Chapter 23 - Family Planning for Adolescents and Women at High Risk for HIV

Key Points for Providers and Clients
*All family planning methods, with the exception of nonoxynol-9 spermicides, are safe for all people at high risk for HIV, including both hormonal (either combined or progestin-only) and non-hormonal methods. Adolescents and women should be offered or referred for an HIV test if needed. In high HIV burden settings (≥5% HIV prevalence), adolescents and women should be offered or referred for an HIV test** as a routine part of family planning services. In low and medium HIV burden settings (<5% HIV prevalence), family planning providers should give information to help adolescents and women determine if they are at high risk for HIV and therefore if they need an HIV test. All adolescents and women at high risk for HIV should be counseled about how to prevent HIV and should be screened to see if they would benefit from pre-exposure prophylaxis (PrEP) for HIV prevention. PrEP can be used safely with all family planning methods and while breastfeeding. Male and female condoms are the only methods that can prevent both HIV and other sexually transmitted infections (STIs), as well as unintended pregnancy, when used consistently and correctly. Testing male partners for HIV has many benefits for women and men. Regardless of an individual’s level of risk, it is possible to contract HIV after having unprotected sex even just once, even in low-risk settings. * Repeated and high-dose use of nonoxynol-9 spermicide has been found to be associated with increased risk of genital lesions, which may increase the risk of acquiring HIV (see Chapter 16 – Spermicides and Diaphragms, Question 3). For this reason, the MEC category for spermicides and diaphragms is Category 4 (i.e. “Method not to be used”) for women who are at high risk of acquiring HIV (see Appendix D – Medical Eligibility Criteria for Contraceptive Use).

Key Points for Providers and Clients

All family planning methods, with the exception of nonoxynol-9 spermicides,* are safe for all people at high risk for HIV, including both hormonal (either combined or progestin-only) and non-hormonal methods.
Adolescents and women should be offered or referred for an HIV test if needed.
- In high HIV burden settings (≥5% HIV prevalence), adolescents and women should be offered or referred for an HIV test as a routine part of family planning services.
- In low and medium HIV burden settings (<5% HIV prevalence), family planning providers should give information to help adolescents and women determine if they are at high risk for HIV and therefore if they need an HIV test.
All adolescents and women at high risk for HIV should be counseled about how to prevent HIV and should be screened to see if they would benefit from pre-exposure prophylaxis (PrEP) for HIV prevention.
PrEP can be used safely with all family planning methods and while breastfeeding.
Male and female condoms are the only methods that can prevent both HIV and other sexually transmitted infections (STIs), as well as unintended pregnancy, when used consistently and correctly.
Testing male partners for HIV has many benefits for women and men.
Regardless of an individual’s level of risk, it is possible to contract HIV after having unprotected sex even just once, even in low-risk settings.

* Repeated and high-dose use of nonoxynol-9 spermicide has been found to be associated with increased risk of genital lesions, which may increase the risk of acquiring HIV (see Chapter 16 – Spermicides and Diaphragms, Question 3). For this reason, the MEC category for spermicides and diaphragms is Category 4 (i.e. “Method not to be used”) for women who are at high risk of acquiring HIV (see Appendix D – Medical Eligibility Criteria for Contraceptive Use).

Some adolescents and women are at high risk for acquiring HIV. Family planning providers must recognize this in order to provide high-quality family planning services. As shown in the map on the next page, the incidence of HIV infection is especially high among adolescents and young women in parts of East and Southern Africa.

Adolescents and women at high risk for HIV can safely use all family planning methods, with the exception of nonoxynol-9 spermicides. Family planning providers should also support adolescents and women to access HIV testing (including HIV self-tests) for themselves and their partners, as well as prevention services and care when indicated. Adolescents and women who are at risk for HIV may also be at risk of gender-based violence, including sexual violence, force, or coercion. If a provider suspects this is the case, or if a client discloses this information, refer to the section on Violence Against Women in Chapter 25 – Reproductive Health Issues for information on how to support and care for the client. The client may also be at increased risk of acquiring an STI, including human papillomavirus (HPV). For more detailed information on STIs, including HPV, please see Chapter 22 – Sexually Transmitted Infections, Including HIV.