Results of a pivotal clinical trial among 7,829 women ages 16-35 in East and Southern Africa provide important evidence to help inform women’s choices for contraception and HIV prevention. The Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study found no substantial difference in HIV risk among women using the three methods of contraception in the study – the copper-releasing intrauterine device (Cu-IUD), a levonorgestrel (LNG) implant (Jadelle) and depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as Depo-Provera.
The data, released today at the South African AIDS Conference, also sound an alarm about rates of HIV infection among women in East and Southern Africa. Overall, HIV infection rates among the study population were almost 4 percent – underscoring the need to integrate HIV and sexual and reproductive health programs and to dramatically and quickly expand HIV prevention information and services.
“These highly anticipated results contain good news and bad news: on the one hand, a well-run randomized clinical trial has demonstrated no difference in HIV risk among three highly effective family planning methods that are safe and effective. On the other hand, the trial delivered a sobering reminder that women and girls in East and Southern Africa are still at very high risk of HIV infection. An overall HIV infection rate of almost 4 percent in the study points to a public health crisis for women in the region,” said Mitchell Warren, AVAC Executive Director. “ECHO provides the data needed to help guide clear policy decisions that support programs that give women fully integrated HIV and pregnancy prevention information and choice.”
Previous trials of HIV prevention options in the region have often shown very high rates of HIV infection among participants, but the eligibility criteria for those trials usually include characteristics that are associated with HIV risk, such as transactional sex, history of sexually transmitted infections or self- reported high-risk behaviors. In the ECHO study, the only sexual behavioral eligibility criterion was being sexually active. This makes the high rates of HIV infection seen in this general population alarming; the World Health Organization guidelines for oral PrEP say that a 3 percent rate of new infections is the definition of “substantial risk”.
“The women in this trial are our sisters and daughters and mothers who were simply seeking contraception,” says Lillian Mworeko, Executive Director of the International Community of Women Living with HIV/AIDS Eastern Africa and co-chair, with AVAC, of the Civil Society HC-HIV Advocacy working group, an Africa-based network of women and allies working on HIV and sexual and reproductive health and rights in the context of ECHO and beyond. “It is a wake-up call to put HIV prevention on-site at every family planning clinic including PrEP and female condoms with peer support and trained providers.”
“Women urgently need access to information about contraception and HIV prevention, and they need expanded access to the full range of proven contraceptives and HIV prevention options, including female condoms and daily oral PrEP,” Warren added. “And we need to accelerate the development of and access to additional women-controlled HIV prevention options like the monthly dapivirine vaginal ring (currently pending regulatory approvals), and other long-acting methods, including vaccines. At the same time, ECHO provides added urgency to the development of methods that combine HIV prevention and contraception.”
The announcement of the ECHO results is an important step for women’s health as it provides evidence that WHO and national Ministries of Health will use to make decisions that will have impact on policies, programs and women’s lives. “Policy makers, funders and program implementers must urgently work to provide women with access to all sexual and reproductive health options in the same place at the same time, delivered with accurate and adequate information and without judgement,” Warren said.