Contraceptive Options for Women and Couples with HIV Injectable Contraceptives Types of Injectable Contraceptives Progestin-only Combined Hormones progestin progestin + estrogen Duration of effect 3 months, 2 months 1 month Type DMPA, NET-EN Cyclofem, Mesigyna Effectiveness Spermicides Female condom Standard Days Method Male condom Oral contraceptives DMPA IUD (TCu-380A) Rate during perfect use Female sterilization Rate during typical use Implants 0 5 10 15 20 25 30 Percentage of women pregnant in first year of use Source: CCP and WHO, 2007. DMPA – Mechanism of Action Suppresses hormones responsible for ovulation Thickens cervical mucus to block sperm DMPA – Most Widely Used Injectable • Best known as Depo-Provera • Used by more than 14 million women worldwide • Administered by deep intramuscular injection • 150 mg every 3 months • Injection site: upper arm or buttocks Characteristics of DMPA: Advantages • Safe • Highly effective • Easy to use • Long acting • Reversible • Can be discontinued without provider’s help • Can be provided outside of clinics • Requires no action at time of intercourse • Use can be private • Has no effect on lactation • Has noncontraceptive health benefits Characteristics DMPA: Non-contraceptive Health Benefits DMPA use may reduce: • Risk of endometrial cancer • Risk of ectopic pregnancy • Risk of symptomatic pelvic inflammatory disease • Uterine fibroids • Frequency and severity of sickle cell crises • Symptoms of endometriosis Source: CCP and WHO, 2007. Characteristics DMPA: Disadvantages • Causes side effects, particularly menstrual changes • Action cannot be stopped immediately • Causes delay in return to fertility • Provides no protection against STIs/HIV DMPA – Common Side Effects • Menstrual changes – prolonged or heavy bleeding – irregular bleeding or spotting – amenorrhea (absence of menses) • Weight gain • Headaches, dizziness, changes in mood and sex drive One third of users discontinue during the first year because of side effects. Source: WHO, 1983. DMPA – Return to Fertility • Does not permanently reduce fertility • Length of time DMPA was used makes no difference • Return to fertility depends on how fast woman fully metabolizes DMPA – on average, it takes 9 to 10 months for women to become pregnant after their last injection Source: Pardthaisong, 1984; Schwallie, 1974. Infant Exposure to DMPA through Breastfeeding • DMPA has no effect on: – onset or duration of lactation – quantity or quality of breast milk – health and development of infant • When to initiate: – after child is 6 weeks old (preferred) Source: Koetsawang, 1987; WHO Task Force for Epidemiological Research on Reproductive Health, 1994; WHO, 2004; updated 2008. Effect of DMPA on Bone Density • DMPA users have lower bone density than non-users • Women initiating use as adults regain most lost bone • Long-term effect in adolescents unknown – concern that osteoporosis may develop later – long-term studies are needed – generally acceptable to use Source: Cromer, 1996; Cundy, 1994; WHO, 2004; updated 2008. Category 1 and 2 Examples (not inclusive): Who Can Use DMPA WHO Category Conditions Category 1 heavy smokers, breastfeeding after six weeks postpartum, thyroid disorders, severe dysmenorrhea, uterine fibroids, STIs/PID, use of rifampicin or rifabutin, anticonvulsants, or any type of ARV drug Category 2 ≤18 years, adequately controlled hypertension, uncomplicated diabetes, gall-bladder disease Source: WHO, 2004; updated 2008. Category 3 and 4 Examples (not inclusive): Who Should Not Use DMPA WHO Category Conditions Category 3 breastfeeding before 6 weeks postpartum, severe hypertension (≥160/≥100), vascular disease, acute DVT/PE, current or history of ischemic heart disease or stroke, complicated diabetes, severe liver disease and most liver tumors Category 4 current breast cancer Source: WHO, 2004; updated 2008. DMPA Use by Women with HIV WHO Eligibility Criteria Condition Category • Women with HIV or AIDS can use without restrictions • Nevirapine reduces blood progestin level by ~20% HIVinfected 1 AIDS 1 • DMPA dose provides wide margin of effectiveness 1 • On-time injections emphasized ARV therapy • Dual method use should be encouraged Source: WHO, 2004, updated 2008; Mildvan, 2002; Said, 1986. How to Take DMPA: When to Initiate • Anytime during menstrual cycle if provider is reasonably sure woman is not pregnant – backup recommended if given after day 7 • Postpartum: – not breastfeeding: immediately – breastfeeding: delay 6 weeks • Postabortion: immediately Source: WHO, 2004; updated 2008. How to Take DMPA: Injection Schedule • Injection every 3 months or 13 weeks • Can be up to 2 weeks early or 4 weeks late Source: WHO, 2004; updated 2008. Management of DMPA Side Effects: Counseling about Bleeding Counseling is the most important tool for managing bleeding irregularities. • Before first injection, counsel that bleeding changes are normal and expected • Provide ongoing counseling and reassurance • If client is concerned or bleeding is severe, treatment or discontinuation may be necessary Management of DMPA Side Effects: Treatment of Bleeding • Treatment options – ibuprofen (800 mg three times/day for 5 days) – combined oral contraceptives (COCs) for 21 days – with very heavy bleeding, rule out pregnancy or gynecological problems (uterine evacuation not indicated) Iron supplements can help prevent anemia. Source: CCP and WHO, 2007; WHO, 2004; updated 2008. Management of DMPA Side Effects: Amenorrhea • Medical treatment not required • If no reason to suspect pregnancy, counsel and reassure that amenorrhea is normal • Pregnancy may need to be ruled out in some cases Sterile Injection Procedures • Wash hands • Clean injection site • Use sterile needle and syringe • Dispose of waste correctly • Needles and syringes: – single-use must be disposed of safely – reusable must be sterilized Counseling about DMPA Factors for clients to consider: • Other available contraceptive options • Characteristics (advantages and disadvantages) • Side effects, including menstrual changes • Timing of return to fertility • Need for regular, timely injections Counseling about DMPA continued ... Messages after choosing DMPA: • Do not massage injection site • Expect bleeding 12–15 days after injection • Return with problems or concerns • No protection from STIs/HIV Counseling Reduces DMPA Discontinuation • Menstrual changes most common reason for discontinuation • Women receiving appropriate counseling more likely to continue using injectables Source: Lei, 1996. DMPA – Summary • Safe, effective, easy to use • Nonclinical provision possible • Appropriate counseling essential