Does contraception affect HIV treatment?
Does contraception affect HIV treatment?
Is your family planning facility seeing more women who are HIV-positive? Statistics point to a "yes." In 2003, women accounted for 27% of the estimated 32,048 diagnoses of HIV infection in the United States, according to statistics from the Atlanta-based Divisions of HIV/AIDS Prevention of the Centers for Disease Control and Prevention (CDC).1
Antiretroviral (ARV) drugs are an important first-line defense in treating HIV infection. Clinicians now use combinations of ARV drugs, known as highly active antiretroviral therapy or HAART, to suppress HIV replication. When it comes to birth control, women are concerned about potential interactions between hormonal therapies and HAART, particularly if the interactions may affect the efficacy of the birth control method or how well they may respond to their HAART therapy, says Rebecca Clark, MD, PhD, associate professor of medicine at Louisiana State University Health Sciences Center and maternal/child director of the HIV outpatient program of the Medical Center of Louisiana, all based in New Orleans.
Just-published research indicates that the hormones in birth control do not influence the effectiveness of HAART.2 Until recently, there has been no information regarding the hormonal contraceptive influence on HAART effectiveness, she notes. Findings from the new study are reassuring that such drugs do not affect response to HAART, Clark adds.
Focus on the findings
Findings from the latest paper come from the Women’s Interagency HIV Study, a long-term, ongoing comprehensive cohort study of HIV-infected and at-risk women, explains co-author Stephen Gange, PhD, associate professor in the Department of Epidemiology at Bloomberg School of Public Health, Johns Hopkins University in Baltimore. The study was begun in 1993, prior to the advent of HAARTs introduced in the mid 1990s. Since anti-HIV therapy now is so widespread, study investigators have many initiatives evaluating factors that may affect the response to HAART, he explains.
To conduct the current analysis, the study authors matched hormonal contraceptive users with nonusers, according to age, race/ethnicity, pre-HAART CD4+ T-lymphocyte counts, and viral load. They focused on effects on the two main markers of HIV disease progression: CD4 cell count and viral load.
No association was found between hormonal contraceptive use and changes in CD4+ cell count or time to viral load suppression after initiation of HAART. There was also no relationship between those outcomes and the duration of hormonal contraception use before HAART initiation.2
Counsel on methods
While women undergoing HAART are concerned about the effectiveness of their HIV treatment, they also look to the efficacy of their chosen birth control method to protect against unplanned pregnancy. Clinicians should cover all possible side effects associated with the various hormonal methods and their HAART regimen, says Clark, co-author of A Woman’s Guide to Living with HIV Infection, a book aimed at helping women deal with the medical, emotional, and social issues surrounding HIV infection (Johns Hopkins Press; 2004).
HAART regimens may include combinations of nucleoside reverse transcriptase inhibitors such as zidovudine (AZT), lamivudine (3TC), and abacavir, all of which may slow the spread of HIV in the body and delay the start of opportunistic infections; non-nucleoside reverse transcriptase inhibitors such as nevirapine and efavirenz; and protease inhibitors such as indinavir, ritonavir, and lopinavir, which interrupt the virus from making copies of itself at a later step in its life cycle.3,4 The drug interactions between oral contraceptives and many drugs used in HIV disease make an additional means of contraception advisable in many cases.5
"We do know that protease inhibitors and non-nucleoside reverse transcriptase inhibitors may have significant pharmacokinetic interactions with oral contraceptive pills, which will result in affecting hormonal levels and potentially efficacy," states Clark. "Therefore, a second form of birth control is recommended to be used concurrently for most HAART regimens, as outlined in Department of Health and Human Services guidelines.6 (See the resources, below, for information on accessing the guidelines.)
According to information from the Department of Health and Human Services, oral contraceptives significantly interact with amprenavir/fosamprenavir, efavirenz, lopinavir, nelfinavir, nevirapine, and ritonavir (RTV).5 An additional method of contraception, such as condoms, is recommended.5
"I think it is important to continue counseling HIV-infected women in the use of contraception [e.g., barrier methods] that reduce the chance of transmitting the virus," observes Gange. "Needless to say, further research in microbicides and other compounds to reduce the chance of HIV transmission is critical."
References
1. Centers for Disease Control and Prevention, Divisions of HIV/AIDS Prevention. HIV/AIDS among Women. Fact sheet. Accessed at: www.cdc.gov/hiv/pubs/facts/women.htm.
2. Chu JH, Gange SJ, Anastos K, et al. Hormonal contraceptive use and the effectiveness of highly active antiretroviral therapy. Am J Epidemiol 2005; 161:881-890.
3. National Institute of Allergy and Infectious Diseases. HIV Infection and AIDS: An Overview. Fact sheet. March 2005. Accessed at: www.niaid.nih.gov/factsheets/hivinf.htm.
4. Family Health International. Safe and Effective Introduction of Antiretroviral (ARV) Drugs for HIV/AIDS. Fact sheet. Accessed at: www.fhi.org/en/HIVAIDS/pub/fact/introarv.htm.
5. Department of Health and Human Services. A Guide to Primary Care for People with HIV/AIDS. Bethesda, MD; 2004.
6. Panel on Clinical Practices for Treatment of HIV Infection. Guidelines For The Use Of Antiretroviral Agents In HIV-1-Infected Adults And Adolescents. Bethesda, MD: Department of Health and Human Services; April 2005.
Resource
- To get the latest guidelines on use of antiretroviral agents in HIV treatment, visit the National Institutes of Health web site, aidsinfo.nih.gov. Click on "Guidelines," "Adult and Adolescent Guidelines," then "Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents — April 07, 2005." The guidelines are available in Adobe PDF and Personal Digital Assistant (PDA) versions.
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