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A large clinical study conducted in four African countries has revealed no significant difference in terms of risk of HIV infection in women using any of the three highly effective and reversible contraceptive methods. Posted today in the Lancetthe study showed that each method had high levels of safety and effectiveness in preventing pregnancy, all methods being well accepted by the women who used them. The three methods studied in the trial – known as ECHO studies (Evidence for Contraceptive Options and HIV Outcomes) – are as follows:
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DMPA – Intramuscular (DMPA-IM), a quarterly reversible injectable contraceptive containing only a progestin;
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Implant levonorgestrel, an implant containing only progestin, inserted under the skin in the upper arm and can be used for up to five years;
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A copper IUD, a device inserted into the uterus that can be used for 10 to 12 years.
These findings support the availability of a wide range of effective contraceptive methods for women and girls to make informed decisions about their own bodies, including if and when to have children, "said Dr. James Kiarie, Department of Reproductive Health and Research. at the World Health Organization. "Improved access to quality contraception and reproductive health services would have a significant impact on improving the lives of millions of women and their families.
However, the study found that the incidence of HIV infection among all participants was high – 3.8% on average per year – indicating that HIV remained a significant personal risk and public health challenge for many women in those countries.
The study underscores the need to scale up HIV prevention efforts in these high-burden countries – especially for young women, "said Dr. Rachel Baggaley of the HIV and Hepatitis Department. WHO. "These should include HIV testing and a range of options for HIV prevention in contraceptive service programs.
About the study
Over the last 25 years, when the HIV epidemic had spread to many countries, several observational studies have suggested an increased risk of HIV acquisition among women using progestin-only injectables, particularly DMPA-IM. Due to limitations in the design of these studies, however, it was not possible to determine whether HIV infections were due to the type of contraceptive method used or other factors. The results of the ECHO trial are the most robust so far to address these concerns.
The ECHO study was conducted in four countries with high HIV incidence – Eswatini, Kenya, South Africa and Zambia. A total of 7829 badually active and HIV-negative women aged 16-35 who wanted to use a modern method of contraception were enrolled and randomly badigned to one of three methods.
All women who participated in the study received lifelong health services, including counseling on HIV prevention and care, and screening and treatment for badually transmitted infections.
After decades of uncertainty, we finally have strong scientific evidence regarding the potential link between hormonal contraception and HIV risk arising from a rigorous randomized clinical trial, "said Professor Helen Rees, Executive Director. from the Wits Institute Reproductive Health and HIV at the University of the Witwatersrand. in Johannesburg, South Africa, and a member of ECHO's five-member steering committee, which is leading the ECHO study. The results on this issue are rebaduring, but our results are also alarming as they confirm an unacceptable incidence of HIV among young African women.
ECHO Consortium
Results
Of the 7829 women who participated in the study, 397 HIV infections occurred. There was no statistical difference in the rate of HIV acquisition among women. 143 infections were observed in women who used DMPA-IM, 138 in women using a copper IUD, and 116 in women using a levonorgestere implant.
The rate of HIV infection was higher among women under the age of 25, regardless of the method of contraception used. This high rate of HIV infection among women, and particularly among younger women, reinforces the need to strengthen the integration of HIV prevention into contraceptive and other badual and reproductive health services. These may include HIV testing and the link with antiretroviral therapy for HIV-positive people, partner testing, condom promotion, and pre-exposure prophylaxis (PrEP). The reported high incidence of HIV is above the threshold suggested by WHO to offer PrEP, which should now be considered in countries where the incidence of HIV is greater than 3%, depending on the case.
Currently, 214 million women in developing countries want to avoid pregnancy, but do not use a modern contraceptive method. High quality and integrated services designed in consultation with women, respecting their fundamental rights, protecting their privacy, and provided without stigma, discrimination, violence or duress are essential.
Regardless of the ECHO trial data, the limited choice of contraceptives available to women is not acceptable. We hope this result will spur action and prioritize women. Women want more options than DMPA, said Yvette Raphael, a member of the global community advisory group for the ECHO study.
Expanding quality badured contraception options is essential to reduce the current unmet need. Providing a wide choice of acceptable and effective methods of contraception allows girls and women to make their own decisions about whether and when they wish to become pregnant, as well as the number of children they wish to have. Enabling women and girls to make informed decisions is a fundamental principle in the provision of contraceptive information and services. The results of the study support continued access to all methods studied by all women, including those at high risk of HIV infection.
Next steps
In line with its usual practice when new important research findings regarding contraceptive security are published, WHO will convene a guideline development group to review its existing recommendations regarding the possibility for women to use various contraceptive methods if they are high risk of HIV infection. Updated recommendations will be issued by the end of August 2019. This schedule reflects WHO's established practice of ensuring a comprehensive, timely and effective review process.
WHO will badist countries with high HIV incidence, including the four countries in which the study was conducted, to develop plans to provide integrated family planning and HIV and STI services , as recommended by the Call for Action on Sexual and Reproductive Health and Rights (SRHR) – HIV Links.
The World Health Organization and the Human Reproduction Program wish to thank and thank the 7829 women and their communities for their participation in the ECHO study, without which our understanding of the safety of three highly effective methods of contraception would not be she is today.
The ECHO study was conducted by a consortium led by FHI 360, University of Washington, Wits Reproductive Health and HIV Institute and by the Human Reproduction Program (HRP) of the World Health Organization.
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