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• W3004802609 abstract "We read with interest the first public report from the ECHO trial,1Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial ConsortiumHIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial.Lancet. 2019; 394: 303-313Summary Full Text Full Text PDF PubMed Scopus (168) Google Scholar which showed no significant differences in HIV risk in women using intramuscular injection of depot medroxyprogesterone acetate (DMPA), levonorgestrel (LNG) implant, or copper intrauterine device (IUD) for contraception. This report might profoundly affect public health and family planning policies in countries where disproportionate numbers of young women live with HIV, and we feel that it is appropriate to comment on study results and conclusions that seem to generate more questions than answers. One unexpected and inadequately addressed result is the dissimilar sexual behaviour in women randomly assigned to DMPA versus long-acting reversible contraception (LARC). Although study participants had similar behaviour at enrolment, self-report of sexual behaviour during follow-up identified more multiple and new sexual partners, and unprotected sex in women randomly assigned to the LNG implant and copper IUD groups (all p<0·001). Despite the authors conclusion that the highly significant increase in high-risk activity in women beginning LARC use did not confound data interpretation, this behavourial change seems worth commenting on. Also worth addressing is the observation that more than 10% of women enrolled had serum MPA concentrations indicating DMPA use in the previous 3 months. Recent DMPA use was listed as an exclusion criterium in the ECHO trial, but whether data from these women were censored is unclear. Of potential greatest impact, the inability to randomly assign women to a no contraceptive group in the ECHO study made risk factor identification dependent on a differential outcome. This requirement of study design is relevant because effects of LNG implant and copper IUD on HIV transmission are essentially unknown, and make it impossible for the ECHO trial to exclude the possibility that all three contraceptives did not comparably increase HIV susceptibility. Finally, in sub-Saharan Africa, where adolescent girls and young women represent 10% of the population but 25% of new infections,2UNAIDSMiles to go: closing gaps, breaking barriers, righting injustices.https://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdfDate: 2018Date accessed: June 26, 2019Google Scholar variables that increase HIV susceptibility by less than the 30% trial threshold increase that the ECHO study was statistically powered to detect could still have devastating consequences. Therefore, concluding that trial results showed that all three contraceptive methods are safe and support increased access to contraceptive methods might be overly broad. We declare no competing interests. TLC receives support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD094634). The content of this Correspondence is solely the authors’ responsibility and does not necessarily represent the National Institutes of Health's views. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trialWe did not find a substantial difference in HIV risk among the methods evaluated, and all methods were safe and highly effective. HIV incidence was high in this population of women seeking pregnancy prevention, emphasising the need for integration of HIV prevention within contraceptive services for African women. These results support continued and increased access to these three contraceptive methods. Full-Text PDF Open AccessECHO: context and limitationsWith WHO's recent downgrading of Medical Eligibility Criteria (MEC) for women at high risk of HIV from category 2 (advantages outweigh risks) to category 1 (no restrictions) for intramuscular medroxyprogesterone acetate,1 known commonly as Depo Provera, the misleading published interpretation of the ECHO trial2 results carries considerable weight. Full-Text PDF ECHO: context and limitationsThe ECHO study results1 have been widely misreported in the media. This open-label randomised trial was designed primarily to detect whether a difference of at least 50% in HIV-1 risk occurs between three contraceptive methods. Because of the absence of a no contraception control group, the results do not inform on absolute risk of HIV-1 infection for any of the methods. Whether the levonorgestrel (LNG) implant or copper intrauterine device (IUD) increase HIV-1 risk is unknown, although plausible biological mechanisms have been reported. Full-Text PDF ECHO: context and limitations – Authors’ replyWe appreciate the interest in our recently reported ECHO trial findings.1 Before its initiation, some people questioned whether methodological challenges would prevent the trial from yielding interpretable results.2 The trial's successful recruitment of 7829 women, paired with high retention and contraceptive method continuation, provide robust data on the important global question of the relationship between use of contraceptive method and risk of HIV acquisition. Full-Text PDF ECHO: context and limitationsWe congratulate the ECHO Consortium on a well-executed trial, showing that use of intramuscular depot medroxyprogesterone acetate (DMPA) did not confer excess HIV risk relative to use of levonorgestrel-based implant or a copper intrauterine device (IUD).1 These results are crucial to inform good reproductive health policy. Moreover, the high HIV incidence observed emphasises the need for accelerated HIV prevention efforts, and the participants’ acceptance of less familiar contraceptives shows potential for expanding the contraceptive method mix in this population. Full-Text PDF ECHO: context and limitationsThe ECHO Trial Consortium found no statistically significant increase in risk of HIV acquisition for women using intramuscular injectable depot medroxyprogesterone acetate (DMPA-IM) compared with those using the copper intrauterine device or the levonorgestrel (LNG) implant.1 In response, WHO revised their medical eligibility criteria, which are used to develop counselling materials for women, to indicate that DMPA-IM should have no restriction on its use.2 However, this decision does not adequately reflect the totality of evidence available. Full-Text PDF" @default.
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