Sex and HIV
Contraception lets you avoid pregnancy or plan a pregnancy when you’re ready to have a child. There is a wide range of methods to choose from, each with their own advantages and disadvantages. Before choosing a method of contraception it is important to discuss all options with your doctor, with particular attention to the way contraception may aggravate issues associated with your HIV infection, and ways your HIV infection and any antiretroviral treatments you are taking may undermine the effectiveness of contraception.
A number of agencies have produced great resources about contraception:
- Shine SA provides detailed information about different forms of contraception on their website.
- Family planning NSW has great factsheets about different forms of contraception (they’re listed below).
- NAM has an interactive tool, HIV & Contraception, designed to give women with HIV personalised information about different contraception choices. It includes questions about any HIV treatments you may be taking. (Just be aware, it is UK based, so you’ll need to double check any information with your doctor.)
Importantly, the only contraceptives that also prevent HIV transmission are male and female condoms.
Male condoms are highly effective at preventing pregnancy, as well as preventing the transmission of HIV and most sexually transmitted infections. However, condoms need to be used properly to be effective. Male condoms should not be used with female condoms (see below). Find out more about condoms from Family Planning NSW’s male condom factsheet.
Female condoms (Femidom) may be a good option for some women with HIV. They are not readily available in Australia but are available at some sexual health clinics, some family planning clinics, selected women’s health clinics and pharmacies, and can also be ordered over the Internet. Female condoms may be slightly less effective at preventing pregnancy than male condoms (95% effective compared to 98%) but are comparable to the efficacy of a diaphragm or cap. Female condoms should not be used with male condoms. Find out more about female condoms from Family Planning NSW’s female condoms factsheet.
Diaphragms and caps
Both diaphragms and caps are rubber dome-shaped devices that fit over the cervix. They need to be expertly fitted by a doctor but from then on are self-inserted before sex.
The main disadvantage to diaphragms and caps is that to be effective, they need to be used and used correctly each time sexual intercourse occurs. The effectiveness of diaphragms and caps is hard to measure, partly because they must be positioned correctly (and you must remember to insert them). Australian sexual health services estimate that if 100 women used diaphragms and caps for a year, between four and twenty of them would get pregnant.
Previously diaphragms and caps were not recommended for women with HIV because it was thought that spermicide had to be used with them, and spermicide can irritate the vagina and increase the chances of transmitting HIV. However, there is no added contraceptive benefit to using spermicide with diaphragms or caps, and doing so is no longer recommended. Find out more from Family Planning NSW’s diaphragms and caps factsheet.
The main advantage of hormonal contraception is that you are in control of it and you don’t need to remember to use it each time you have sex, although you may need to remember to take it every day depending on what hormonal method you choose.
A major problem with hormonal contraceptive products is that many antiretroviral treatments reduce their efficiency so they increase the likelihood of pregnancy. These drugs include non-nucleoside reverse transcriptase inhibitors, nevirapine (Viramune) and efavirenz (Sustiva) and protease inhibitor drugs. It is vital you ask your doctor to consider all possible drug interactions. Also, hormonal contraceptive methods do not reduce HIV transmission risk.
The most common form of hormonal contraception is the Pill. It is estimated to be more than 99% effective in preventing pregnancy, although this may be decreased if you take certain other medication or if you experience vomiting or diarrhoea. Some other medications, including some antibiotics, can make the Pill less effective.
Drugs in several HIV antiretroviral treatments may make some brands of the Pill less effective. Generally, women taking antiretroviral treatment that interacts with the Pill should avoid ‘low dose’ Pill formulations. If you want to use the Pill, it is important to discuss the interaction of antiviral therapies with different formulations of the Pill to find a combination that works for you. Find out more about the Pill from Family Planning NSW’s combined oral contraceptive pill factsheet.
Depo-Provera is a contraceptive injection that lasts for approximately 12 weeks. Depo-Provera is not affected by antiretroviral treatments except for the drug Atazanavir. To find out more about Depo-Provera, see Family Planning NSW’s contraceptive injection factsheet.
