Revised WHO Guidance on Injectable Contraceptives Due to Potential HIV Risk

Over two days this past December, the World Health Organization (WHO) gathered together physicians, researchers, epidemiologists, experts in HIV and family planning, and other decision makers from around the world to discuss new evidence of a potential risk of HIV infection in women who use hormonal contraception. This group, referred to as the Guideline Development Group (GDG), decided to alter its recommendation of the use of progestogen-only injectables so that women considering this type of birth control will be aware of the possible increased risk of contracting HIV.

The group looked at 13 observational studies that included injectable contraceptives and discovered that there was some association between the use of progestogen-only injectables, such as Depo-Provera, and the risk of contracting HIV. There was no way, however, to determine whether this association was causal or whether the study had inherent limitations that led to this finding. According to a guidance statement issued by the GDG, “Women using particular hormonal contraceptive methods may also have other behavioral characteristics that could have impact on HIV acquisition risk, such as particular patterns of condom use or non-use, multiple sexual partners, or increased coital frequency.”

Originally, the WHO had classified progestogen-only injectables as “category 1,” or safe for everyone with no limitations. The contraceptive is now a “category 2” recommendation, which means that the benefits of using it still outweigh any potential risk of HIV acquisition. The GDG emphasized that women worldwide should still be able to get this contraceptive despite the potential risk, and that healthcare providers should make sure to advise women about this risk, alert them to the fact that it’s unknown whether there’s a causal link between the contraceptive and HIV transmission, and make sure they know how to best protect themselves from HIV.

The injectable progestogen-only contraceptive is, of course, just one of many possible ways to prevent pregnancy. Howevere, according to WHO, injectable contraceptives play an outsize role in regions where HIV proliferates and women have high rates of dying in childbirth, such as sub-Saharan Africa. In these regions, alternative birth control methods often are scarce or shunned, and the GDG felt that having the option of an injectable contraceptive versus potentially no contraceptive at all was worth any possible risk of contracting HIV. According to the global partnership FamilyPlanning2020, which supports and enables reproductive rights for girls and women worldwide, in 27 out of 69 developing countries—including many African nations—injectable contraceptives are the most common birth control used. In Ethiopia alone, 76% of women using a modern method of birth control rely on injectables.

The GDG asserts in its guidance statement that the needs of women at high risk of contracting HIV who want to prevent pregnancy were kept at the forefront of the discussions in December. “At the core of the group’s decision-making was the human rights principle of promoting informed and free decision-making, and the value of contraceptive choice,” the members write. To that end, the members have developed a dissemination and evaluation plan to ensure that the updated guidelines are implemented into national policies and programs in all areas that the WHO covers. The WHO intends to continue monitoring studies that focus on contraceptives and HIV, and will review its recommendations again four years from now.

Laurie Saloman, MS, is a health writer with more than 20 years of experience working for both consumer and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.