A large clinical research study conducted in four African countries revealed no significant differences in the risk of HIV infection among women using one of the three highly effective reversible contraceptive methods. Published today in the Lancet, the study showed that each method had high levels of safety and efficacy in preventing pregnancy, with all the methods well accepted by women who use them. The three methods investigated in the study – known as the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study – were:
DMPA – intramuscular (DMPA-IM), a reversible 3-month injectable contraceptive, progestin, reversible;
Levonorgestrel implant, a progestin-only implant inserted under the skin at the top of the arm that can be used for up to five years;
A copper-bearing IUD, a device inserted in the uterus that can be used for a maximum of 10-12 years.
These results support the making available to women and girls of a wide choice of effective contraceptive methods that enable them to make informed decisions about their bodies – including if and when to have children ", said Dr. James Kiarie, of Department of Health and Reproductive Research at the World Health Organization. "Better access to contraception and quality reproductive health services would have a dramatic impact on improving the lives of millions of women and their families.
The study found, however, that the incidence of HIV infections among all participating women was high – an average of 3.8% per year – indicating that HIV remains a personal risk significant and a public health challenge for many women in these countries.
The study underlines the need to intensify HIV prevention efforts in these countries with high workloads – particularly for young women, "said Dr. Rachel Baggaley of the Department of HIV and Medicine. Hepatitis of the WHO. "These should include the provision of HIV tests and a series of HIV prevention choices within the contraceptive service programs.
About the study
In the last 25 years, when the HIV epidemic has spread to many countries, a series of observational studies have suggested a possible increase in the risk of acquiring HIV for women who used only progestin-related injectables, in particular 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 to other factors. The results of the ECHO trial are the most solid to date that address these concerns.
The ECHO study was conducted in four countries with high HIV incidence facilities – Eswatini, Kenya, South Africa and Zambia. A total of 7,829 sexually active HIV-negative women aged 16 to 35 who wanted to use a modern method of contraception were enrolled and randomly assigned to one of three methods.
All women who participated in the study received ongoing health services, including counseling on HIV prevention and care, screening and treatment for sexually transmitted infections.
After decades of uncertainty, we finally have solid scientific evidence on the potential relationship between hormonal contraception and HIV risk from a rigorous randomized clinical trial, "said Professor Helen Rees, executive director of Wits Reproductive Health and HIV Institute at # 39. ; Witwatersrand University in Johannesburg, South Africa, and member of the ECHO Management Committee of five people who run the ECHO study The results on this question are reassuring, but our findings are making us think, because they confirm an unacceptable incidence of HIV among young African women.
Among the 7829 women who took part in the study, 397 HIV infections occurred. There was no statistical difference in the HIV acquisition rate among women. 143 infections were in women who used DMPA-IM, 138 were in women who used a copper-bearing IUD and 116 in women who used a levonorgesterel implant.
The rate of HIV infection was higher for women under the age of 25 regardless of the method of contraception used. This high rate of HIV infection among women, and especially younger women, reinforces the need to strengthen the integration of HIV prevention within contraceptives and other sexual and health services. reproductive. These may include HIV tests and links to antiretroviral therapy for those who are testing HIV positive tests, partner tests, condom promotion and pre-exposure prophylaxis (PrEP). The high HIV incidence is above the threshold suggested by the WHO for the offer of PrEP, which should now be considered in countries where the incidence of HIV is higher. at 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 and respecting the human rights of women and girls, protecting their privacy and being provided without stigma, discrimination, violence or coercion are essential.
Regardless of the ECHO trial data, the limited choice of contraceptives that women have is not OK. We hope this result will prompt action and put women first. "Women want more options than DMPA," said Yvette Raphael, a member of the ECHO Global Community Advisory Group.
The expansion of quality assured contraceptive options is essential to reduce the current unmet need. Providing a wide choice of effective and acceptable methods of contraception allows girls and women to decide for themselves if and when they wish to become pregnant and how many children they wish to have. Allowing women and girls to make informed decisions is a fundamental principle when providing contraceptive information and services. The results of the study support continued access to all the methods studied by all women, including those at high risk of HIV infection.
Following his standard practice when important new research results related to contraceptive safety are published, the WHO will convene a guideline development group to review its existing recommendations on the eligibility of women at the use of various contraceptive methods if they are at high risk of HIV. The updated recommendations will be published by the end of August 2019. This calendar reflects the established practice of the WHO to ensure a timely, solid and inclusive review process.
The WHO will support countries with high HIV incidence rates, including the four countries where the study was conducted, to develop integrated family planning and HIV and STI services as recommended in the invitation at the action on health and sexual and reproductive rights (SRHR) HIV Connections.
The World Health Organization and Human Reproduction Program would like 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 contraceptive methods would not be what and today.
The ECHO study was conducted by a consortium led by FHI 360, University of Washington, Wits Reproductive Health and HIV Institute and Human Reproduction Program (HRP) at the World Health Organization.
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