WHO has changed its recommendations for progestogen-only injectables and intrauterine devices (IUDs) for women at high risk of HIV from a Category 2 to a Category 1. Additional clarifications are provided for the IUD recommendation.
These recommendations stem from a meeting of the Guideline Development Group at which a wide range of stakeholders were represented including experts in family planning and HIV, representatives from affected populations, clinicians, epidemiologists, researchers, programme managers, policy-makers and guideline methodologists.
The Group reviewed evidence on hormonal contraception and HIV acquisition published since the previous review in 2016, along with a systematic review on copper-bearing IUDs (Cu-IUDs) and the risk of HIV acquisition.
The new evidence, particularly from one high-quality randomized clinical trial (the ECHO trial), demonstrated no statistically significant differences in HIV acquisition among women using intramuscular depot medroxyprogesterone acetate (DMPA-IM), copper intrauterine devices (Cu-IUDs), and levonorgestrel (LNG) implants.
This high-quality evidence superseded the low to low-moderate quality observational evidence previously available.
For combined oral contraceptives (COCs) and norethisterone enanthate (NET-EN) injectables, low to low-moderate quality evidence from observational studies indicated no increased risk of HIV infection.
While no direct evidence was available for subcutaneous DMPA (DMPA-SC), LNG-IUDs, or etonogestrel (ETG) implants, there was no biological or clinical reason to believe that a lower hormonal dose, different delivery mechanism, or different progestogen would modify HIV risk.
In developing these updated recommendations, the values and preferences of the end users were taken into consideration and supported informed contraceptive choice in which, for example, a woman’s risk of HIV should not restrict her contraceptive choice.
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The provision of a wide range of contraceptive options is essential and greater efforts are needed to expand method options and ensure full and equitable access to services.
Alongside the provision of family planning and contraceptive services, HIV and STI testing and prevention services are also critical. These services should be integrated where appropriate and include access to sexual and reproductive health services more broadly.