Does using hormonal contraception increase a woman's risk of getting HIV?
Key messages
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DMPA (depot medroxyprogesterone acetate) injections likely result in little to no difference in the risk of getting HIV compared to the copper intrauterine device (IUD).
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The levonorgestrel implant (LNG) likely results in little to no difference in the risk of getting HIV compared to the copper IUD.
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DMPA injections likely slightly increase the risk of getting HIV compared to LNG implants.
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We are not certain about the effect of DMPA compared to norethisterone enanthate (NET-EN) on HIV acquisition.
What Is HIV?
HIV is a virus that affects the body's immune system and weakens the ability to fight off everyday infections and diseases. The virus is found in the bodily fluids of an infected person. The virus is most commonly spread from one person to another through unprotected sex. People can also get the virus from sharing needles or syringes. Babies can be infected during pregnancy, birth or breastfeeding.
Although there is no cure for HIV, treatment is highly effective and can improve life expectancy and quality of life.
What is contraception?
Contraceptive methods are birth-control methods. The aim of using contraception is to avoid unwanted pregnancies. There are many different contraceptive methods. Some contraceptives contain hormones, whilst others do not. Common modern methods include injections, implants, pills and intrauterine devices (IUDs, which sit inside the womb). DMPA is an injection given every three months. The LNG implant is placed under the skin of the upper arm and can remain effective for up to five years. NET-EN is an injection given every two months, which contains progesterone (a type of hormone).
What did we want to find out?
We wanted to find out if using hormonal contraception puts women at a higher risk of getting HIV than if they used other contraceptive methods.
What did we do?
We searched for all studies that looked at the effects of using hormonal contraception for women living in areas where there is a high risk of getting infected with HIV. We compared and summarised the results of these studies and rated our confidence in the evidence, based on factors like study methods and sizes.
What did we find?
We found four studies that involved 9726 HIV-negative women. We were interested in the risk of women getting HIV, and the risk of becoming pregnant.
The review found that using DMPA injections likely results in little to no difference in the chance of getting HIV when we compare it to using a copper IUD.
Using an LNG implant likely results in little to no difference in the chance of getting HIV compared to copper IUD.
Using DMPA injections or LNG implants probably reduces pregnancy risk compared to copper IUDs, but this effect might be due to the controlled environment of a study that encourages women to continue their contraceptive methods.
We also found that using DMPA probably slightly increases the risk of HIV infection when compared to using the LNG implant, but DMPA probably results in little to no difference in the risk of pregnancy compared to LNG.
The evidence is very uncertain about the effect of DMPA compared to NET-EN on the chances of getting HIV or becoming pregnant.
What are the limitations of the evidence?
None of the trials compared the risk of women using contraception to women using no contraception, so we cannot be certain what a woman's risk of getting HIV is if she uses no contraception. The trials only looked at a few specific contraceptive methods, not all the methods available on the market.
How up to date is this evidence?
This review updates the previous review. The evidence is up to date to 13 September 2023.
Read the full abstract
Objectives
To determine the effects of hormonal contraception on HIV acquisition in women who live in settings with high HIV prevalence.
Search strategy
We searched CENTRAL, MEDLINE, Embase, SCOPUS, Global Index Medicus and trial registries (together with reference checking, citation searching and contacting study authors), to identify studies up to 13 September 2023.
Authors' conclusions
HIV incidence was high in all groups, regardless of contraceptive used, as would be expected in a setting with high HIV prevalence. All contraceptives used in the included studies are widely used and known to prevent pregnancy. When comparing different contraceptive methods, DMPA injections compared to copper IUD may result in little to no difference in HIV acquisition and result in a slight reduction in pregnancy. LNG implants compared to copper IUDs likely result in little to no difference in HIV acquisition and in a slight reduction in pregnancy. DMPA injections compared to LNG implants likely result in a slight increase in HIV acquisition and likely result in little to no difference in pregnancy. The evidence is very uncertain about the effect of DMPA compared to NET-EN on HIV acquisition and pregnancy.
HIV acquisition and pregnancy are important outcomes that have a long-lasting impact. Access to safe, effective contraception is important for women wanting to prevent unplanned pregnancies, as pregnancies have long-lasting physical, social and economic ramifications. Evidence from included studies shows that across groups, many participants report engaging in condomless sexual activity, even when living in high HIV prevalence settings. HIV prevention methods such as pre-exposure prophylaxis and HIV education remain crucial in the fight against HIV.
Funding
This Cochrane review had no dedicated funding.
Registration
Protocol available via (DOI: 10.1002/14651858.CD015701).
