Letter From the Editor

Modern intrauterine devices (IUDs) are safe, highly effective and cost-effective. Unfortunately, the 1995 National Survey of Family Growth found that the use of IUDs has dropped to 1% or less of U.S. women using contraception.

Worldwide Perspective on IUD Use

Intrauterine devices are the most widely used reversible contraceptive method worldwide. One country, China, accounts for about 70% of the 106 million users globally.

Modern IUDs are safe, highly effective for contraception and cost-effective. Despite these findings, use remains variable around the world. Some countries have wide usage and others practically none. For example, use among all married women of reproductive age (not just contraceptive users) is highest in China (33% of all married women), the Scandinavian countries (18%), Asian nations (13%) and the Near East and North Africa (12%). About 7% of all married European and Russian women rely upon the IUD, while about 5% from Australia and New Zealand do so. On the other hand, the overall use of the IUD is lowest in North America (1.5%) and sub-Saharan Africa (0.8%).

The wide variation in use reflects different patterns of availability, clinician and patient perceptions, and cultural values. For example, although the IUD is used by less than 1% of sub-Saharan African women, use of all forms of contraception in this area of the world is generally low. In addition, accessibility of trained providers is limited. On the other hand, the IUD is very popular in China and Scandinavia; women learn about its safety and efficacy, and the method is widely available.

Increasing Access to IUDs

In 1995, the World Health Organization (WHO) released revised medical eligibility criteria guidelines to assist family planning agencies and clinicians prescribe contraceptives.

Antibiotics Unnecessary at IUD Insertion

An early randomized trial from Kenya suggested that the use of prophylactic antibiotics at IUD insertion helped to prevent PID. Subsequent randomized trials, however, have failed to confirm such an effect.

PATIENT UPDATE:
What to Expect When Having an Intrauterine Device (IUD) Inserted

When you are making a decision about contraception, your clinician will ask you certain questions about your medical, contraceptive and sexual history.

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IUDs May Be Safe for Women with HIV Infection

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Summary

Current recommendations suggest IUDs should not be the first method of choice for women with HIV infection.

Current recommendations suggest IUDs should not be the first method of choice for women with HIV infection. The World Health Organization and International Planned Parenthood Federation® recommend that HIV-infected women not use the IUD for contraception.1,2 These recommendations are based upon theoretical concerns about an increased risk of infection and possible increased risk of female-to-male HIV transmission from increased menstrual blood loss. The recommendation also reflects concern about behavioral characteristics that may make some HIV-positive women more susceptible to STDs and PID.

IUD Use in HIV-Infected Women

Research conducted in Kenya by Family Health International suggests that carefully selected HIV-infected women may safely use the IUD for contraception.3,4 Researchers enrolled 649 women who otherwise met eligibility criteria for IUD insertion, including a low risk of STDs.3 Women came from two family planning clinics in Nairobi, Kenya.

The investigators followed 156 HIV-1 infected women and 493 non-infected women. Researchers gathered data on complications related to the IUD at 1 and 4 months after insertion. Overall complications were defined as pelvic inflammatory disease (PID), full or partial IUD expulsion, pregnancy, or IUD removal because of infection, pain, or bleeding. Infection-related complications consisted of any pelvic tenderness criterion upon physical assessment or IUD removal for infection or pain. IUD-related complaints included other complaints such as bleeding, bleeding for longer than normal, abdominal pain, backaches, itching and yellowish discharge.

Researchers found no statistically significant difference between HIV-infected and non-infected women in overall complications (OR=0.8; 95% CI, 0.4-1.7) (see Figure). They also found no difference in infection-related complications between the two groups (OR=1.0; 95% CI, 0.5-2.3). These results were adjusted for marital status, study site, previous IUD use, ethnic origin, and frequency of sexual intercourse.

The investigators also explored whether HIV-infected women might have more complications based on their immune status. They found no difference in overall complication rates, infection-related complications or IUD-related complaints among HIV-infected women who were severely, moderately, or mildly immunocompromised.

The authors suggest that, although their study cannot rule out a small increased risk for HIV-infected women related to IUD use, the data support the use of IUDs in appropriately selected HIV-infected women. The authors emphasize that rates of PID were low in both groups of women (1.4% for HIV-infected vs. 0.2% for non-infected) (2 cases among HIV-infected women and 1 case among non-infected women). Furthermore, rates of infection-related complications were similar in HIV-infected and non-infected women (6.9% vs. 5.7%, respectively).

Because some data indicate that HIV-infected women may have a more severe presentation of PID,5,6 HIV-infected women need continuing access to medical care. The researchers conclude, "Our data suggest that IUDs may be a safe contraceptive method for appropriately selected HIV-1 infected women with continuing access to medical services."

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References

1	World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. Geneva: WHO, 1996.
2	IPPF International Medical Advisory Panel. Statement on contraception for clients who are HIV positive. IPPF Med Bull 1991;25:1-2.
3	Sinei SK, Morrison CS, Sekadde-Kigondu C, et al. Complications of use of intrauterine devices among HIV-1-infected women. Lancet 1998;351:1238-1241.
4	Hicks DA. What risk of infection with IUD use? Lancet 1998;351:1222-1223.
5	Barbosa C, Macasaet M, Brockmann S, et al. Pelvic inflammatory disease and human immunodeficiency virus infection. Obstet Gynecol 1997;89:65-70.
6	Sweet RL, Landers DV. Pelvic inflammatory disease in HIV-positive women. Lancet 1997;349:1265-1266.