Should women with HIV, or at high risk of contracting HIV, use progestogen-containing contraception?

The randomised trial was carried out in 599 HIV infected postpartum women who were not receiving antiretroviral therapy at the time of randomisation. 18 19 However, it was not designed or powered to detect an impact on HIV progression by method of contraception, lacked a control group receiving no contraception, and had a high loss to follow-up and disproportionate discontinuation of contraceptive method in the group using an intrauterine device. [...]actual use analysis was performed in addition to intention to treat, although this negates the advantages of randomisation. Alternative methods of contraception-Oral contraceptives (though with potential interactions with antiretroviral therapy 3 ), the copper intrauterine device (with careful exclusion of sexually transmitted infections and monitoring for pelvic infection), and possibly injectable norethisterone (if superior safety is confirmed) seem safer than injectable medroxyprogesterone. Importance of accessing antiretroviral therapy-A recent (unpublished) small cohort study showed no change in HIV infectivity (assessed indirectly by viral load) in HIV positive women taking antiretroviral therapy who started medroxyprogesterone, leading the authors to recommend priority initiation of antiretroviral therapy in women intending to use hormonal contraception. 23 We should not deny medroxyprogesterone to women who want to use it, as there is insufficient evidence against its use; preventing unintended pregnancy must continue to be at the forefront. Intervention and comparisons-Ideally use randomised trial design to clarify impact of different hormonal contraceptive methods on HIV acquisition and infectivity, using non-hormonal methods (such as copper intrauterine devices) as controls (in view of ethics of randomising to use of male condoms only).