“I suspect that this will turn out to be one of the most important studies in the HIV and SRH (sexual and reproductive Health) fields,” said Prof Helen Rees (executive director, Wits RHI and personal professor, obstetrics and gynaecology, University of Witwatersrand). She was speaking at the official release of the results of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study, at the South African AIDS Conference last month.

In settings with high HIV prevalence, a major effort will be needed to rapidly scale up provision of combination HIV prevention services as part of contraceptive service delivery.

A member of the five-person ECHO management committee that leads the ECHO Study, Prof Rees said, “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 randomised clinical trial. The results on this question are reassuring, but our findings are also sobering, because they confirm unacceptably high HIV incidence among young African women.”

Conducted in four African countries, the ECHO study found no significant difference in risk of HIV infection among women using one of three highly effective, reversible contraceptive methods DMPA-IM injectables, Levonorgestrel implants and copper-bearing IUDs. “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,” said Dr James Kiarie, from the department of Reproductive Health and Research at the World Health Organization (WHO).

“Better access to contraception and quality reproductive health services would have a dramatic impact in improving the lives of millions of women and their families.” However, the study also found 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.

While welcoming the results of the study, 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) said, “These results are not good. The women in this trial are our sisters, mothers, and daughters who were simply seeking contraception. The results of the ECHO trial are a wakeup call to put HIV prevention on-site at every family planning clinic including PrEP and female condoms with peer support and trained providers.”

Mworeko raised concerns that, “The South African government continues to keep PrEP (pre-exposure prophylaxis) a secret, only targeting certain people for access to PrEP and not making it available to women in this country. Women need strategies to prevent HIV and AIDS.” Mworeko said the reason the Department of Health and clinic facilities were failing women was in part, “Due to corruption and the stealing of money meant for programmes for women.”

Highlighting impossibly long queues at clinics and the lack of choices of birth control, Mworeko said this was only the beginning of a long fight. “When choosing a contraceptive method, women have the right to the latest and best information and to access their preferred options that is safe, effective and acceptable,” she said.

Dr Rachel Baggaley from WHO’s HIV and Hepatitis department echoed Mworeko’s sentiments. “The study highlights the need to step up HIV prevention efforts in these high-burden countries – particularly for young women. These should include providing HIV testing and a range of HIV prevention choices within contraceptive service programmes,” she said.

“Regardless of the data from the ECHO trial, the limited choice of contraceptives that women have is not okay. 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). The WHO said HIV remains a significant personal risk and public health challenge for many women.

“In settings with high HIV prevalence, a major effort will be needed to rapidly scale up provision of combination HIV prevention services as part of contraceptive service delivery. Expanding quality-assured contraceptive options for voluntary family planning is critical in reducing the current unmet need of some 214 million women of reproductive age in developing countries who want to avoid pregnancy but are not using a modern contraceptive method. Enabling women and girls to make informed decisions is a fundamental principle when providing any contraceptive information and service.”

WHO stressed that when choosing a contraceptive method, women have the right to the latest and best information and to access their preferred options that is safe, effective and acceptable.

THE ROAD AHEAD

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, programmes and women’s lives. “Policy makers, funders, and programme 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,” said Mitchell Warren, executive director of AVAC (Global Advocacy for HIV Prevention).

“ECHO provides the data needed to help guide clear policy decisions that support programmes that give women fully integrated HIV and pregnancy prevention information and choice,” he said. Committing to issue updated recommendations by the end of August 2019, the 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.

WHO said it 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. “Ultimately, the response to ECHO results must be centred on and informed by women and girls in Africa, where the trial occurred and where substantial burden persists in unmet need for family planning and HIV prevention, both of which have suffered from siloed approaches to funding and programming,” Lisa Noguchi (Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University) and Princess Simelela (WHO) said in the Lancet (How should we listen to ECHO? published online 13 June 2019).

“Going forward, health systems need innovative models that more conveniently integrate services according to the preferences of women already too burdened with unpaid work and acknowledge the reality of how partners and family members affect women’s choices,” said Noguchi and Simelela. “However, policies and guidelines must reflect women’s and girls’ right to autonomous decision making over their own bodies and promote access to comprehensive sexual and reproductive health services. Realisation of this goal does require remedying the inadequate quality of care that discourages many people, especially adolescents, from using such services.

“Without addressing underlying drivers of poor delivery, experience, and uptake of care, we will not achieve true universal health coverage or the sustainable development goal of good health and wellbeing for all. Gender bias continues to contribute to gaps in resources needed to address these drivers and, consequently, the world is still failing its most vulnerable women and girls.”