Intramuscular depot medroxyprogesterone acetate, copper intrauterine devices (IUDs), and levonorgestrel implants have all demonstrated safety and efficacy, as well as similar rates of HIV risk among a population of African women seeking pregnancy prevention. This finding was recently published in The Lancet. The high rate of HIV within the population highlights the need for HIV prevention to be incorporated into contraceptive practices.
This open-label, multicenter trial (Evidence for Contraceptive Options and HIV Outcomes [ECHO]; ClinicalTrials.gov identifier: NCT02550067) included 7715 women aged 16 to 35 years who were did not have HIV; of these, 2556 were randomly assigned to quarterly intramuscular depot medroxyprogesterone acetate 150 mg/mL, 2571 to copper IUD, and 2588 to levonorgestrel implant. All women reported not having used injectable, intrauterine, or implantable contraceptives for 6 months prior to study initiation. Research took place in 12 facilities in Kenya, Zambia, South Africa, and eSwatini.
The primary endpoint of the study was the rate of HIV infection, and the safety endpoint was a serious adverse event or treatment-related discontinuation. The trial took place over 18 months between 2015 and 2017. Follow-up visits took place at 1 month and every third month until the end of the trial, during which time contraceptive counseling, safety monitoring, and HIV testing were conducted. HIV prevention counseling was also performed at each visit, and participants received HIV testing for partners, access to condoms, and pre-exposure prophylaxis.
The participants used their respective forms of contraception for 92% of the total follow-up time, during which 397 cases of HIV infection were diagnosed (incidence, 3.81 per 100 woman-years [95% CI, 3.45-4.21]). HIV infections occurred in 143 women in the intramuscular depot medroxyprogesterone acetate group (4.19 per 100 woman-years [95% CI, 3.54-4.94]); among 116 women with levonorgestrel implants (3.31 per 100 woman-years [95% CI, 2.74-3.98]); and among 138 women with a copper IUD (3.94 per 100 woman-years [95% CI, 3.31-4.66]). Coital frequency was similar across all 3 groups throughout follow-up.
The risk of developing HIV infection was not statistically different among contraceptives. HIV infection hazard ratios were as follows:
• Intramuscular depot medroxyprogesterone acetate vs copper IUD, 1.04 (96% CI, 0.82-1.33; P =.72)
• Intramuscular depot medroxyprogesterone acetate vs levonorgestrel implant, 1.23 (96% CI, 0.95-1.59; P =.097)
• Copper IUD vs levonorgestrel implant, 1.18 (96% CI, 0.91-1.53; P =.19)
Serious adverse events were reported in 4% of the copper IUD group, 2% of the intramuscular depot medroxyprogesterone acetate group, and 3% of the levonorgestrel implant group. Contraception was discontinued due to adverse events in 8% of the copper IUD group, 4% of the intramuscular depot medroxyprogesterone acetate group, and 9% of the levonorgestrel implant group (P <.0001, intramuscular depot medroxyprogesterone acetate vs copper IUD and levonorgestrel implant). Pregnancies occurred among 116 participants with copper IUD, 61 with intramuscular depot medroxyprogesterone acetate, and 78 with levonorgestrel implant.
The study researchers concluded that “These results underscore the importance of continued and increased access to these three contraceptive methods, as well as expanded contraceptive choices, complemented by high-quality HIV and [sexually transmitted infection] prevention services. Women’s informed choice in sexual and reproductive health services is essential.”
Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial [published online June 13, 2019]. Lancet. doi: 10.1016/S0140-6736(19)31288-7