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ART Selection in Women of Childbearing Age and During Pregnancy

Susan Cu-Uvin, MD
Program Director
Jean Rene Anderson, MD
Released: August 6, 2020

Contraception and ART

DHHS Recommendations on Contraception in Women With HIV

The DHHS perinatal guidelines recommend discussing reproductive desires with all women of childbearing age on an ongoing basis throughout the course of their care and providing information about effective and appropriate contraceptive methods to reduce the likelihood of unplanned or unintended pregnancy.[5] Although HIV infection does not preclude the use of any contraceptive method, there are drug–drug interactions between hormonal contraceptives and certain ARV agents that should be considered. If potential drug–drug interactions are identified, additional or alternative methods of contraception may be recommended.

Drug–Drug Interactions Between Hormonal Contraceptives and NNRTIs and NRTIs

There are no known or expected interactions between any hormonal contraceptive methods and NRTIs; therefore, no additional contraceptive protection is needed with concomitant administration of these drugs.[5]

Regarding NNRTIs, EFV is the only agent for which known interactions have been identified, as shown in red on the table. Indeed, both PK and clinical data suggest that contraceptive implants have decreased efficacy when used with EFV-based regimens.[6] There also appears to be lower etonogestrel levels for vaginally administered contraceptive rings.[1] Therefore, coadministration of EFV and these hormonal contraceptive agents should prompt consideration of an alternative or additional method of contraception, such as a reliable barrier method. It should be noted, however, that these recommendations are largely based on PK data and not on clinical outcomes, with the exception of implants where several studies have shown cases of contraception failure and higher pregnancy rates among women using implants in combination with EFV vs implants in combination with non–EFV-containing ART or no ART.[6-9]

The injectable progestin-only contraceptive, depot medroxyprogesterone acetate (DMPA), can be used without restriction with any ARV agent because of its relatively higher dose than other progesterone-based contraception. Indeed, limited studies have shown no significant interaction between DMPA and ARV drugs.[10-13]

Drug–Drug Interactions Between Hormonal Contraceptives and PIs

This figure illustrates drug–drug interactions between hormonal contraceptives and PIs.[5] Green indicates that no change in contraceptive method or ARV agent is needed. Red indicates that an alternative or additional contraceptive method should be considered, and yellow indicates a situation where an alternative method or a reliable barrier method can be considered, but the recommendation is less strong.

The only PK interaction noted between etonogestrel implants and PIs is with DRV plus RTV. In addition, cobicistat (COBI)-boosted ATV is contraindicated and COBI-boosted DRV should be avoided (or requires clinical monitoring) with oral contraceptive methods that contain the progestin drospirenone because of the potential risk of hyperkalemia.

Drug–Drug Interactions Between Hormonal Contraceptives and INSTIs

This figure shows that no additional contraceptive protection is needed upon coadministration of any of the INSTIs with hormonal contraceptives, given the current body of data.[5] Of note, however, there are very limited or, in some cases, no clinical data available for coadministration of these agents, and the recommendations are based almost entirely on PK data.

IUDs and ART

IUDs are highly effective contraceptive methods that are long acting and fully reversible. They are an excellent choice for many women for contraception today, and progestin-releasing IUDs, specifically levonorgestrel IUDs, are being used with increasing frequency in the United States. Efficacy of this method is largely through local or intrauterine hormonal release rather than through systemic absorption.

According to the CDC US Medical Eligibility Criteria for Contraceptive Use, which looks at a variety of medical conditions and different contraceptive methods, progestin-releasing IUDs are category 1 and can be used without restriction for women with HIV who are clinically well and on ART, including any antiretroviral drugs.[14] For women not clinically well or not receiving ART, continuation of the levonorgestrel IUD is also category 1 and initiating use of the levonorgestrel IUD is listed as category 2, which indicates that the benefits outweigh the risks.

Although used less frequently, no interactions have been identified between the copper IUD and any ARV agent. The copper IUD is a highly effective, but inert, IUD that is inserted into the uterus and is effective for 10 years.

DMPA and Efavirenz

A recent study examined the PKs and pharmacodynamics of injectable DMPA in women coinfected with HIV and tuberculosis who were receiving EFV-based ART and rifampin-based tuberculosis treatment.[15] Investigators found that 5 of 42 evaluable women, or almost 12%, had medroxyprogesterone acetate (MPA) levels below the level that has been determined to prevent ovulation at Week 12, and 1 of these 5 women had this low level by Week 10. Median MPA clearance was higher in women receiving EFV vs those with HIV who were not receiving ART. These results led the study authors to suggest dosing DMPA more frequently in women receiving EFV-based and rifampin-based regimens, such as every 8-10 weeks (vs the standard recommendation to dose every 12 weeks).

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