HIV-positive women have reproductive patterns similar to those of HIV-negative women and would benefit from counselling about reversible methods of contraception.  AIDS/WHO estimates that 42 million people are living with HIV/AIDS   worldwide   and   50%  of   all   adults   with   HIV   infection   are women, predominantly   infected   via   heterosexual   transmission ⁽¹⁾.

Particularly, HIV/AIDS disproportionately affects young women of color ⁽²⁾. Recent, Highly Active Antiretroviral Therapy (HAART), with or without protease inhibitor (PI), has greatly improved the outlook for HIV-infected women, even those with an AIDS diagnosis ⁽³⁾.

Consequently, the dramatic reduction in HIV-related morbility and mortality had led to a growing number of HIV-infected individuals and their partners   requiring   education   and   counseling   regarding   HIV-disease   and reproduction ⁽⁴⁾. 

Assessment of options for birth control,  and pre-conception counseling should be integral components of gynecologic health care for these women ⁽⁵⁾. The use of hormonal contraception by HIV-1-infected women seems to be associated with an increased risk of cervicitis and cervical chlamydia infection. 

HIV-1-seropositive women using hormonal contraception should be counseled about the importance of consistent condom use to prevent both sexually transmitted diseases (STI) and HIV-1 transmission ⁽⁶⁾. HIV infected womens need to be prepared to integrate contraception and gynecological care.

In fact, underuse of highly effective contraception and barrier methods leaves women with HIV-infection at risk for unintended pregnancy and disease transmission ⁽³⁾. Was reported that among HIV-seropositive women,barrier use is more likely among women who had been pregnant(OR 1.37) and among those with higher CD4 lymphocyte counts (OR 1.10,  p =  0.0006),  whereas hormone use was linked to higher CD4 counts   (OR 1.12,  p=.01)⁽⁶⁾.

It is evident that in areas at high prevalence for HIV-infection, selection of longer-acting injectable contraception could   be   associated   with   lower   rates   of   pregnancy   among   HIV-positive women.  ⁽⁷⁾

It   seems   that   women   using   the   injectable   contraceptive   depot medroxyprogesterone acetate might be at increased risk of Chlamydia trachomatis infection (hazard ratio (HR)  3.1,  P =  0.05)  and cervicitis (HR 1.6,  P =  0.03) compared with women using no contraception. While, the use of oral contraceptive pills could be associated with an increased risk of cervicitis (HR 2.3, P = 0.001).

Hormonal contraception seems not associated with an increased risk of infection with   Neisseria   gonorrhoeae ⁽³⁾. HIV-1-seropositive   women   using   hormonal contraception should be counseled about the importance of consistent condom use to prevent both STI and HIV-1 transmission. 

In multivariate analysis,  use of hormonal, either estrogen/progesterone oral combination or medroxyprogesterone acetate intramuscular contraceptives,  high cervical mucous concentrations of interleukin (IL)-12,  a positive HPV test,  and persistent low-grade squamous intraepithelial lesion (LSIL) were significantly associated with the development of HSIL.  The role of hormonal contraception as a risk factor deserves further investigation. (Infectious Diseases Society of America) ⁽⁸⁾.

However,  in the past was believed a trend between use of high–dose oral contraceptive pills and HIV-acquisition ^{(HR   2.6)}, today   no   association   was   found   between   hormonal contraceptive use and HIV acquisition, overall. Furthermore,  users who are HIV-seronegative but Herpes-simplex-virus type 2 (HSV- 2) seropositive seem to have an higherrisk ^(9,10,11).  How to promote dual protection (combined hormonal contraceptive plus condom) and how to make them acceptable in long-term relationship remains a challenge. Therefore, support for the birth control in women living with HIV is a priority ⁽¹²⁾.

—
Rosa Sabatini
General Hospital Policlinico, University of Bari, Italy
—

REFERENCES

1. Mitchell,  H.S.,  Stephens,  E.  (2004).Contraception choice for HIV positive women. Sex. Transm. Infect, 80(3), 167-73. 
2. Rove,  C., Perlmutter   Silverman,  P.,  Krauss, B.(2007).  A   brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents:a randomized clinical trial.  Health Educ.Behav, 34(4), 608-21. 
3. Massad, L.S., Evans, C.T., Wilson, T.E., Golub, E.T., Sanchez-Keeland, L., Minkoff, H., Weber, K., Watts, D.H. (2007). Contraceptive use among U.S. women with HIV. J.Women Health(Larchmt), Jun,16(5), 657-66.
4. Barreiro,  P.,  Duerr,  A.,  Beckerman,  K.,  Soriano,  V.  (2006).  Reproductive options for HIV-serodiscordant couple. AIDS Rev,8(3),158-70. 
5. Aaron,  E.,  Levine,  A.B.  (2005). Gynecologic care and family planning for HIV-infected women. AIDS Read, 15(8), 420-3,426-8. 
6. Lavreys,  L., Chohan,  V.,  Overbaugh,  J.,  Hassan,  W.,  McClelland,  R.S., Kreiss, J., Mandaliya, K., Ndinya-Achola, J., Baeten, J.M. (2004). Hormonal contraception and risk of cervical infections among HIV-1-seropositive Kenyan women. AIDS, Nov 5, 18(16), 2179-84.
7. Mark,  K.E.,  Meinzen–Derr,  J.,  Stephenson,  R.,  Haworth,  A.,  Ahmed,  Y., Duncan,  D., Westfall,  A.,  Allen,  S.  (2007). Contraception   among   HIV concordant and discordant couples in Zambia:a randomized controlled trial. J. Womens Health(Larchmt), 16(8),1200-10. 
8. Moscicki AB, Ellenberg JH, Crowley-Nowick P, Darragh TM, Zu J, Fahrat S. (2004). Risk of high-grade squamous intraepithelial lesion in HIV-infected adolescents. J.Infect.Dis, 190(8), 1413-21.
9. Martin, H.L. Jr., Nyange, P.M., Richardson, B.A., Lavreys, L., Mandaliya, K.,  Jackson,  D.J.,  Ndinya-Achola,  J.O.,  Kreiss,  J.  (1998).  Hormonal contraception,sexually   transmitted   diseases,and   risk   of   heterosexual transmission of human immunideficiency virus type 1. J.Infect.Dis, 178(4), 1053-9.
10. Morrison, C.S., Richardson, B.A., Mmiro, F., Chipato, T., Celentano, D.D., Luoto, J., Mugerwa, R., Padian, N., Rugpao, S., Brown, J.M., Cornelisse, P., Salata,  R.A.  (2007).  Hormonal   Contraception   and   the   Risk   of   HIV Acquisition(HC-HIV)Study Group. Hormonal contraception and the risk of HIV acquisition. AIDS, 21(1), 85-95.
11. Macqueen,  K.M.,  Johnson,  L.,  Alleman,  P.,  Akumatey,  B.,  Lawoyin,  T., Nyiama,  T.  (2007).  Pregnancy prevention practices among women with multiple partners in an HIV prevention trial. J.Acquir.Immune Defic. Syndr, 46(1), 32-8.
12. Delvaux, T., Noslinger, C. (2007). Reproductive choice for women and men living   with   HIV:  contraception,  abortion   and   fertility. Reprod. Health Matters, 15(29 Suppl.), 46-66.