Study finds no difference in HIV risk among three common methods of contraception

A landmark clinical trial in eastern and southern Africa has found no substantial difference in the risk for acquiring HIV among women using any of three common methods of contraception, but also, Johns Hopkins experts say, showed an unacceptably high incidence of HIV infection among women who participated in the study.

Data from the Evidence for Contraceptive Options and HIV Outcomes, or ECHO, study, published today in The Lancet. The journal also includes a commentary on the study co-authored by Lisa Noguchi, director of maternal and newborn health for Jhpiego, a non-profit affiliate of Johns Hopkins and a global leader in the creation and delivery of both HIV prevention and family planning services in high HIV prevalence settings.

"While ECHO has answered important questions about risk of HIV acquisition among women seeking effective contraception, a great deal of work remains to be done to ensure all women and girls receive better integrated family planning, HIV prevention, and maternal health services," Noguchi said.

Added Leslie Mancuso, Jhpiego's president and CEO: "The study results are particularly reassuring for women and girls at high risk for HIV acquisition, many of whom live in countries served by Jhpiego programs in family planning, HIV, and maternal and newborn health. This evidence is critical for Jhpiego staff and health providers who care for millions of women and girls at risk for HIV who depend on or are planning to use contraception. It also compels us to find more robust ways to engage women and girls in their own health."

For the trial, 7,829 sexually active, HIV-negative women between the ages of 16 and 35 were randomly assigned to use one of three highly effective methods of contraception:

• An injectable depot medroxyprogesterone acetate intramuscular, or DMPA-IM
• A progestin-based implant containing the hormone levonorgestrel, or LNG implant
• A non-hormonal copper intrauterine device, or copper IUD

Results were announced today at the South African AIDS Conference in Durban, South Africa.

The World Health Organization plans to issue guidance in late July on the medical eligibility criteria for the contraceptive methods used in the study, and Jhpiego will work closely with in-country partners to incorporate updated guidelines into practice for frontline health care providers, most of whom are nurses and midwives.

Kelly Curran, Jhpiego's senior director for HIV and infectious diseases, said she welcomed the results of the study but lamented the high rate of new HIV infections among study participants.

Curran noted that overall HIV incidence in ECHO was nearly 4% per year, despite the fact that participants received extensive HIV prevention counseling. While this figure might sound low, Curran said, "if 100 girls are HIV negative at age 15, but 4% of them acquire HIV each year, you can see how prevalence in these settings becomes sky high by age 30.

"This demonstrates that many women in southern and eastern Africa remain at risk and need access to evidence-based HIV prevention strategies," she added.

The ECHO Study randomly assigned HIV-negative women from the Kingdom of Eswatini, Kenya, South Africa, and Zambia to use one of the three contraceptive methods. Women received counseling on family planning and HIV prevention and referral for oral PrEP, or pre-exposure prophylaxis, where available. A key impetus for the trial was ongoing uncertainty about whether DMPA-IM increased women's risk of contracting HIV, a concern that has been ongoing for several decades.

Importantly, the results of ECHO confirmed that the three methods—all used in countries where Jhpiego works—are safe and effective for preventing pregnancy.