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Contraceptives
& HIV-Infected Women

Summer 1998

HIV-infected women, like all women, are more likely to succeed with a contraceptive they have chosen for themselves and feel comfortable using. Prevention of HIV, the transmission of STDs and prevention of pregnancy are important issues to consider when choosing the type of contraception for you. Regardless of the method chosen, latex condoms will decrease the potential risk of exposure to HIV and other STD's.


Condoms

Condom use is the most effective method for preventing transmission of sexually transmitted disease, including HIV infection. The condom should be applied tightly and should extend approximately " beyond the tip of the penis to collect the ejaculate. Latex and synthetic condoms are the most effective and show a decreased risk of HIV transmission when used in any type of insertive-receptive sexual intercourse.

The timing of when to put on a male condom is an important issue. Some men will leak seminal fluid from a fully erect penis. This fluid can contain HIV and other pathogens. When a condom is used to prevent infection of HIV or other STDs, it must be rolled on to the penis before it comes in contact with the mouth, rectum or vagina.

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Use of condoms has been shown to reduce HIV transmission in several studies. A study of 256 sexually active serodiscordant heterosexual couples who were followed for a median of 22 months found no seroconversions among the 123 couples who always used condoms and 12 seroconversions in the 122 couples who used condoms intermittently. Other factors that may have played a role in this study were stage of disease, viral load, T-cells and whether genital infections were present at the time of seroconversion. Condoms clearly decrease the risk of STDs and HIV-infection and should be considered important to utilize in all sexual encounters, whether or not an additional measure will be used. There are several problems that can occur when condoms are used.

Condoms can break, slip off or leak. The timing of the breakage and the location can help to determine the risk of both pregnancy and infection transmission. A rupture of the condom at or near the base of the penis is less likely to be associated with risk of pregnancy or infection. The number of broken condoms can be reduced by proper application and the use of a sufficient amount of a water-based lubricate to minimize friction during sexual intercourse. The use of an oil based lubricant may decrease the integrity of the latex, allowing the condom to break during use. Oil based lubricates are not recommended. These products include but are not limited to baby oil, burn ointments, coconut oil/butter, fish oils, olive oils, margarine, mineral oil, petroleum jelly, vaginal creams or rubbing alcohol. Safe lubricates to use include contraceptive foams, egg whites, glycerin, K-Y Jelly, saliva, and water. Sheep intestine, also known as lamb skin, natural condoms are not recommended because the pores of the condoms can still allow infection with HIV, HSV and hepatitis B virus.


Female Condom

The female condom provides a physical barrier that lines the inside of the vaginal vault and provides some protection to the outer labia and perineum. The Reality Female condom is a thin polyurethane sheath that is approximately 7.8 cm in diameter and 17cm long. The loosely fitting sheath contains two flexible polyurethane rings. One ring is located at the closed end of the sheath which is inserted into the vagina and serves as an internal anchor. The other ring forms the external opening into the vagina and remains outside the vagina after insertion. The female condom provides a lubrication located on the inside of the condom. The Reality female condom is approved for over the counter sale (without a prescription). The polyurethane sheath is soft and is stronger than latex. It is also an acceptable alternative for those individuals who are allergic to latex. According to the product label, it can be worn for up to 8 hours before sexual intercourse. There is limited data on the female condom and the risk of HIV infection.


Spermicides

Vaginal foams, creams, jellies, and suppositories: All spermicides contain an ingredient (usually nonoxynol 9) that disables or kills sperm on contact. The spermicide must be inserted before each sexual encounter.

Ulcerations or cervicitis can create an increased risk factor for HIV transmission. One advantage of spermicides is that they prevent transmission of sexually transmitted diseases that cause genital ulcers and cervicitis such as gonorrhea, trachomatous, vaginalitis, Treponema pallidum, genital mycoplasmas, HSV, and HIV. A possible disadvantage is that in some people the spermicide may cause genital tract irritation, increasing the risk of transmission. There is evidence that spermicides may alter the normal bacterial flora in the vagina; the impact of this on transmission of HIV is unknown. Ongoing studies are evaluating new preparations of nonoxynol-9 gel for prevention of HIV transmission.


Oral Contraceptives

Since the approval of "the pill" in 1960, it has become one of the most extensively studied medications. Oral contraceptives (OC) are one of the most safe and effective methods of birth control. The OCs prevent pregnancy primarily by suppressing ovulation through the combined action of estrogen and progestin.

Steroid hormones have many effects on the female reproductive tract. Estrogen increases vaginal epithelial thickness. The extra cells ultimately cause a decease in the vaginal pH, thus changing the vaginal flora.

