Contraceptive Options for

Women and Couples with HIV

Intrauterine Device
(IUD or IUCD)

Copper T-380A
Types of IUDs
• Most common:
– T-shaped, copper bands on plastic stem/arms

• Inserted in uterus through

vagina and cervical opening
Copper T-380A
• Strings:
– assure IUD is in place; facilitate removal

• Most common copper IUD: TCu-380A

• Less common: hormonal IUDs
Effectiveness
Spermicides
Female condom
Standard Days Method
Male condom
Oral contraceptives
DMPA
IUD (TCu-380A) Rate during perfect use
Female sterilization
Rate during typical use
Implants
0 5 10 15 20 25 30
Percentage of women pregnant in first year of use

Source: CCP and WHO, 2007.

Mechanism of Action of Copper IUDs

Prevents fertilization by:

• Impairing the viability of

the sperm

• Interfering with sperm

movement

Source: Ortiz, 1996.

Characteristics of Copper IUDs:
Advantages
• Highly effective and very safe
• Does not interfere with intercourse
• Easy to use
• Long lasting
• Easily reversible
• Quick return to fertility
• No systemic effects
• Complications are rare
Source: CCP and WHO, 2007.
Characteristics of Copper IUDs:
Disadvantages

• Side effects, including cramping and increased

or prolonged bleeding
• Rare complications include perforation and
pelvic inflammatory disease
• Method failure can lead to ectopic pregnancy
(extremely rare)
• Insertion and removal require trained provider
• No STI/HIV protection
Source: CCP and WHO, 2007.
Copper IUDs – Common Side Effects

• Cramping and increased or

prolonged menstrual
bleeding

• Possible bleeding between

menstrual periods

Side effects are most common during the

first 3 months.
Source: CCP and WHO, 2007; Larsson, 1993; DeMaeyer, 1989; WHO, 2004, updated 2008; WHO Special
Programme of Research Development and Research Training in Human Reproduction, 1997.
IUDs – Pelvic Inflammatory Disease (PID)
PID is an infection of a woman’s upper genital tract.

Risk of PID in IUD users:

• Low overall
– risk of PID attributable to IUD is 0.15% to 0.30%
• Higher during first 20 days after insertion
• Due mostly to presence of gonorrhea or
chlamydia at time of insertion
• Similar to risk of PID in women with gonorrhea
and chlamydia who are not using IUD

Source: Shelton, 2001.

IUDs – Reducing the Risk of PID
• Do not insert IUD if:
– at high individual risk of STIs, or
– clinical symptoms and signs of an STI are present

• Counsel about risk of PID

• Follow infection prevention procedures during
insertion
• Recommend follow-up visit at 3 to 6 weeks to
check for infection
– return immediately if any symptoms of PID develop
Source: WHO, 2004; updated 2008.
IUDs – Perforations
Very rare: 1 in 1,000 insertions

Risk:
• Linked to skill and experience of provider
• Reduced through supervised training
• Greater for postpartum insertions performed
between 48 hours and 4 weeks after delivery

Source: WHO, 1987.

IUDs – Expulsions
Partial or unnoticed expulsion may result in
irregular bleeding or pregnancy

Factors contributing to expulsion:

• Provider’s skill placing IUD at top of uterine
cavity
• Age and parity of woman
• Time since insertion
• Timing of insertion

Source: Anteby, 1993; O’Hanley, 1992; Zhang, 1992; Petersen, 1991; Sivin, 1992.
IUDs Safe for Women with HIV

Little difference
in complications
between IUD
acceptors with
and without HIV.

Percentage of women in Kenyan study

Source: Morrison, 2001.

IUD Use Does Not Increase HIV Transmission

Theoretical concern:
• IUD use by women with HIV may increase
risk of transmission to partner

Research has found:

• No postinsertion increase in cervical
shedding
• No increased risk of partner
exposure to higher dose of virus ? ? ?
??

Source: Richardson, 1999.

IUD Use by Women with HIV

WHO Eligibility Criteria • Safe for majority of

women with HIV
Category
Condition • Initiation not
Initiate Continue
recommended if
woman has AIDS and
HIV-infected 2 2 is not on ARV therapy

AIDS • Dual method use

(without ARVs)
3 2 should be
encouraged
ARV therapy 2 2
(clinically well)

Source: WHO, 2004; updated 2008.

Category 1 and 2 Examples (not inclusive):
Who Can Use Copper IUDs
WHO
Category
Conditions

Category 1 ≥20 years, hypertension, deep venous

thrombosis, ischemic heart disease,
migraine headaches, cervical ectopy,
breast disease (including breast cancer)

Category 2 menarche to <20 years, nulliparous,

heavy or prolonged bleeding, severe
dysmenorrhea, endometriosis, anemia,
high risk of HIV

Source: WHO, 2004; updated 2008.

Category 3 and 4 Examples (not inclusive):
Who Should Not Use Copper IUDs
WHO
Category
Conditions

Category 3 48 hours to <4 weeks postpartum, ovarian

cancer/if initiating use, high individual risk of
STIs, AIDS (no ARV treatment or not well on
ARVs)
Category 4 pregnancy; postpartum/postabortion sepsis;
unexplained vaginal bleeding (prior to eval.);
uterine fibroids with cavity distortion; current
PID; purulent cervicitis; endometrial cancer,
cervical cancer, or pelvic TB/if initiating use

Source: WHO, 2004; updated 2008.

Timing of IUD Insertion

Interval insertion
• Anytime during menstrual cycle if woman is not
pregnant
Postpartum insertion
• Immediately after vaginal or cesarean delivery if
no infection or bleeding (within 48 hours or delay
at least 4 weeks)
Postabortion insertion
• Immediately if no infection
Source: WHO, 2004; updated 2008.
IUD Counseling Topics
• Characteristics of IUDs
• Effectiveness and how IUDs work
• Common side effects
• Client’s risk of STIs
• Insertion and removal procedures
• Instructions for use and follow-up visit
(including signs of complications that require
immediate return to the clinic)
Counseling about IUD Side Effects:
What to Expect
During Insertion:
• Some pain and cramping

First few days:

• Light bleeding and mild cramping

First few months:

• Heavier and/or prolonged menstrual bleeding
• Menstrual cramping
• Spotting between periods
Source: CCP and WHO, 2007.
IUD Use and Follow-up

• Teach client how to check for strings:

– with clean fingers
– after each menses
(expulsion most likely in first 6 months)

• Schedule follow-up visit at:

– 3 to 6 weeks

• Counsel to return immediately if any

signs of complications
Source: CCP and WHO, 2007; WHO, 2004, updated 2008.
Signs of Possible IUD Complications

Advise to return immediately if experiencing:

• Bleeding and severe abdominal cramping
3 to 5 days postinsertion perforation
• Irregular bleeding or pain every cycle
partial expulsion, perforation
• Fever, unusual vaginal discharge, low abdominal
pain infection
• Missing IUD strings, missed period expulsion,
pregnancy
Source: CCP and WHO, 2007.
Dispelling IUD Myths

IUDs:
• Are not abortifacients
• Do not cause infertility
• Do not cause discomfort for the male partner
• Do not travel to distant parts of the body
• Are not too large for small women

Source: CCP and WHO, 2007; Farr, 1994.

IUDs – Summary

IUDs are:
• Safe, effective, convenient, reversible,
long lasting, cost-effective, easy to use,
appropriate for the majority of women
Providers can ensure safety by:
• Informative counseling
• Careful screening
• Appropriate infection prevention
practices
• Proper follow-up