Contraceptive Options for
Women and Couples with HIV
Injectable Contraceptives
Types of Injectable Contraceptives
Progestin-only Combined
Hormones progestin progestin +
estrogen
Duration of 3 months, 1 month
effect 2 months
Type DMPA, Cyclofem,
NET-EN 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 • Can be provided
• Highly effective outside of clinics
• Easy to use • Requires no action at
time of intercourse
• Long acting
• Use can be private
• Reversible
• Has no effect on
• Can be discontinued lactation
without provider’s
help • Has non-
contraceptive 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
• Women with HIV or AIDS
WHO Eligibility Criteria
can use without restrictions
Condition Category • Nevirapine reduces blood
HIV- progestin level by ~20%
infected
1
• DMPA dose provides wide
AIDS 1 margin of effectiveness
• On-time injections
ARV
therapy
1 emphasized
• 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