Birth control in HIV: What women can safely use and what doctors warn about

HIV-positive women have several safe birth-control options, but viral load, ART interactions, treatment stability still guide what doctors recommend for reliable contraception and partner protection

HIV already sounds complicated and confusing, and planning contraception or a pregnancy with HIV can feel even more overwhelming. On World AIDS Day 2025, we turn to specialists for guidance on what HIV-positive women can safely choose when it comes to contraception and partner protection.

 

When one partner is HIV-positive, the obvious question is transmission risk. As Dr Vinoad Bharrati, Senior Consultant Gynaecologist and Obstetrician, Founder and Director, Elite Momz – Rising Medicare Hospital, Pune, explains, biology is not symmetrical. “Male-to-female transmission risks are higher than female-to-male, but the risk is not zero either way. And even when both partners are HIV-positive, unprotected sex can allow different strains to mix and create superinfection, making treatment harder.”

 

Male condoms remain the most reliable way to reduce transmission. If a woman’s viral load is consistently suppressed for at least six months, the risk during condomless sex drops to almost zero under the “undetectable = untransmittable” (U=U) principle. Still, Dr Bharrati notes that if pregnancy is not the goal, condoms remain the safer choice.

 

How do ART drugs affect hormonal contraceptives?

According to Dr Bharrati, some antiretroviral therapy (ART) drugs speed up liver enzymes that break down contraceptive hormones, especially those metabolised through the CYP3A4 pathway. Others slow them down. Some have minimal impact. This variation is exactly what leads to contraceptive failure. 

1. Combined hormonal contraceptives (pills, patch, ring)

Efavirenz (EFV) is the major disruptor as it reduces oestrogen and progestin levels enough to risk failure. Nevirapine reduces oestrogen too, though less sharply. Ritonavir-boosted protease inhibitors may increase oestrogen exposure or lower ethinyl oestradiol levels.

 

Clinicians typically use combined pills with at least 30–35 µg ethinyl oestradiol and monitor for breakthrough bleeding. If EFV is part of the regimen, many doctors recommend switching the contraceptive or shifting to a non-interacting ART. 

2. Progestogen-only pills (POPs)

These pills are more vulnerable. Efavirenz can significantly reduce levonorgestrel levels, raising pregnancy risk. Breakthrough pregnancies are well documented. Most experts avoid this combination or pair POPs with condoms.

3. Implantable contraceptives

Etonogestrel implants and EFV often interact. EFV lowers hormone levels enough to cause failures. Ritonavir-boosted PIs may also reduce effectiveness.

 

If a woman wants an implant, doctors often recommend ART that does not interfere or advise using a barrier backup. 

4. Injectable DMPA (Depo-Provera)

“This one is the unproblematic hero of HIV care,” says Dr Bharrati. DMPA maintains hormone levels high enough to withstand enzyme-inducing ART. It does not meaningfully interact with EFV, protease inhibitors or integrase inhibitors. It is reliable and widely used. 

5. IUDs – copper and hormonal

Copper IUDs do not interact with ART at all. Levonorgestrel-releasing IUDs also work well because very little systemic hormone enters the bloodstream.

 

For women with heavy periods or anaemia, LNG-IUDs offer added benefit.

 

According to Dr Bharrati, a woman with a well-suppressed viral load can safely use almost any contraceptive method. If the viral load is detectable, IUDs remain strong options. Barrier protection becomes more important for both pregnancy prevention and transmission reduction.

What do doctors recommend when ART stability is uncertain?

 

When treatment stability is uncertain or ART has been recently initiated, many clinicians prefer the “double Dutch” approach — one hormonal method plus a barrier method. 

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This content is for informational purposes only and is not a substitute for professional medical advice