Page 134 - HIV/AIDS Guidelines

• Metabolic complications: A few studies have compared women to men in terms of metabolic
complications associated with ARV use. Compared with HIV-infected men, HIV-infected women are
more likely to experience increases in central fat with ART and are less likely to have triglyceride
elevations on treatment. 14-15 Women have an increased risk of osteopenia/osteoporosis, particularly after
menopause, and this risk is exacerbated by HIV and ART. 16-17 At the present time, none of these
differences requires women-specific recommendations regarding treatment or monitoring.

Women of Childbearing Potential
All women of childbearing potential should be offered preconception counseling and care as a component of
routine primary medical care. Counseling should include discussion of special considerations pertaining to
ARV use when trying to conceive and during pregnancy (see Perinatal Guidelines ). Sexual activity,
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reproductive desires and plans, HIV status of sexual partner(s), and use of effective contraception to prevent
unintended pregnancy should be discussed. An HIV-infected woman who wishes to conceive with an HIV-
uninfected male partner should be informed of options to prevent sexual transmission of HIV while
attempting conception. Interventions include initiation of maximally suppressive ART, which has been
shown to significantly decrease the risk of sexual transmission (see Preventing Secondary Transmission of
HIV), and artificial insemination including the option to self-inseminate with the partner’s sperm during the
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periovulatory period . More extensive discussion can been found in the Reproductive Options for HIV-
Concordant and Serodiscordant Couples section of the Perinatal Guidelines. As part of the evaluation for
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initiating ART, women should be counseled about the potential teratogenic risk of EFV-containing regimens
should pregnancy occur. EFV-containing regimens should be avoided in women who are trying to conceive
or who are or may engage in sexual activity that could result in pregnancy (AIII). The most vulnerable
period in fetal organogenesis is early in gestation, often before pregnancy is recognized.

Hormonal Contraception

Safe and effective reproductive health and family planning services to reduce unintended pregnancy and
perinatal transmission of HIV are an essential component of care for HIV-infected women of childbearing
age. Counseling about reproductive issues should be provided on an ongoing basis.

Providers should be aware of potential interactions between ARV drugs and hormonal contraceptives that
could lower contraceptive efficacy. Several protease inhibitors (PIs) and non-nucleoside reverse transcriptase
inhibitors (NNRTIs) have drug interactions with combined oral contraceptives (COCs). Interactions include
either a decrease or an increase in blood levels of ethinyl estradiol, norethindrone, or norgestimate (see
Tables 15a and b), which potentially decreases contraceptive efficacy or increases estrogen- or progestin-
related adverse effects (e.g., thromboembolism). In small studies of HIV-infected women receiving injectable
depot-medroxyprogesterone acetate (DMPA) while on ART, there were no significant interactions between
DMPA and efavirenz (EFV), NVP, nelfinavir (NFV), or NRTI drugs. 19-21 Contraceptive failure of the
etonogestrel implant in two patients on EFV-based therapy has been reported and a study has shown EFV
may decrease plasma progestin concentrations of COCs containing ethinyl estradiol and norgestimate. 22-23
Several RTV-boosted PIs decrease oral contraceptive estradiol levels. 24-25 A small study from Malawi showed
that NVP use did not significantly affect estradiol or progestin levels in HIV-infected women. Overall, data
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are relatively limited and the clinical implications of these findings are unclear. The magnitudes of change in
drug levels that may reduce contraceptive efficacy or increase adverse effects are unknown. Concerns about
pharmacokinetic interactions between hormonal contraceptives and ARVs should not prevent clinicians from
prescribing hormonal contraceptives for women on ART. However, when women wish to use hormonal
contraceptives and drug interactions with ARVs are known, additional or alternative contraceptive methods
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may be recommended (see drug interaction Tables 15a, 15b, and 15d and Perinatal Guidelines ). Consistent
use of male or female condoms to prevent transmission of HIV and protect against other sexually transmitted

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-18

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