Potential Implanon failure in patients on ART
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* Sarah Duncan
* Fran Hawkins
* Noreen Desmond

We read with interest the letter by Lakhi and Govind highlighting the potential failure of Implanon® if used in combination with antiretroviral therapy.1 The letter demonstrates the consequent importance of disclosure of HIV status to reproductive health care services, and the responsibility of HIV physicians to discuss contraceptive choices with female patients.

Our clinic has provided an integrated sexual health service since 1995, aiming to provide a holistic approach to HIV and reproductive health care. All female patients are invited to attend a dedicated ‘Family Planning Plus (FP Plus)’ clinic which provides contraception, preconception counselling, cervical cytology and basic medical gynaecology for HIV-positive women. As a result, one set of case notes is used to address and document both current HIV therapy and current contraception, aspiring to reduce the number of women in whom the absence of disclosure could lead to suboptimal contraceptive prescribing and unintended adverse events.

Following the introduction of the FP Plus service in 2002, an audit in 2005 demonstrated significant improvement in the number of women attending for annual cervical cytology and in the documentation of women's contraceptive choices, as well as better sexual history taking and sexually transmitted infection screening.2

Despite progress in our understanding of HIV as a disease, and greater awareness of the complex issues facing people living with HIV in the UK, disclosure of HIV status remains difficult for many patients. Several factors influence the ability and willingness of patients to disclose their HIV status to other health care providers, which may include fear of stigma, low self confidence, anxiety and depression,3 and the misconception that HIV status may not be relevant to other health care domains such as contraception.

However, disclosure of a woman's HIV status is essential if she is to receive optimal reproductive health care. HIV-positive women require specialist management of abnormal cervical cytology, appropriate preconception advice to minimise the risks of HIV transmission to partners and children, and tailored contraceptive provision to avoid interactions with antiretroviral drugs.4

While we have previously recognised that payment by results does not incentivise the provision of one-stop services,5 we feel that the FP Plus clinic has significantly contributed to the sexual and reproductive well being of women attending our service. As Lakhi and Govind acknowledge, the majority of HIV-positive women in the UK are of reproductive age. We feel that strengthening the links between HIV and reproductive health care services for women living with HIV to provide a multidisciplinary approach is an essential step in overcoming the barriers to receiving optimal care that can result from a lack of disclosure.

*   Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

## References

1.  Lakhi N, Govind A. Implanon failure in patients on antiretroviral medication: the importance of disclosure. J Fam Plann Reprod Health Care 2010;36:181–182.
    
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4.  Fakoya A, Lambda H, Mackie N, et al.; British HIV Association (BHIVA), the British Association for Sexual Health & HIV (BASHH) and the Faculty of Family Planning & Reproductive Health Care. 2007 UK Guidelines for the Management of Sexual and Reproductive Healthcare of People Living with HIV Infection. [http://www.bashh.org/documents/91/91.pdf](http://www.bashh.org/documents/91/91.pdf) [accessed 12 September 2010].
    
    

5.  Barber TJ, Coyne KM, Hawkins F, et al. One-stop care for HIV-positive women. Int J STD AIDS 2009;20:67.
    
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