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Contraceptive Use During ART
Avoiding Drug Interactions Among Hormonal Oral Contraceptives and ARVs

Released: April 10, 2017

Expiration: April 09, 2018

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In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features an HIV-infected woman in her late 20s who is virologically suppressed on antiretroviral therapy (ART) and wants to initiate oral hormonal contraception. Included below is an exploration of potential drug–drug interactions that should inform whether this patient maintains or switches her current ART regimen.

Case Details
A 29-year-old woman currently suppressed on ritonavir (RTV)-boosted atazanavir (ATV) plus emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF) without any adverse events reports high adherence and continuous virologic suppression throughout her 3-year HIV infection. Her past medical history is otherwise unremarkable. She recently married an HIV-uninfected male and, because they have no immediate desire for children, she wants to start oral hormonal contraception.

Key Considerations
The patient’s current regimen is performing well, both in its efficacy and its safety, with no evident adverse events. Because she wants to add a medication, drug–drug interactions that could affect the level of hormonal contraceptive or the activity of her ART must be considered to avoid unwanted pregnancy, regimen failure with breakthrough viremia, or even antiretroviral resistance.

The DHHS and WHO both offer guidance on potential interactions among combined oral contraceptives (COCs) and the various antiretroviral classes (Table).

Table. Guidance on Drug Interactions Among Hormonal Contraceptives and Antiretrovirals

Less Optimal Regimens and Those to Avoid
Potential drug–drug interactions with COCs accompany the use of RTV-boosted PIs such as ATV, DRV, and LPV; the NNRTIs EFV, ETR, and NVP; and the COBI-boosted INSTI EVG. Because of this, although the patient is stably suppressed on ATV/RTV plus FTC/TDF, maintaining this regimen during the addition of oral hormonal contraception would not be optimal. Similarly, a switch to EVG/COBI/FTC/TDF or EVG/COBI/FTC/TAF would not be optimal for this patient, as the EVG/COBI components also have potential drug–drug interactions with oral hormonal contraceptives.

Preferred Treatment Options
NRTIs as a class do not exhibit significant interactions with COCs. Similarly, safe to use in this case would be the INSTIs DTG or RAL or the NNRTI RPV. Given these options, a switch to a DTG-containing regimen such as DTG plus FTC/TDF, DTG plus FTC/TAF, or DTG/ABC/3TC would mitigate the risk of COC drug–drug interactions. Also, a switch to RPV/FTC/TDF or RPV/FTC/TAF would be safe. However, a switch to an RPV-based regimen would require counseling the patient to take it with a full meal and to avoid concomitant use of agents that increase gastric pH (eg, proton pump inhibitors). The food requirement would not be new for this patient because her current ATV-containing regimen also requires coadministration with food.

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Poll

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When selecting a single-tablet ART regimen for women of childbearing age in your clinical practice who may require oral hormonal contraception, which of the following is your preferred choice to avoid potential drug–drug interactions?
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