Intervention Update: Hormonal Contraception and HIV

The past year has seen lots of discussion and some action in the search for answers as to whether hormonal contraceptives including long-acting methods such as Depo-Provera (DMPA) and other injectable contraceptives and the implant affect women’s risk of acquiring HIV.

In mid-2014, there was uncertainty about the fate of the proposed ECHO trial that would use a randomized design to directly measure rates of HIV acquisition in women using three different methods: DMPA, the Jadelle implant and the copper IUD. Many women’s groups in the US and in Africa have voiced their support for ECHO as part of a comprehensive approach to ensuring that women can make fully-informed choices about HIV prevention and family planning.

It now appears likely that the trial will move forward. As AVAC Report went to press, the trial hadn’t officially been funded, but there was reinvigorated community engagement and the signs continued to seem good.

Also, in early 2015, there were two publications of new meta-analyses of existing data on contraceptive use and risk of HIV acquisition among women. The data, all observational, were gathered from participants in a range of studies. None of these studies randomly assigned women to different methods, which can result in biased results. Much of the data had been previously reviewed in systematic reviews. These meta-analyses used different techniques to crunch the numbers on these data—plus some new findings—and came up with largely the same conclusions as the prior systematic reviews.

Both of the new meta-analyses indicate that use of DMPA may potentially increase women’s risk of HIV acquisition. Both the magnitude and the statistical significance (e.g., the degree of confidence that the finding was real and not a coincidence) varied by the study quality and/or the population considered.

These findings are not news in and of themselves. However, each time a study or analysis is published on this issue, particularly when the results suggest a significant effect, in a zone of such uncertainty it triggers fresh discussion and debate.

In light of these recent publications, it would be appropriate for the WHO to reconvene an expert stakeholder group to review both current recommendations and communication strategeies regarding DMPA and similar products with a particular focus on the countries in East and Southern Africa where rates of HIV and DMPA use are high.

The new studies add information and questions that need to be conveyed to women living in countries where DMPA use and HIV prevalence are both high. These countries are mainly in East and Southern Africa—the location of the proposed ECHO trial.

It is critical that the ECHO team engage with civil society stakeholders to explore the understanding and implication of this paper as part of a broader discussion about the planned launch of the trial later in 2015.

During the November 2014 “summit” of the FP2020 initiative (the global family planning initiative that aims to increase women’s access to contraception worldwide), FP2020 leadership indicated that it would await and follow the results of the ECHO trial as well as country and WHO guidance.

It would be invaluable to the field for FP2020 to convene a meeting of family planning policy makers and implementers in potentially—affected countries to discuss existing plans, proposed expansion of method mix, and processes for interpreting and acting on these results.

There is a robust civil society constituency following the issues around HC-HIV. Members of this dialogue have diverse views on whether a randomized trial such as ECHO is on the critical path—but are united in the need for family planning and HIV programming to:

• Address the uncertainty with clear messages on knowns and unknowns, risks and benefits of all methods;
• Invest in increased method mix today; and
• Sustain investment in developing new contraceptive, HIV prevention and, especially, multipurpose prevention options that could, in the future, reduce HIV risk and prevent unwanted pregnancies.

AVAC will continue to work with partners to distill new findings, convene dialogues with scientists and other partners, and ensure that an informed advocacy voice helps guide decisions in this key area.