Background. A randomized controlled trial raised concerns that use of hormonal contraception (HC) may accelerate progression of HIV disease in HIV-infected (HIV+) women. The objective of this study was to explore trends and predictors of HC use in HIV+ women in Rakai, Uganda, and to determine whether HC use influenced the rate of HIV progression.

Methods. We used data from a population-based cohort study in Rakai to assess levels and trends of HC use between 1994 and 2006, and to determine which factors were associated with HC use in HIV+ women. Using generalized estimating equations and multivariate logistic regression, we calculated odds ratios for predictors of HC use at three time intervals. Then, using a sample of 625 incident HIV seroconverters, we performed multivariate Cox regression analyses to assess the effect of HC use on time from HIV seroconversion to death, or the effect of HC use on time until the composite outcome of AIDS or death.

Results. HC method use more than tripled among HIV+ women in Rakai between 1994 and 2005, but the burden of unintended pregnancy remains high. Variables associated with increased HC use included higher education, higher socioeconomic status, higher parity, higher sexual frequency and number of sexual partners, being currently married or in a relationship, discussion of family planning with a partner, and receipt of HIV results. Variables associated with lower HC use included fewer sexual partners, condom use, breastfeeding, and opportunistic infections. Most associations remained stable over time. Survival analyses suggested that HC use does not accelerate HIV progression, and that HC use is safe for women with HIV. Some analyses suggested that HC use may be associated with reduced hazards of progression, but given the potential for self-selection in observational data, we view this finding with caution.

Conclusions. The weight of observational evidence suggests that HC use in HIV+ women is no more dangerous than non-use. International guidelines should maintain the position that HC use is safe for HIV+ women, particularly those not yet on antiretroviral therapy. HC (with condoms, when possible) should be promoted to HIV+ women who wish to prevent pregnancy.