Contraception for Women at High Risk for HIV: CDC's Updated Eligibility Guidance

This page describes an update CDC made to its 2016 contraception guidance after a 2019 evidence review. CDC's contraceptive guidance has been revised since; check current recommendations.

The U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) 2016 is CDC's evidence-based guide to which contraceptive methods are safe for women with particular characteristics or medical conditions. It is adapted from World Health Organization (WHO) guidance and kept current by continuous review of new research.

What changed

After weighing new evidence and WHO's 2019 update, CDC adopted WHO's revised guidance:

• Progestin-only injectables, including depot medroxyprogesterone acetate (DMPA), and intrauterine devices (IUDs, both levonorgestrel-releasing and copper) moved to category 1 — safe without restriction — for women at high risk for HIV. Both had been category 2 (advantages outweigh risks).
• For IUDs, CDC added a note: many women at high risk for HIV are also at risk for other sexually transmitted diseases (STDs), so providers should consult the U.S. MEC recommendations for women with other STD-related factors and the U.S. Selected Practice Recommendations on STD screening before insertion. (For those women, IUD use is category 2; if a woman hasn't been screened, screening can be done at insertion without delaying it.)
• Other hormonal methods — combined hormonal contraceptives, implants and progestin-only pills — stayed at category 1.
• CDC clarified that its recommendations on combining hormonal contraception or IUDs with antiretroviral treatment also apply to antiretrovirals taken to prevent HIV (preexposure prophylaxis, PrEP).

The recommendations assume no other conditions are present; providers should check the full U.S. MEC for other conditions.

Why it matters

Nearly half of U.S. pregnancies were unintended — 45% in 2011, and higher among women aged 15–19 (75%) and Black women (64%). About 80% of new HIV infections among U.S. women are attributed to heterosexual contact; an estimated 7,100 women were newly diagnosed with HIV in 2018, with higher rates among racial and ethnic minorities. HIV is linked to worse pregnancy outcomes, including illness during pregnancy and transmission to the baby, and pregnancy-related death risk is about three times higher for Black than for White women. Preventing both unintended pregnancy and HIV is therefore critical.

How CDC decided

• Two systematic reviews prepared for WHO's July 2019 consultation: one on hormonal contraception and HIV risk (36 studies, 17 meeting minimum quality criteria) and one on copper IUDs (7 studies, 3 meeting the criteria), covering studies published through June 2019.
• Biological evidence presented at the WHO consultation.
• U.S. data on unintended pregnancy, contraceptive use, maternal illness and death, and HIV.
• Expert input in September 2019 from eight outside reviewers and one CDC expert with backgrounds in HIV and family planning, who gave individual views rather than a consensus.

The evidence

• The main new evidence was the ECHO trial (Evidence for Contraceptive Options and HIV Outcomes), a large randomized trial in Eswatini, Kenya, South Africa and Zambia of about 7,800 women assigned to DMPA, levonorgestrel implants or copper IUDs. It found no statistically significant difference in HIV acquisition among the three, and was judged high quality for its size, randomization, follow-up and analysis — and because randomization avoided the confounding by sexual behavior that clouded earlier observational studies.
• Observational studies of progestin-only injectables were inconsistent and methodologically limited. Limited evidence on other methods did not suggest raised risk.
• Animal and laboratory data suggest possible mechanisms — changes in the vaginal lining and in immune responses — but their relevance to real outcomes in women is unclear.
• Studies of women using PrEP and hormonal contraception together found no drug interactions.

ECHO did not compare users with non-users, but it answered the practical question of whether risk differs between methods for women who want effective contraception.

Beyond hormonal methods and IUDs

• Condoms, used correctly and consistently, reduce the risk of pregnancy and of STDs, including HIV.
• Spermicides and diaphragms with spermicide are category 4 for women at high risk for HIV, because repeated, high-dose use of the spermicide nonoxynol-9 is linked to genital lesions that may raise HIV risk.

HIV prevention still essential

HIV infection was common in the ECHO trial — 3.81 per 100 woman-years — even though participants received comprehensive prevention services. CDC urged strong encouragement of prevention for all women at risk: PrEP and postexposure prophylaxis, fewer sexual partners, and correct and consistent condom use. At the time, daily oral PrEP combining tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) had been shown safe and effective for adults and adolescents weighing at least 77 lbs (35 kg), but PrEP was underused among women.

Family planning providers are well placed to offer HIV prevention. STD and HIV counseling and screening aren't required before starting contraception, but they are a core part of family planning care, and building PrEP into family planning services could substantially widen access.

Sources

• Tepper NK, Curtis KM, Cox S, Whiteman MK. "Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Updated Recommendations for the Use of Contraception Among Women at High Risk for HIV Infection." Morbidity and Mortality Weekly Report 69(14), Centers for Disease Control and Prevention.