Contraceptive Options for Women and Couples with HIV Implants, POPs and Emergency Contraception

1. Contraceptive Options for Women and Couples with HIVImplants, POPs and Emergency Contraception

2. Subdermal Implants • Progestin-filled rods or capsules that are inserted under the skin • Norplant: 6-capsule system, effective for 5 years • Second generation implants • Jadelle and Sinoplant: 2-rod system, effective for 5 years • Implanon: 1-rod system,effective for 3 years • Mechanism of action similar to injectables

3. Implants – Characteristics Disadvantages • Have common side effects • Cannot be initiated/ discontinued without provider’s help • Provide no protection from STIs/HIV Advantages • Safe, 99.95% effective, easy to use, reversible • Can be used by breastfeeding women • Offer health benefits, such as reducing risk of symptomatic PID and anemia Source: Hatcher, 2007; WHO, 2004, updated 2008; CCP and WHO, 2007.

4. Implants – Side Effects • First several months:light bleeding/spotting, prolonged irregular bleeding, infrequent bleeding, amenorrhea • After one year:light bleeding for fewer days, irregular bleeding, infrequent bleeding, amenorrhea • Other side effects: nausea, headaches, breast tenderness, weight change, abdominal pain • less common than with progestin-only injectables • diminish after the first few months Source: Shoupe, 1991; CCP and WHO, 2007.

5. Category 1 and 2 Examples (not inclusive):Who Can Use Implants WHO Category Conditions Category 1 breastfeeding after 6 weeks postpartum, heavy smokers, complicated valvular heart disease, endometriosis, endometrial or ovarian cancer, thyroid disorders Category 2 blood pressure ≥160/100, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD Source: WHO, 2004; updated 2008.

6. Category 3 and 4Who Should Not Use Implants WHO Category Conditions Category 3 breastfeeding before 6 weeks postpartum, acute DVT/PE, unexplained vaginal bleeding, history of breast cancer, severe liver disease and most liver tumors, systemic lupus disease continuation only: ischemic heart disease, stroke, migraine with aura Category 4 current breast cancer Source: WHO, 2004; updated 2008.

7. Women with HIV or AIDS can use without restrictions Some ARV drugs reduce blood progestin level Efficacy is not affected because implants provide consistent dose of hormone over time Dual method use should be encouraged Implant Use by Women with HIV Source: WHO, 2004, updated 2008; Mildvan, 2002.

8. Progestin-Only Pills (POPs) • Contain no estrogen • Less progestin than COCs • All pills in pack are active • Progestin amount same throughout • 28-35 pills per pack • Eligibility criteria is similar to those of implants POPs are especially suitable for breastfeeding women and others who should not use estrogen. Source: WHO, 2004; updated 2008.

9. Progestin-Only Pills (POPs) continued … • Mechanism of action: • partial suppression of ovulation (more pronounced in breastfeeding women) • thickening of cervical mucus • Have no known adverse effects • Side effects are similar to those of implants • irregular or prolonged bleeding is not common in breastfeeding women • Require stricter pill-taking schedule than COCs • 1 pill each day within 3 hours of same time • no breaks between packs * within 12 hours for POPs containing desogestrel 75μg Source: CCP and WHO, 2008 update.

10. POPs – Missed Pills • Take most recent missed pill as soon as possible • Abstain or use backup method for 48 hours • Take next pill at regular time • Consider use of emergency contraception if appropriate • No backup method or emergency contraception needed if pills are missed by a woman who is still protected by LAM Source: CCP and WHO, 2008 update.

11. POP Use by Women with HIV • Women with HIV or AIDS can use without restrictions • Women on ARVs other than ritonavir can use POPs safely • Should not be used by women who take ritonavir • Dual method use should be encouraged • Breastfeeding status provides additional protection from pregnancy Source: WHO, 2004, updated 2008; Sekar, 2008.

12. Use to prevent pregnancy after unprotected intercourse progestin-only and combined estrogen-progestin regimens start as soon as possible; counsel to adopt regular method Use if regular method was used incorrectly, failed, or was not used Safe for all women(including women with HIV/AIDS and taking ARV drugs) ECP Use by Women with HIV There is no evidence to justify changes to emergency contraceptive pill regimens for ARV clients. Source: Hatcher, 2007; WHO, 2004, updated 2008.

13. ECP Pill Regimens:Progestin-Only Oral Contraceptives Start within 120 hours (5 days) after unprotected intercourse pills formulated as emergency contraception regular progestin-only pills More effective than COC regimen; most effective when used early. 1.5 mg levonorgestrel or 3 mg norgestrel; take all at once or in two doses 12 hours apart Source: CCP and WHO, 2007; WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; Piaggio, 1999; von Hertzen, 2002.

14. low-dose pills* repeat dose high-dose pills repeat dose 12 hours 12 hours ECP Pill Regimens:Combined Oral Contraceptives Start within 120 hours (5 days) after unprotected intercourse Each dose should contain at least: 0.1 mg ethinyl estradiol and 0.5 mg levonorgestrel Known as Yuzpe regimen *or 5 pills for each dose, if each pill contains 0.02 mg of ethinyl estradiol Most effective when used early. Source: WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; CCP and WHO, 2007.

15. ECPs – Key Counseling Messages • Use and effectiveness • More effective the sooner they are begun • Side effects (nausea and vomiting) may occur; less common with progestin-only regimen • Next menses may come a week early or late • Do not provide pregnancy protection for future intercourse or protection from STIs/HIV • After using, regular method should be considered