A large clinical research study conducted in four African countries found no significant difference in risk of HIV infection among women using one of three highly effective, reversible contraceptive methods.

A Publication in the Lancet and copied to the Ghana News Agency, said a study showed that each method had high levels of safety and effectiveness in preventing pregnancy, with all methods well-accepted by the women using them.

The three methods investigated in the trial known as the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study were: DMPA - intramuscular (DMPA-IM), a three monthly, progestogen-only, reversible injectable contraceptive.

The rest are; Levonorgestrel implant, a progestogen-only implant inserted under the skin in the upper arm that can be used for up to five years and the copper-bearing IUD, a device inserted into the uterus that can be used for up to 10-12 years.

Dr James Kiarie, Department of Reproductive and Research, World Health Organisation said “These results support making available to women and girls a broad choice of effective contraceptive methods that empower them to make informed decisions about their own bodies - including if and when to have children.”

“Better access to contraception and quality reproductive health services will have a dramatic impact in improving the lives of millions of women and their families.

The study found, however, that incidence of HIV infections among all of the women participants was high – an average of 3.8% per year- indicating that HIV remains a significant personal risk and public health challenge for many women in these countries.

The study highlights the need to step up HIV prevention efforts in these high-burden countries - particularly for young women,” said Dr Rachel Baggaley from WHO’s HIV and Hepatitis Department.

“These should include providing HIV testing and a range of HIV prevention choices within contraceptive service programmes.

About the study: Over the past 25 years, as the HIV epidemic took hold in many countries, a number of observational research studies suggested a possible increased risk of HIV acquisition for women using progestogen-only injectables, particularly DMPA-IM. Because of limitations in the design of these studies, however, it was not possible to determine whether HIV infections were due to the type of contraceptive method used or other factors. The results of the ECHO trial are the most robust to date that addresses these concerns.

The ECHO Study was carried out in four countries with settings of high HIV incidence. Eswatini, Kenya, South Africa and Zambia. A total of 7,829 sexually active HIV-negative women aged 16 to 35 years, who wanted to use a modern method of contraception, were enrolled and were randomly assigned to one of the three methods.

“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,” said Professor Helen Rees, Executive Director of Wits Reproductive Health and HIV Institute at the University of Witwatersrand in Johannesburg, South Africa, and a member of the five-person ECHO Management Committee that leads the ECHO Study.

The results on this question are reassuring, but our findings are also sobering, because they confirm unacceptably high HIV incidence among young African women.

Results: Among the 7,829 women who took part in the study, 397 HIV infections occurred. There was no statistical difference in the rate of acquisition of HIV among women. 143 infections were in women who used DMPA-IM, 116 in women who used a levonorgestrel implant and 138 were in women who used the copper-bearing IUD.

The rate of HIV infection was higher for women aged less than 25 years, irrespective of the method of contraception used. This high rate of HIV infection among women, and especially younger women, reinforces the need to strengthen HIV prevention integration within contraceptive and other sexual and reproductive health services.

These may include HIV testing and linkage to antiretroviral therapy for those testing HIV-positive, partner testing, condom promotion, and pre-exposure prophylaxis (PrEP).

The high incidence of HIV reported is above the WHO suggested threshold for offering PrEP, which should now be considered in countries where the incidence of HIV is above 3%, as appropriate.

Currently 214 million women in developing countries want to avoid pregnancy but do not use a modern contraceptive method. High-quality and integrated services that are designed in consultation with women and that respect the human rights of women and girls, protect their privacy, and are provided free of stigma, discrimination, violence or coercion are essential.

Regardless of the data from the ECHO trial, the limited choice of contraceptives that women have is not right. We hope that this result will prompt action and put women first. Women want more options beyond DMPA, said Yvette Raphael, member of the Global Community Advisory Group for the ECHO Study.

Expanding quality-assured contraceptive options is critical in reducing the current unmet need. The study findings support continued access to all the methods studied by all women including those at high risk of HIV infection.

Next steps: WHO will convene a Guideline Development Group to review its existing recommendations concerning women’s eligibility for using various contraceptive methods if they are at high risk of HIV and updated recommendations issued by the end of August 2019. This timeline reflects WHO’s established practice to ensure a timely, robust and inclusive review process.

The WHO will support countries with high HIV incidence rates, including the four countries in which the study was conducted, to develop plans to provide integrated family planning and HIV and STI services as recommended in the Call to Action on Sexual and Reproductive Health and Rights(SRHR)-HIV Linkages.

The ECHO study was carried out by a consortium led by FHI 360, University of Washington, Wits Reproductive Health and HIV Institute, and the Human Reproduction Programme (HRP) at the World Health Organisation.