Women at high risk for HIV infection can use any form of reversible hormonal contraception without any restrictions, including progestogen-only injectables, implants, and intrauterine devices (IUDs), the World Health Organization (WHO) said.
All forms of hormonal birth control are now classified as category 1 ("use the method in any circumstances") under the WHO's Medical Eligibility Criteria for Contraceptive Use (MEC) guideline.
However, correct and consistent condom use is also recommended to prevent HIV and sexually transmitted infections (STIs), as well as pre-exposure prophylaxis (PrEP) in areas where incidence of HIV exceeds 3%, according to the updated guidance document published on the WHO website.
"Evidence shows that a woman's risk of HIV should not restrict her contraceptive choice," said Peter Salama, MBBS, the WHO's executive director of universal health coverage/life course, in a statement. "All women should have access to a wide range of options for contraception as well as to HIV prevention and to treatment if needed."
This turnaround from the WHO had a couple of stages. It started with the long-awaited results of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial back in June, which found no significant difference in HIV incidence among women randomized to intramuscular depot medroxyprogesterone acetate (DMPA-IM), copper IUDs, or levonorgestrel (LNG) implants.
These findings were discussed in greater detail at the International AIDS Society (IAS) Conference on HIV Science in July in a series of subanalyses of the ECHO trial data. At a press conference, a WHO representative noted that the organization was looking at the evidence and a guidelines group was meeting in late July about this issue.
This updated guidance replaces the WHO's previous and more cautious MEC guideline, which the organization said was based on "low to low-moderate quality evidence from observational studies."
However, a Guideline Development Group consisting of 28 participants from 19 countries decided that based on the high-quality evidence from the ECHO trial, all forms of reversible contraception are now MEC category 1, including:
- Progesterone-only contraceptive methods, including the pill, DMPA-IM and subcutaneous depot medroxyprogesterone acetate (DMPA-SC), norethisterone enanthate (NET-EN), LNG implants, and etonogestrel (ETG) implants
- Copper-bearing IUDs and LNG-IUDs, with the caveat that women should be screened for STIs prior to IUD insertion
- Combined methods of contraception, including oral contraceptives, injectable contraceptives, contraceptive patches, and vaginal rings
Notably, the authors said that while there was no direct evidence available for DMPA-SC, LNG-IUDs, or ETG implants, "there was no biological or clinical reason to believe that a lower hormonal dose, different delivery mechanism or different progestogen would modify HIV risk."
In addition, the WHO noted another finding from the ECHO trial -- namely the need to integrate STI prevention services within contraceptive services. At the IAS meeting, Nelly Mugo, MBChB, of Kenya Medical Research Institute in Nairobi, said, "We need a call for urgent action; [we have] an urgent need to respond to high rates of incident infections [among these women]."
"We have failed young women," she added.
The WHO agreed, saying in a statement that they will work with Ministries of Health and other organizations that provide both contraception and STI/HIV services, including youth organizations, to help implement these recommendations.
"There is a clear need to ensure women in Africa have access to high quality HIV and STI prevention and testing services, along with a wide range of contraceptive options to suit their values, preferences, views, and concerns," said Felicitas Zawaira, MD, director of family and reproductive health in WHO's African region, in a statement, adding that this includes condom promotion, PrEP, linkages to care for those testing positive for HIV, and partner testing.
In addition, WHO said it established an advisory group of women living with HIV, to ensure their perspectives about HIV and sexual reproductive health and rights are considered across the organization.