Post written by Stephanie Jaffe and Bailey Knight, FHI 360
On June 13, 2019, the results of the much-anticipated Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial were presented live at the SA AIDS 2019 conference in Durban, South Africa, and published online by the Lancet. This randomized controlled trial found no meaningful difference in risk of HIV acquisition across three forms of reversible modern contraceptive methods: the intramuscular depot medroxyprogesterone acetate injectable (DMPA-IM), the copper intrauterine device (IUD), and the levonorgestrel (LNG) implant. Over 7800 HIV seronegative women from four African nations—Eswatini, Kenya, South Africa, and Zambia—were randomly assigned a contraceptive method and monitored over 18 months for seroconversion.
In many regions in sub-Saharan Africa where HIV prevalence is high, DMPA-IM is the most common contraceptive option that women choose. Women and family planning stakeholders alike were alarmed when observational studies tenuously linked use of DMPA-IM, one of the most effective, discreet contraceptive methods, with a 40% or greater increase in HIV risk. The randomization of the ECHO trial removes the biases and confounding that are inherent in such observational studies, offering evidence that DMPA-IM does not exhibit a higher risk of HIV infection than the copper IUD or LNG implant.
Importantly, the ECHO trial also displayed high continuation rates (89-94%) for all three methods over the 18-month trial period, indicating that new or previously underused contraceptive methods would be welcomed into communities. Yvette Raphael, a member of the Global Community Advisory Group for the ECHO Study, has voiced the importance of improving the available method mix, describing the common scenario of young women “showing up at clinics and being told that they were getting the shot… no matter what method they’d come for, or wanted.” Expanded access to a variety of effective contraceptives, such as those included in the study, empowers a woman to have more control over her reproductive health.
Furthermore, ECHO highlights the importance of increasing efforts to prevent HIV transmission in high-burden countries. Although participants received HIV prevention services including risk reduction counseling, condoms, and partner and participant HIV/STI tests, Wits RHI’s Helen Rees notes that HIV incidence by the end of the study was still “unacceptably high” at 3.81% per year. International and governmental actors must work to integrate family planning and HIV services within communities, including expanded dissemination of pre-exposure prophylaxis (PrEP).
The ECHO study indicates that use of DMPA-IM, the LNG implant, or copper IUD do not increase risk of HIV infection and shows that all three methods are well-accepted by women. However, these findings are also a call to action; global actors must do more to expand the method mix throughout Southern and Eastern Africa and integrate HIV prevention and family planning services to improve the health of women worldwide.
This study was conducted by a research consortium led by FHI 360, the University of Washington, Wits Reproductive Health and HIV Institute (Wits RHI) and the World Health Organization (WHO).
Learn more about the ECHO Study here.