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Hormonal Contraceptives and Risk of HIV Acquisition: What We Know

This article presents the findings of a multicentre trial that investigated the relationship between hormonal contraceptives and HIV risk. The trial found no significant difference in HIV acquisition risk among different contraceptive methods. The results highlight the importance of continued access to these contraceptive methods, complemented by high-quality HIV prevention services.

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Hormonal Contraceptives and Risk of HIV Acquisition: What We Know

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  1. Hormonal Contraceptives and Risk of HIV Acquisition: What We Know • 30 years of epidemiologic and laboratory studies have tried to determine whether there is truly increased risk of HIV acquisition associated with use of hormonal contraception. • Some studies showed that progestin-only injectables, particularly the intramuscular injectable depot medroxyprogesterone acetate (DMPA-IM), were linked to increased HIV risk, but other studies did not show this result. • In meta-analyses, the magnitude of increased HIV risk was approximately 40-50% (i.e., hazard ratios of 1.4-1.5)

  2. Evidence for Contraceptive and HIV Outcomes (ECHO) Trial • ECHO was a multicentre, open-label, randomised clinical trial comparing HIV incidence and contraceptive benefits in women living in areas of high HIV incidence and using one of three highly-effective, licensed contraceptive methods: • intramuscularly-delivered depot medroxyprogesterone acetate (DMPA-IM) • a copper intrauterine device (IUD) • and a levonorgestrel (LNG) implant (Jadelle) • Eliminates bias by using randomization for assigning contraceptive methods • 9 study sites in South Africa, one each in Kenya, Swaziland and Zambia

  3. ECHO Results Overview of Trial design and results

  4. ECHO Trial: Contraceptive Method Use • 7785 / 7829 women (99.4%) accepted their randomized method at enrolment. • Of the 44 who initially declined, 0 were assigned DMPA-IM, 36 (1.4%) copper IUD, 8 (0.3%) LNG implant • Participants used their methods for 92% of the time they were in the study • For DMPA-IM, 99.2% of injections were provided on-site 93.1% 93.7 89.0% Copper IUD 93.7% LNG implant DMPA-IM

  5. ECHO Trial: Pregnancy Outcomes • Pregnancy rates were low, in all three groups, and most pregnancies (71%) occurred among women who had previously discontinued their randomised method. • All methods had high contraceptive effectiveness – the two hormonal methods had lower pregnancy rates than the IUD.

  6. ECHO Trial: HIV Outcomes • The overall rate of new HIV infections was high: 3.81% per year (95% CI 3.45-4.21). • In total, 397 of the 7829 women acquired HIV during the study • The trial was designed to detect a 50% increase in HIV incidence for each of the contraceptive methods compared to each of the others. None of the comparisons showed a 50% increase in HIV incidence.

  7. ECHO Trial: Key Findings • The multi-country randomised trial measured HIV incidence among African women assigned to one of three highly-effective contraceptive methods. • Contraceptive findings: • All methods were acceptable and had very high rate of continuation. • All methods were highly effective and were associated with very low pregnancy rates. • All methods were safe – few serious adverse events. • HIV Findings: • No significant difference in HIV acquisition risk among contraceptive methods. • HIV incidence was high among women using all three contraceptive methods and slightly higher among younger women. • For individual women at very high HIV risk, we acknowledge that even a relatively small effect might be important in contraceptive and HIV prevention decision-making

  8. Programmatic Implications of ECHO Findings • Family Planning • 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. • This trial demonstrates that delivery of high-quality services to support the use of the copper IUD and the LNG implant across multiple African settings is possible with appropriate investment in training, assurance of provider clinical competency, adequate human resources for counselling and management of side effects, and necessary logistical support including management of commodities. • The results cannot be generalized to other contraceptive methods not included in the study (e.g., NET-En, DMPA-SC, hormone-containing IUDs, etc.)

  9. Programmatic Implications of ECHO Findings • HIV • In spite of an individualized HIV prevention package provided to all participants throughout follow-up and country-wide HIV treatment and prevention programmes, HIV incidence was alarmingly high in this population throughout the course of the trial and STI prevalence at baseline was also very high. • The results strongly emphasize the need for more aggressive HIV and STI prevention and management efforts for African women, including HIV pre-exposure prophylaxis (PrEP) and HIV prevention integrated with contraceptive services.

  10. ECHO Trial and Family Planning: Key Points • WHO will provide updated Medical Eligibility Criteria guidance on hormonal contraception for women at high risk of HIV in September 2019. • In the interim the WHO 2017 MEC Guidance for women at high risk of HIV should continue to be followed. Women at high risk of HIV who consider progestin-only injectables should not be restricted from use and should: • Be advised about the potential increased risk of HIV acquisition because of risky situations and acts. • Receive HIV prevention information • Be advised that dual method use is the best option to prevent both STI/HIV acquisition and unintended pregnancy • Have access to a wide range of contraceptive methods to make a free and informed choice of the method that best fits their needs/situation (including their HIV risk)

  11. Additional Resources on the ECHO Trial • For further information on the ECHO Trial and its results please go to the following sources: • The official site of the ECHO Consortium http://echo-consortium.com/ • This site contains a variety of resources for understanding the trial, its results and the way forward, including press releases, official statements, published articles, slide decks and • The presentation of the results in South Africa https://www.youtube.com/watch?v=gUgnLa24GBc&feature=youtu.be • The WHO page for the ECHO Trial https://www.who.int/reproductivehealth/hc-hiv/en/ • This site provides a statement on the trial and its results in English, French and Spanish, as well as links to additional materials about the trial, its results, and going forward

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