Your 6-step guide to the ECHO Study on contraceptive choice and HIV

1 What is the ECHO study?
The ECHO Study compared three long-acting contraceptive methods to understand if any of them are cause an increased risk of HIV acquisition. The study also assessed the contraceptive benefits of each method. The ECHO study was conducted among more than 7,800 sexually active, HIV negative women aged 16 to 35 across 12 sites in four countries – eSwatini, Kenya, South Africa, and Zambia. The women were randomly assigned one of three highly-effective reversible contraceptives:

• Jadelle implant that prevents pregnancy for up to 5 years
• Copper inter-uterine device (IUD or commonly known as the coil)
• DMPA injection into the muscle given every three months (also known as Depo or Depo Provera)

Throughout the study, women received a comprehensive package of support including access to regular HIV testing, male and female condoms and sexual health screening and treatment for sexually transmitted infections (STIs) or reproductive tract infections (RTIs) and prevention counselling. Pre-exposure prophylaxis (PrEP), a drug people can take to prevent HIV acquisition, was introduced later in the trial.

2 Why was the ECHO Study needed?
Some observational studies showed that the use of progesterone only contraceptives (especially DMPA) was associated with an increased risk of HIV acquisition, but there was no certainty about whether this association was causal. What was clear is that in regions where long acting hormonal contraceptive injection was used, HIV prevalence was very high among women of reproductive age. The question of causality has been unanswered for more than 15 years. More studies were needed to determine if the risk was caused by the contraceptive used and the ECHO study was designed to answer this question.

3 What are the results?

The study found that the chances of acquiring HIV were almost the same for each type of contraception used in the trial, which means that the risk of HIV acquisition was not related to the contraceptives used in the study. Worryingly, the study found that the overall incidence rate of HIV infections among women who participated in the trial was higher than expected at 3.8% per year. It also showed that young women (under 25) and women who had a sexually transmitted infection at the start of the trial were more likely to acquire HIV. However, the chance of HIV acquisition among this age group was the same across each method.

4 Why does this study matter for women most affected by HIV?

Women who participated in the trial, received access to regular counselling on HIV prevention and care. Despite this, HIV incidence among ECHO trial participants was high across all three of the methods. This highlights the ongoing urgency for expanded and comprehensive HIV prevention efforts. The findings are particularly concerning for women most affected by HIV, including adolescent girls and young women, as well as women at greater risk of HIV like sex workers, who routinely experience barriers to accessing services or exercising choice.

5 What’s next after the ECHO study?

WHO has convened a Guideline Development Group to review the evidence and make recommendations to ministries of health and service providers. It is also imperative that WHO meaningfully engages a broader range of women from countries in the study and others across sub-Saharan Africa and that its recommendations are disseminated systematically to reach all women who are most affected by HIV.

6 What’s next for our advocacy?

The results highlight the urgency for greater investment in comprehensive HIV prevention in sub-Saharan Africa, especially among adolescent girls and young women and other women most at risk. The study results reinforces the need to know more about the non-biological factors that escalate risk of HIV for women. These include violence and poverty and other structural factors such as stigma and gender norms that influence women’s ability to control when and how they have sex or if and when they choose to get pregnant. Their location, sexuality, gender identity, and age must not be a barrier to them accessing services.

As outlined in a joint statement with other civil society partners we see the study results as an excellent opportunity to ensure that women’s specific needs are addressed in WHO’s revised guidelines.

 What the ECHO results tell us is that we cannot and must not continue with business as usual. We face a moral imperative to increase available options for both prevention of HIV and pregnancy, and ensure women and girls have the agency to decide if and when to have sex and get pregnant.Christine Stegling, Frontline AIDS executive director

Countries will now engage with the results of the study, and women’s movements, sexual and reproductive health and rights (SRHR) and HIV organisations must continue to insist on integrated sexual health and HIV prevention services for women. At the local level, it is imperative that women who use contraceptives receive accurate information and access to both contraceptive choice and HIV prevention. And we must invest in building women’s agency to act on their decisions and have control over their own futures.