预防意外怀孕对所有妇女都很重要,包括艾滋病毒携带者。越来越多的妇女,包括艾滋病毒呈阳性的妇女,选择含孕激素的皮下植入物,是最有效的避孕方式之一.然而,避孕激素与基于依非韦仑的抗逆转录病毒疗法(ART)之间的药物-药物相互作用可能会降低植入物的有效性.我们在这个问题上提出了四个相互关联的观点。
首先,作为一个案例研究,我们讨论了有限的数据如何促使国家层面的指导反对在南非同时使用依非韦仑的女性中使用植入物,以及随后对一般植入物使用的负面影响.第二,我们讨论了关于这个主题的现有临床数据,包括来自肯尼亚的一项观察性研究,该研究显示,使用植入物加依非韦伦ART的女性的妊娠率是使用植入物加奈韦拉平ART的女性的3倍.然而,植入物+依非韦伦组的妊娠率较高,仍然低于使用常见替代避孕方法的女性的妊娠率,如注射剂。第三,我们讨论了四项药代动力学研究,这些研究显示,与未接受任何ART的女性相比,同时使用基于依非韦伦的ART的女性的血浆孕激素浓度降低了50-70%.这些药代动力学研究为临床发现提供了生物学基础。第四,我们讨论了有关这一主题的数据如何对全球计划生育和艾滋病毒计划和政策产生重大影响。
这场争论强调了将计划生育服务纳入常规艾滋病毒护理的重要性。适当地指导妇女增加妊娠风险,同时使用植入物和依非韦仑,扩大所有女性的避孕方法组合。随着ART的全球访问范围扩大,需要更多的研究来探索与新型ART方案同时使用时的植入效果.关于艾滋病毒阳性妇女及其伴侣如何选择避孕药具的数据,以及提供者提供的有关如何向患者介绍和咨询避孕方法的信息,以帮助指导政策和服务的提供。最后,需要加强各级艾滋病毒和生殖健康专家之间的合作,以制定成功的战略,以确保感染艾滋病毒的妇女获得最佳的艾滋病毒和生殖健康结果。
Preventing unintended pregnancies is important among all women, including those living with HIV. Increasing numbers of women, including HIV-positive women, choose progestin-containing subdermal implants, which are one of the most effective forms of contraception. However, drug-drug interactions between contraceptive hormones and efavirenz-based antiretroviral therapy (ART) may reduce implant effectiveness. We present four inter-related perspectives on this issue.
First, as a case study, we discuss how limited data prompted country-level guidance against the use of implants among women concomitantly using efavirenz in South Africa and its subsequent negative effects on the use of implants in general. Second, we discuss the existing clinical data on this topic, including the observational study from Kenya showing women using implants plus efavirenz-based ART had three-fold higher rates of pregnancy than women using implants plus nevirapine-based ART. However, the higher rates of pregnancy in the implant plus efavirenz group were still lower than the pregnancy rates among women using common alternative contraceptive methods, such as injectables. Third, we discuss the four pharmacokinetic studies that show 50-70% reductions in plasma progestin concentrations in women concurrently using efavirenz-based ART as compared to women not on any ART. These pharmacokinetic studies provide the biologic basis for the clinical findings. Fourth, we discuss how data on this topic have marked implications for both family planning and HIV programmes and policies globally.
This controversy underlines the importance of integrating family planning services into routine HIV care, counselling women appropriately on increased risk of pregnancy with concomitant implant and efavirenz use, and expanding contraceptive method mix for all women. As global access to ART expands, greater research is needed to explore implant effectiveness when used concomitantly with newer ART regimens. Data on how HIV-positive women and their partners choose contraceptives, as well as information from providers on how they present and counsel patients on contraceptive options are needed to help guide policy and service delivery. Lastly, greater collaboration between HIV and reproductive health experts at all levels are needed to develop successful strategies to ensure the best HIV and reproductive health outcomes for women living with HIV.