Implanon is a small rod inserted under the skin of the upper arm (about the size of a match) that slowly releases the contraceptive hormone. The device is very effective. It provides protection for three years but is readily reversible if pregnancy is desired or if you have side-effects. Implanon effectiveness is impacted by many antiretroviral treatments so ask your doctor to consider all possible drug interactions. To find out more about Implanon, see Family Planning NSW’s contraceptive implant factsheet.
IUD (intra-uterine device)
An IUD is a small T-shaped contraceptive device made from plastic and copper that fits inside the womb (uterus). It is also sometimes called a coil. An IUD releases copper into the body causing changes that prevent sperm from fertilising eggs. It is a highly effective contraceptive and is not affected by antiretroviral treatments. An IUD needs to be fitted by a doctor or nurse. To find out more, see Family Planning NSW’s Copper IUD factsheet.
The Mirena (Intrauterine system)
The Mirena is a small plastic device fitted in the womb. It contains hormones that reduce the risk of heavy periods (sometimes stopping them altogether) and is also used by women with heavy, painful periods as an alternative to hysterectomy. It is highly effective as a contraceptive device and is not affected by antiretroviral treatments. However, it is not recommended for women with a history of pelvic inflammatory disease. A Mirena must be fitted by a doctor or nurse but once fitted, works for five years. For more detailed information see Family Planning NSW’s Mirena factsheet.
Both men and women can have surgery as a permanent form of contraception. For men the procedure is called a vasectomy. A small incision in the scrotum cuts the tubes that carry sperm to the penis. Normal ejaculation still occurs after vasectomy but the semen does not contain sperm. The operation is usually done under local anaesthetic and takes about 15 minutes. Additional contraception needs to be used for two months after the operation as live sperm can persist for some time after a vasectomy. The vasectomy failure rate is very low: approximately 1 in 2000.
For women, sterilisation involves cutting, blocking or sealing off the fallopian tubes. There are several different methods of doing so. Depending on the procedure, anaesthetic may be either local or general, with a hospital stay of a day or more. Other contraception needs to be used until after the first period following the procedure. The failure rate is approximately 1 in 200.
For more information, see Family Planning NSW’s factsheet on male and female sterilisation.
Making your choice
Female and male condoms offer protection from pregnancy, STIs and HIV but some people find them difficult to use every time they have sex. No single contraceptive option is going to suit every woman with HIV so it is important to discuss options, both with your sexual partner(s) and your doctor, to work out what will fit best with your life and your needs.
Longer-lasting options like implants and injectables offer superior efficacy and mean one less pill to take on a daily basis, hence less margin for human error. They are also cheaper. Caps and diaphragms can be inserted ahead of time and left in ‘round the clock’, so can be convenient but they have a high failure rate based in part on women forgetting whether or not they are in place.
Family Planning NSW provides a useful summary of contraception options in their contraception factsheet.
The Emergency Contraceptive Pill
(sometimes called the ‘Morning after Pill’)
If you are concerned about pregnancy because you had sex without using contraception or the contraception failed (for example, a condom broke or came off during sex), you may wish to access the emergency contraceptive pill. It consists of a high dose progesterone-only Pill (which is actually two pills taken together at the same time). For more information see Family Planning NSW’s emergency contraception factsheet.
You need to take the pill within 72 hours of unprotected intercourse although ideally sooner, as the chances of the emergency contraception working reduces with time. If taken within 24 hours, it prevents 95% of pregnancies, although its effectiveness may be undermined by certain antiretroviral drugs. It is available in pharmacies and some sexual health clinics.
It is important that you let the doctor or pharmacist know if you are on HIV treatment, as some anti-HIV drugs interfere with the way the emergency contraceptive pill works, and you may need to take twice the normal dose.
Note: If your partner is HIV negative and you are concerned they may have been exposed to HIV, they should visit a doctor as soon as possible (definitely within 72 hours) to access post-exposure prophylaxis (PEP), which is a short course of anti-HIV drugs that can prevent them from becoming infected with HIV. During the evening or on the weekend, you can access PEP at your hospital emergency department. For more information and details about where you can get PEP visit the Get PEP site.