Choosing the Best Contraceptive for Adolescents with HIV

Adolescents underestimate their risk of contracting HIV, and 60% of infected patients are unaware of their status.

One in 7 sexually active couples report that neither they nor their partner have used any form of contraception. The American College of Obstetricians and Gynecologists advises providers to acknowledge that many adolescents are sexually active and need sexual and reproductive health counseling.

The journal Pediatrics published a study in its September 2016 issue that outlined the American Academy of Pediatrics’ reproductive health recommendations in adolescents.

Combined long-acting reversible contraceptives and barrier methods (eg, condoms) are optimal for HIV-infected adolescents on complex antiretroviral regimens. The long-acting reversible contraceptives need little regular user input, and barrier methods prevent the spread of sexually transmitted infections (STIs).

The progestin implant Nexplanon has a failure rate of 1%, lasts 3 years, and simulates near-perfect oral contraceptive adherence. Efavirenz may decrease the effectiveness of progestin-based contraception due to enzyme induction. The National Institutes of Health recommends adjunctive contraception in patients on hormonal contraception and nevirapine, efavirenz, or most other protease inhibitors.

Hormonal intrauterine devices (IUD) Liletta and Mirena have a 1% failure rate and last 3 and 5 years, respectively. The copper IUD Paragard contains no hormones, lasts 10 years, and does not affect the patient’s menstrual cycle. Active STI (except HIV) and pelvic infection contraindicate IUD placement. However, providers may treat new infections without IUD removal.

Depot medroxyprogesterone acetate (Depo-Provera) is injected every 13 weeks with a 0.2% risk of pregnancy annually with timely use. This medication is unaffected by enzymatic interactions with antiretrovirals.

Combined oral contraceptives have a 9% failure rate in the general population with a higher rate among HIV-infected adolescents due to poor adherence and enzymatic interactions. The guidelines do not highly recommend progestin-only pills because patients must be completely adherent to doses at specific times.

Vaginal ring and transdermal patch formulations have better efficacy than oral products because users apply these products less frequently than they self-administer oral products.

Male latex condoms are the most common contraceptive method used by adolescents. Natural membranes do not provide infection protection. HIV-infected individuals should never use spermicides because these products increase the risk of HIV transmission. Diaphragms and cervical caps are ineffective without spermicides, so HIV-infected patients should not use these products.

Providers should encourage open discussion about contraception with HIV-infected adolescents. They should also discuss HIV transmission prevention. Providers need to emphasize abstinence, delay of sexual initiation, proper condom use, and adherence to antiretroviral regimen.