The new protease inhibitor drugs are extensively metabolized by the liver and can decrease the efficacy of OCs. Condoms are always recommended as a backup method. Little data is available about different OCs and their concurrent use with protease inhibitors. Preliminary data indicates that Nelfinavir, a recently approved protease inhibitor, reduced the levels of oral contraceptives such as Ortho Ovcon 1/35 and Estradiol by 47% and that an alternative method of birth control should be used. Administration of indinavir (800mg every 8 hours) with ORTHO-NOVUM 1/35 for one week resulted in a 24% + 17% increase in ethynyl estradiol AUC and a 26% + 14% increase in norethindrone AUC (Indinavir, 1996). It is generally considered safe to use Ortho-Novum 1/35 with Indinavir.

Other contraindications to the use of oral contraceptive include a past history of any vascular disease, including a past or present history of thromboembolism, thrombophlebitis, atherosclerosis, stroke, and systemic vascular disease. In addition, caution should be used in hypertension, diabetes mellitus with vascular disease, and any woman who is over 35 years of age and is a smoker.


Progestin-only Contraceptives

Great controversies surround Depo-Provera and other injectables or implants and their use in HIV infection. Progestins have the potential to change immune function.

Women who receive injections of Depo-Provera may suffer from unpredictable break through bleeding that may be frequent or of long duration. Whether or not Depo-Provera alters the normal vaginal flora is unclear at this time. One study indicated that implants do not significantly alter vaginal microflora compared to pills.

Another study showed that young women between the ages of 15-45 years who used progestin as their only contraceptive had a significant increase in STDs. Progestins cause an increase in thickening of cervical mucus, this may be a protective barrier against ascending cervical or vaginal infection. Depo-Provera as with other OCs can be an effective barrier to pregnancy but may reduce the likelihood that women will use other methods to protect against STDs or HIV infection.

Depo-Provera is administered every 3 months and has the added benefit of privacy. If a woman's partner wants children, depo-provera gives the woman a choice to put off pregnancy until she chooses. The use of depo-provera does not require cooperation from the sexual partner. This is especially important for a partner who refuses to use condoms.


Women to Women Risks

Very little data exists about women who have sex with women and the risk of HIV transmission. It is important that a good sexual history is taken and common sexual practices must be investigated in order to provide appropriate interventions to reduce the risk of HIV transmission. Using a latex barrier, commonly referred to as a "dental dam" while in contact with any type of vaginal secretion will help to ensure a reduction in risk of HIV infection.

Providing education about sex toys is equally important. Any patient who uses sex toys must be educated about cleaning toys with a 1:10 dilution of bleach and water after use and never sharing sex toys.


Conclusion

Information on heterosexual and homosexual practices (anal, vaginal, and oral intercourse) and partner networks (who does what with whom and when) yields knowledge about the transmission about STDs, including HIV infection. Understand the psycho-social reasons for sexual behaviors is necessary for designing effective interventions for reducing risk taking with respect to pregnancy and infections.

There are several options available for women who seek a secondary method for birth control. These methods alone are not enough for the prevention of transmission of sexually transmitted disease including HIV. If these methods are used in conjunction with condoms, they guarantee pregnancy prevention (see table 1).

A male or female latex or polyurethane condom should be used each time sexual intercourse is engaged in.

If a condom is not available, the next best option is to use a spermicidal agent.


Method
Almost Every Time in First Year
Every Single Time in the First Year
Risk of STDs and HIV infection
Chance
85
85
Yes
Spermicides
21
6
Possible
Withdrawal
19
4
Yes
Diaphragm
18
6
Yes
Condoms:
Female (Reality)
Male

21
12

5
3

Probably Not
Probably Not
Pill:
Progestin Only
Combined
 
0.5
0.1
Yes
Depo-Provera
0.3
0.3
Yes
Norplant (6 capsules)
0.09
0.09
Yes
Female Sterilization
0.4
0.4
Yes
Male Sterilization
0.15
0.15
Unclear
IUD:
Progesterone T
Copper T
380A LNg20

2.0
0.8
0.1

1.5
0.6
0.1
Yes, may be increased

Table I, above: example -- If you use a diaphragm almost every time, you have an 18% chance of getting HIV or some other STD. If you use a diaphragm every single time you have sex, you have a six percent chance of getting HIV or some other STD.


Back to the Women Alive Summer 1998 Contents Page.


  
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This article was provided by Women Alive. It is a part of the publication Women Alive Newsletter.
 
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