One of the largest and most robust studies to be conducted so far on the effect of contraceptive methods on the risk of acquiring HIV concluded that there were no significant differences among users of any of four popular long-acting contraceptives. This includes DMPA, levonorgestrel, and intrauterine devices.
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The Evidence for Contraceptive Options and HIV Outcomes (ECHO) study compared the following contraception methods: 3-monthly DMPA-IM (intramuscular depot medroxy progesterone acetate), implanted LNG (levonorgestrel) that acts for five years, and a copper-carrying IUD (intrauterine device) that lasts 10-12 years.
In total, 7829 women were randomly assigned to receive one of the four contraceptive methods. The researchers then followed their HIV status for the next 18 months, to determine whether any of the methods increased the risk of HIV infection.
The WHO reports that safe and effective contraception is sought by 214 million women in low- and middle-income countries, including almost half of African women who want to avoid pregnancy. The study could help address this need.
Regardless of the data from the ECHO trial, the limited choice of contraceptives that women have is not OK. We hope that this result will prompt action and put women first. Women want more options beyond DMPA.”
Yvette Raphel, Advisory Member for the Study
Responding to previous research
The ECHO study began in response to repeated reports suggesting that the use of contraceptives using only progestogens, including DMPA-IM, could promote HIV infection in the users. This was based on several observational studies.
For instance, the Lancet published a report citing a two-fold risk of HIV infection among women on this injection. This was followed by a report in the journal Lancet Infectious Diseases (2015) which showed an increased risk of 40% in this group. On the other hand, the researchers also warned of the dangers of unwanted pregnancy.
The current paper includes thousands of active women who were HIV negative at the start of the study and live in countries where HIV is highly prevalent – Eswatini, South Africa, Kenya and Zambia. All of them were willing to use modern contraception. Before receiving any of the contraceptive options, the women were counseled on HIV prevention and treatment, screening and the management of other sexually transmitted infections with their partners. They were also provided with condoms, and late in the trial, with pre-exposure prophylaxis (PrEP, a daily antiviral drug which prevents HIV).
During the 18 months that followed, 92% of the women adhered to the contraceptive plans, and almost 400 HIV infections occurred. These were almost equally distributed among the three groups. The risk was 29% higher for DMPA compared with the LNG implant, but only 10% higher than with the copper IUD. The latter had an 18% higher risk compared with the LNG implant.
Discontinuation rates ranged from 4% to 9% and were highest with the copper IUD. 255 pregnancies occurred, of which almost 30% occurred during the use of the contraceptive method. These results will be reflected in the updated WHO contraception guidelines expected in August 2019.
‘A public health crisis’
The study group showed a disturbingly high incidence of new HIV infections in this low-risk group, almost 4% per year. HIV poses both personal and public health challenges in these countries, with 600 000 new female HIV infections each year. This is especially true for sexually active women under the age of 25 years.
Calling this a “public health crisis”, HIV experts recommend that contraception services should include HIV testing and multiple choices for HIV prevention.
For HIV-positive women, this includes linking to antiretroviral therapy, partner testing, and promoting condom use. Condom use is not acceptable in some places. As a result, women bear the brunt of infection in sub-Saharan Africa, reporting almost 60% of new infections.
Scientists are looking for contraceptives which can be used by women rather than by men, and which stop the HIV virus as well. PrEP is the standard for regions where the reported incidence crosses the WHO threshold of 3%.
After decades of uncertainty, we finally have robust scientific evidence about the potential relationship between hormonal contraception and the risk of HIV from a rigorous randomized clinical trial. [However], the findings are also sobering because they confirm unacceptably high HIV incidence among young African women. “
Helen Rees, Researcher
ECHO Consortium (2019). 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. The Lancet. https://doi.org/10.1016/S0140-6736(19)31288-7