risk in male partners of HIV-1 infected women using hormonal contraception.
(conclusion)Data on HIV-1 risk associated with…other hormonal contraceptives, such as implants, patches, or combined injectables . . . and non-hormonal contraceptive methods such as intrauterine devices, are urgently needed, and strategies to improve accessibility and uptake of these lower-dose and non-hormonal methods should be prioritised. Contraceptive counseling should be combined with HIV-1 counseling and testing.”

Charles S Morrison from Clinical Sciences, Durham, USA, wrote in an Accompanying Comment in the same journal:

“Active promotion of DMPA in areas with high HIV incidence could be contributing to the HIV epidemic in sub-Saharan Africa, which would be tragic. Conversely, limiting one of the most highly used effective methods of contraception in sub-Saharan Africa would probably contribute to increased maternal mortality and morbidity and more low birthweight babies and orphans – an equally tragic result.

The time to provide a more definitive answer to this critical public health question is now; the donor community should support a randomised trial of hormonal contraception and HIV acquisition.”

There are two main types of hormonal contraceptives:

  • Combined contraceptives – these contain both an estrogen (ethinyl estradiol) and a progestin. The most popular medication is the combined oral contraceptive pill (COCP), also known as the pill. It is typically taken once daily for 21 consecutive days, followed by nothing for seven days – there are alternatives to this cycle. For those not on ongoing hormonal contraception, COCPs can be administered after sexual intercourse as emergency contraception. COCPs are presented in a variety of formulations.
  • Progestogen-only contraceptive – these contain progesterone or progestin (a synthetic analogue of progesterone). POP (progestogen only pill) is taken every day, within the same three-hour window each day. There are several different POP formulations. POPs are taken every day with no breaks. For those not on continuous POPs, POPs can be taken after sexual intercourse as emergency medication. POPs come in a variety of formulations.

Ormeloxifene, while not a hormone, acts on the hormonal system to prevent pregnancy.

Written by Christian Nordqvist