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Note: All recommendations in this table are based on consensus expert opinion. More details can be found in CDC’s U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.
ARV Drug | Effect on Contraceptive Drug Levels and Contraceptive’s Effects on ART and HIV | Clinical Studies | Dosing Recommendation/ Clinical Comment for COC/P/R | Dosing Recommendation/ Clinical Comment for POPs | Dosing Recommendation/ Clinical Comment for DMPAa | Dosing Recommendation/ Clinical Comment for Etonogestrel Implants | Justification/ Evidence for Recommendation |
---|---|---|---|---|---|---|---|
NNRTIs | |||||||
EFV | COC:
COC:
|
COC:
|
Consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | Consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | No additional contraceptive protection is needed. | Consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | For COCs, some studies suggest higher pregnancy rate and ovulation rate and decreased progestin levels. EFV may decrease, but clinical significance unclear. For DMPA, evidence does not show effects on pregnancy rate, ovulation, or DMPA levels. Also, no effect on HIV disease progression or EFV levels. For implants, some studies suggest higher pregnancy rate and decreased hormone levels. For vaginally administered etonogestrel/EE, PK evaluation showed that etonogestrel levels were 79% lower and EE levels were 59% lower in participants on EFV than in controls after 21 days.56 |
ETR | EE AUC ↑ 22%59 No significant effect on NE59 |
COC:
|
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, one study found no ovulations and no significant change in progestin levels. No data on POPs. |
NVP |
EE AUC ↓ 29%;60 no change in EE AUC61
COC:
|
COC:
|
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additiofnal contraceptive protection is needed. | No additional contraceptive protection is needed | For COCs, evidence does not show effects on pregnancy rate or ovulations. Evidence demonstrated small decrease in progestin levels. No effect on NVP levels. For DMPA, evidence does not show effects on pregnancy rate, ovulation, or DMPA levels. No effect on HIV disease progression. For implants, evidence does not show effects on pregnancy rate or HIV disease progression. |
RPV | EE AUC ↑ 14%34
No significant change on NE34 Changes in ARV Levels and/or Effects on HIVCOC: No change in RPV levels compared to historical controls34 |
COC:
|
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, evidence does not show effects on ovulation or progestin levels. No change in RPV levels. No data on POPs. |
DOR | No clinically significant interaction with EE and LNG67 | N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No clinical data. |
RTV-Boosted PIs | |||||||
ATV/r | EE AUC ↓ 19%68 Norgestimate AUC ↑ 85%68 POP:
|
N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, increase in progestin levels seen in only one study. For POPs, increase in progestin levels seen in only one study. RTV inhibits CYP3A4, which may increase contraceptive hormone levels. |
DRV/r | EE AUC ↓ 44%70 NE AUC ↓ 14%70 |
N/A | Can consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | Can consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | No additional contraceptive protection is needed. | Can consider an alternative method (or a reliable method of barrier contraception) in addition to this method. | For COCs, small decrease in progestin levels. No data on POPs. |
LPV/r | EE AUC ↓ 55%25 NE AUC ↓ 17% Patch:
Patch:
|
COC:
|
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, nonsignificant increase in pregnancy rate. Small decrease in progestin level. For patch, no ovulations and progestin levels increased. For DMPA, evidence shows no effect on pregnancy rate or ovulations. Progestin levels increased. For implants, evidence shows no effect on pregnancy rate. Progestin levels increased. |
COBI-Boosted PIs | |||||||
ATV/c |
Drospirenone AUC ↑ 2.3-fold 25% decrease in EE C2442 |
N/A | Contraindicated with drospirenone-containing hormonal contraceptives due to potential for hyperkalemia. Consider alternative or additional contraceptive method. |
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No data on POPs. |
DRV/c | Drospirenone AUC ↑ 1.6-fold EE AUC ↓ 30%43 |
N/A | Clinical monitoring is recommended when DRV/c is used in combination with drospirenone-containing COCs as a result of the potential for hyperkalemia. Consider alternative or additional contraceptive method. |
No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No data on POPs. |
PIs without RTV | |||||||
ATV | COC:
|
N/A | Prescribe oral contraceptive that contains no more than 30 mcg of EE or recommend alternative contraceptive method. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, increased concentrations of estrogen and progestin, but the only data available are from the product label. No data on POPs. |
CCR5 Antagonist | |||||||
MVC | COC:
|
N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, no change in EE or progestin. No clinical data. No data on POPs. |
INSTIs | |||||||
BIC/FTC/TAF | No significant drug interactions with EE or norgestimate. | N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No clinical data. |
DTG | COC:
|
N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, no change in EE or progestin. No clinical data. No data on POPs. |
EVG/c | COC:
|
N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | When administered as the four-drug regimen EVG/c/FTC/TDF, increases in progestin and a small decrease in EE were observed. No clinical data. No data on POPs. |
RAL | COC:
|
N/A | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | No additional contraceptive protection is needed. | For COCs, no change in EE and a small increase in progestin. No clinical data. No data on POPs. |
a Because the hormonal levels achieved with DMPA are substantially higher than the levels that are required for contraception, any small reduction in hormonal level attributed to ARV drugs is unlikely to reduce contraceptive effectiveness. Key to Symbols: ↑ = increase ↓ = decrease Key: APV = amprenavir; ART = antiretroviral therapy; ARV = antiretroviral; ATV = atazanavir; ATV/c = atazanavir/cobicistat; ATV/r = atazanavir/ritonavir; AUC = area under the curve; BIC = bictegravir; C12h = concentration at 12 hours post-dose; C24h = concentration at 24 hours post-dose; CD4 = CD4 T lymphocyte; CDC = Centers for Disease Control and Prevention; CHC = combination hormonal contraceptives; CI = confidence interval; Cmin = minimum plasma concentration; COBI = cobicistat; COC/P/R = combined oral contraceptives/patch/ring; CYP = cytochrome P450; DMPA = depot medroxyprogesterone acetate; DOR= doravirine; DRV/c = darunavir/cobicistat; DRV/r = darunavir/ritonavir; DTG = dolutegravir; EE = ethinyl estradiol; EFV = efavirenz; ENG = etonogestrel; ETR = etravirine; EVG/c = elvitegravir/cobicistat; FPV = fosamprenavir; FPV/r = fosamprenavir/ritonavir; FTC = emtricitabine; IDV = indinavir; INSTI = integrase strand transfer inhibitor; LNG = levonorgestrel; LPV/r = lopinavir/ritonavir; MVC = maraviroc; NE = norethindrone; NFV = nelfinavir; NNRTI = non-nucleoside reverse transcriptase inhibitor; NVP = nevirapine; P = progestin; PI = protease inhibitor; PI/r = protease inhibitor/ritonavir; PK = pharmacokinetic; POP = progesterone-only oral contraceptive pills; RAL = raltegravir; RPV = rilpivirine; RTV = ritonavir; SQV/r = saquinavir/ritonavir; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TPV = tipranavir; TPV/r = tipranavir/ritonavir Source: Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV. Department of Health and Human Services. Tables 21a, 21b, and 21d. |