Today at a satellite
symposium at the South African AIDS Conference linked to a publication in The
Lancet, the ECHO trial of contraceptive use and impact on HIV risk released its
results. The Evidence for Contraceptive Options and HIV Outcomes Study, or ECHO,
was designed to evaluate the risk of acquiring HIV in HIV-negative women who
used the copper-releasing intrauterine device (Cu-IUD), a levonorgestrel (LNG)
implant (Jadelle) and depot medroxyprogesterone acetate-intramuscular
(DMPA-IM), also known as Depo-Provera.
The topline finding:
There was no substantial difference in HIV risk among women using DMPA-IM, the
LNG implant or the copper IUD. These are long-awaited data from the most
rigorous trial of HIV and contraceptive interactions in history. They are an
urgent call to action at a time when women’s reproductive health and rights are
under threat in many countries, and the mobilization by and for women’s lives
is vibrant and strong.
As AVAC and the women
advocates who have led this work in Africa have said in the months and years
prior to the result: ECHO must prompt action. Now is the time for investment in
woman-centered programs that offer a full range of contraceptive choices and
HIV prevention strategies at the same site and in the context of a true
informed-choice approach. The ECHO results tell us this is the case. The women
who made the trial possible deserve nothing less
ECHO trial did not
find any significant difference in HIV risk among women using the three methods
studied: DMPA-IM, LNG implant and the copper IUD. Not very many women used
pre-exposure prophylaxis, or PrEP, for HIV prevention during the trial; women
who used DMPA-IM reported more condom use and fewer partners. These choices
don’t seem to have made a difference in HIV risk.
All of the
contraceptive methods tested were safe, effective and acceptable; the majority
of women stayed on the method that they were assigned to use. Very few became
pregnant while they were using the method.
There were high HIV
incidence rates in all three arms of the trial. This does not mean that the
methods increased women’s risk. These incidence rates are comparable to those
seen in young women in these countries in other trials and contexts. What is
notable, though, is that many trials with comparable incidence rates recruited
women with specific HIV risk factors, such as numbers of partners, commercial
sex work, sexually transmitted infections, etc. In ECHO, HIV risk factors were
not part of enrollment criteria. The participants were sexually active young
women looking for contraception. ECHO gives a stark picture of the risk facing
these young women. HIV prevention services must meet them where they are—in
contraceptive clinics and other related services.
The results are a
clear call for contraceptive programs that offer more method choices, including
DMPA-IM for women who want to start or continue it, along with comprehensive
HIV prevention interventions. The new information from ECHO should be used to improve
counseling, expand method choices and rapidly and urgently integrate HIV
prevention and treatment with contraceptive programs. The level of HIV risk
among eSwatini, Kenyan, South African and Zambian women in the trial was
profoundly high. The majority of the participants were under 25, who were not
identified as at high risk for HIV—but were simply sexually active and seeking
contraception.
The ECHO results are
not “good news”. The women in the trial did not have any specific HIV risk
criteria. They recruited women who wanted contraception and were sexually
active. It is a wake-up call to put HIV prevention on site at every family
planning clinic including PrEP and female condoms with peer support, trained
providers.
A key question about
DMPA-IM has been answered, but that does not mean the method can continue to
dominate women’s contraceptive programs in East and Southern Africa. We don’t
believe that DMPA-IM should continue to be the only long-acting method
available. Black and brown women in East and Southern Africa want choices,
dislike side effects and deserve equity with the high-quality contraceptive
programs often available in high-income countries.
ECHO shows method mix
is possible. Women use many things. Make it happen.
Women need strategies
to prevent pregnancies and HIV infection at the same sites, from the same
providers, in a rights-based, woman-centered context. Throughout ECHO, the
risks of unplanned pregnancy and HIV were pitted against each other by
scientists and normative agencies. Now is the time for integration. This has to
include investigation—more research on how to deliver services that meet
contraceptive and HIV needs well, what is driving HIV risk and how to address
it, and more.
The Evidence for
Contraceptive Options and HIV Outcomes Study, or ECHO, was designed to evaluate
the risk of acquiring HIV in HIV-negative women who used the copper-releasing
intrauterine device (Cu-IUD), a levonorgestrel (LNG) implant (Jadelle) and
depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as
Depo-Provera. The trial also compared pregnancy rates among women using these
methods, documented rates of method discontinuation and switching, and provides
a valuable body of evidence about acceptability of these methods among African
women.
Many women1 at risk
for HIV are also concerned about avoiding or postponing pregnancy. Some
observational studies have suggested that specific injectable contraceptives
(e.g., DMPA-IM)2 can increase women’s risk of acquiring HIV, while other
studies have not suggested this link between DMPA-IM and HIV risk. Before ECHO,
very little was known about other methods and their relationship to HIV risk—no
other randomized trial had been conducted on the relationship between HIV risk
and a contraceptive method. ECHO was designed to gather high-quality
information about how different methods affected risk—whether increasing or
possibly decreasing it. One key goal for the trial was to gather information
that could be used to shape the WHO classification of and, by extension, the
service-delivery approaches for the three methods. In the past years, WHO has
used its Medical Eligibility Criteria system for evaluating contraceptives to
signal the theoretical possibility that DMPA and similar methods might increase
HIV risk. This complex classification hasn’t translated into action in terms of
women being informed about risks and benefits, or into procurement of
additional alternative methods in most settings. ECHO was also designed to help
understand acceptability of methods not widely used in the trial countries.