There is no difference in the risk of acquiring HIV for women using three different types of long-acting, reversible contraception in sub-Saharan Africa, according to the findings of the ECHO study that were released today at the South African AIDS Conference in Durban. The findings were simultaneously published in The Lancet.
The Evidence for Contraceptive Options and HIV Outcomes (ECHO) study was designed to investigate whether the long-acting contraceptive injection DMPA-IM (intramuscular depot medroxyprogesterone acetate, or Depo Provera) raised the risk of HIV infection for women compared to other widely available and highly effective methods of long-acting contraception.
The study was conducted after several meta-analyses of observational studies indicated that women using DMPA-IM had a 40%-50% higher risk of HIV infection. In 2017, the World Health Organization recommended that women choosing an injectable progestin-only contraceptive and at high risk of HIV infection should be advised of the potential increased risk. But the expert panel that framed this guidance also concluded that more high-quality evidence was needed before WHO could issue guidelines on contraceptive choices for women at risk of HIV infection.
DMPA-IM has been used more frequently than other methods in sub-Saharan Africa, although the overall use of modern contraceptive methods remains low owing to lack of funding of contraceptive services in many countries in the region. Approximately 58 million women use modern contraceptive methods in sub-Saharan Africa.
“We have a massive unmet need for contraception in our region and the method that the majority of women are choosing or being given is injectable,” Prof Helen Rees of Wits Reproductive Health and HIV Institute, South Africa told delegates at the conference.
The ECHO study compared three long-acting, reversible contraceptive methods in 7829 HIV-negative women aged 16-35 years seeking an effective contraception method in South Africa eSwatini, Kenya, and Zambia. Participants were recruited in districts where local epidemiology showed that women were at high risk of HIV infection.
Women were randomised to DMPA-IM, copper intrauterine device or levenorgestrel implant. The study was open-label as there was no way of blinding investigators or participants to the type of contraception being used.
The primary outcome measured in the study was HIV infection, and the study was designed to detect a 50% increase in the risk of HIV infection for any contraceptive type.
The median age of study participants was 23 years, 81% of women were unmarried and 29% were living with a partner. Eighty-one percent had been pregnant at least once. At baseline, just under half (48%) reported that a condom had not been used at last sexual act and 73% reported unprotected sex in the past three months.
There were 397 HIV infections (an incidence of 3.8% per year) in the study – 143 in the DMPA-IM group (4.2% per year), 138 in the copper IUD group 3.9%), and 116 in the LNG implant group (3.3%). There was no significant difference in the risk of HIV infection according to the form of contraception used, and the lack of difference persisted when analysis was restricted to continuous users of the assigned contraceptive method (86% of the total follow-up recorded).
All three contraceptive methods were highly effective. Approximately one percent of women in each study arm became pregnant, among study participants who were counted as continuous users. Women using either one of the hormonal methods continuously were significantly less likely to become pregnant than women using the copper IUD method (p=0.027).
“These results underscore the importance of continued and increased access to these three contraceptive methods, as well as expanded contraceptive choices, complemented by high-quality HIV and STI prevention services. Women’s informed choice in sexual and reproductive health services is essential. This evidence will enhance women’s contraceptive decision making and assist providers and policymakers in delivering high-quality, rights-based contraceptive care,” Prof Rees said.
Reference: HIV incidence among women using
intramuscular depot medroxyprogesterone acetate, a copper intrauterine device,
or a levonorgestrel implant for contraception: a randomised, multicentre,
open-label trial. Evidence for Contraceptive Options and HIV Outcomes (ECHO)
Trial Consortium. The Lancet. Published 13 June 2019. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31288-7/fulltext