1. Contraceptive Options for Women and Couples with HIV Implants, POPs and Emergency Contraception

2. Subdermal Implants Progestin-filled rods or capsules that are inserted under the skin Norplant: 6-capsule system, effective for 5 years Second generation implants –Jadelle and Sinoplant: 2-rod system, effective for 5 years –Implanon: 1-rod system, effective for 3 years Mechanism of action similar to injectables

3. Implants – Characteristics Disadvantages Have common side effects Cannot be initiated/ discontinued without provider’s help Provide no protection from STIs/HIV Source: Hatcher, 2007; WHO, 2004, updated 2008; CCP and WHO, 2007. Advantages Safe, 99.95% effective, easy to use, reversible Can be used by breastfeeding women Offer health benefits, such as reducing risk of symptomatic PID and anemia

4. Implants – Side Effects First several months: light bleeding/spotting, prolonged irregular bleeding, infrequent bleeding, amenorrhea After one year: light bleeding for fewer days, irregular bleeding, infrequent bleeding, amenorrhea Other side effects: nausea, headaches, breast tenderness, weight change, abdominal pain –less common than with progestin-only injectables –diminish after the first few months Source: Shoupe, 1991; CCP and WHO, 2007.

5. Category 1 and 2 Examples (not inclusive): Who Can Use Implants blood pressure ≥160/100, history of DVT/PE, diabetes with vascular complications, heavy or prolonged vaginal bleeding patterns, multiple risk factors for CVD Category 2 breastfeeding after 6 weeks postpartum, heavy smokers, complicated valvular heart disease, endometriosis, endometrial or ovarian cancer, thyroid disorders Category 1 Conditions WHO Category Source: WHO, 2004; updated 2008.

6. Category 3 and 4 Who Should Not Use Implants current breast cancer Category 4 breastfeeding before 6 weeks postpartum, acute DVT/PE, unexplained vaginal bleeding, history of breast cancer, severe liver disease and most liver tumors, systemic lupus disease continuation only: ischemic heart disease, stroke, migraine with aura Category 3 Conditions WHO Category Source: WHO, 2004; updated 2008.

7. Implant Use by Women with HIV Women with HIV or AIDS can use without restrictions Some ARV drugs reduce blood progestin level Efficacy is not affected because implants provide consistent dose of hormone over time Dual method use should be encouraged WHO Eligibility Criteria ConditionCategory HIV- infected 1 AIDS 1 ARV therapy 2 Source: WHO, 2004, updated 2008; Mildvan, 2002.

8. Progestin-Only Pills (POPs) Contain no estrogen Less progestin than COCs All pills in pack are active Progestin amount same throughout 28-35 pills per pack Eligibility criteria is similar to those of implants POPs are especially suitable for breastfeeding women and others who should not use estrogen. Source: WHO, 2004; updated 2008.

9. Progestin-Only Pills (POPs) continued … Mechanism of action : –partial suppression of ovulation (more pronounced in breastfeeding women) –thickening of cervical mucus Have no known adverse effects Side effects are similar to those of implants –irregular or prolonged bleeding is not common in breastfeeding women Require stricter pill-taking schedule than COCs –1 pill each day within 3 hours of same time –no breaks between packs Source: CCP and WHO, 2008 update. * within 12 hours for POPs containing desogestrel 75μg

10. POPs – Missed Pills Take most recent missed pill as soon as possible Abstain or use backup method for 48 hours Take next pill at regular time Consider use of emergency contraception if appropriate No backup method or emergency contraception needed if pills are missed by a woman who is still protected by LAM Source: CCP and WHO, 2008 update.

11. POP Use by Women with HIV Women with HIV or AIDS can use without restrictions Women on ARVs other than ritonavir can use POPs safely Should not be used by women who take ritonavir Dual method use should be encouraged Breastfeeding status provides additional protection from pregnancy Source: WHO, 2004, updated 2008; Sekar, 2008. WHO Eligibility Criteria ConditionCategory HIV-infected 1 AIDS 1 ARV therapy (which does not contain ritonavir) 2 Ritonavir/ ritonavir- boosted PIs (as part of ARV regimen) 3

12. ECP Use by Women with HIV Use to prevent pregnancy after unprotected intercourse –progestin-only and combined estrogen-progestin regimens –start as soon as possible; counsel to adopt regular method Use if regular method was used incorrectly, failed, or was not used Safe for all women (including women with HIV/AIDS and taking ARV drugs) There is no evidence to justify changes to emergency contraceptive pill regimens for ARV clients. Source: Hatcher, 2007; WHO, 2004, updated 2008.

13. Start within 120 hours (5 days) after unprotected intercourse ECP Pill Regimens: Progestin-Only Oral Contraceptives More effective than COC regimen; most effective when used early. pills formulated as emergency contraception regular progestin- only pills 1.5 mg levonorgestrel or 3 mg norgestrel; take all at once or in two doses 12 hours apart Source:CCP and WHO, 2007; WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; Piaggio, 1999; von Hertzen, 2002.

14. Start within 120 hours (5 days) after unprotected intercourse ECP Pill Regimens: Combined Oral Contraceptives Most effective when used early. high-dose pills repeat dose 12 hours Each dose should contain at least: 0.1 mg ethinyl estradiol and 0.5 mg levonorgestrel Known as Yuzpe regimen low-dose pills * repeat dose 12 hours Source: WHO Task Force on Postovulatory Methods of Fertility Regulation, 1998; CCP and WHO, 2007. * or 5 pills for each dose, if each pill contains 0.02 mg of ethinyl estradiol

15. ECPs – Key Counseling Messages Use and effectiveness More effective the sooner they are begun Side effects (nausea and vomiting) may occur; less common with progestin-only regimen Next menses may come a week early or late Do not provide pregnancy protection for future intercourse or protection from STIs/HIV After using, regular method should be considered