Health Matters

Contraception and women at high risk of HIV: Solutions under the spotlight

By Chanel Retief 31 July 2019

Over 60 global leaders representing 12 countries have written an open letter to the World Health Organisation asking it to tread carefully when reviewing its guidelines on recommending the use of contraceptive methods by women at high risk of contracting HIV following the results of the Echo Trial. The WHO guideline development group is currently meeting to discuss its current recommendations.

Over the past three days, the World Health Organisation guideline development group has been meeting to discuss its recommendations for the use of contraceptive methods by women at high risk of contracting HIV.

In particular, the group will review the status of the three monthly injectable contraceptive Depo-Provera, using new evidence from a randomised clinical trial, the Evidence for Contraceptive Options and HIV Outcomes (Echo) trial, published in the Lancet in June.

The Echo trial was carried out in South Africa, Kenya, Swaziland, and Zambia, and was designed to settle ongoing uncertainty and debate over whether the three monthly injectable contraceptive Depo-Provera, a copper IUD (non hormonal inter-uterine device) and an LNG implant (a progestin-based implant containing the hormone levonorgestrel) increased the possibility of HIV transmission in women who used it.

The study found no substantial difference in the risk of getting HIV among 7,829 women randomly assigned to use one of three reversible, highly effective contraceptives: DMPA-IM, copper IUD and LNG implant.

But the global leaders in an open letter to WHO argue that the way that the study was designed showed a “lack of concern for high rates of HIV infection and lack of access to safe contraception”.

It is clear to us that for African women and girls, it has been decided that a pregnancy is worse than an HIV infection. This must end today,” Dr Tlaleng Mofokeng said in a statement.

The Echo consortium designed a study that could only measure a 50% increase in HIV risk from using the contraception Depo-Provera. Rather than measuring an individual’s risk and then claims the study findings show no increased risk of HIV. To us, this shows African’s well-being was not considered. The WHO GDG must ensure our need for truthful information, and policy which protects us from hazard is taken seriously,” Rev Phumzile Mabizela, Executive Director of The International Network of Religious Leaders Living with or Personally Affected by HIV, INERELA+ which operates in 18 countries, and three continents said.

WHO is undermining the vulnerability of women,” Mabizela told Daily Maverick, “they need to report on the findings accurately and not downplay it.” 

Announcing the results of the Echo trial in June, WITS RHI Executive Director, Professor Helen Rees said the results were reassuring but added: “our findings are also sobering because they confirm unacceptably high HIV incidence among young African women irrespective of which contraception method they were assigned to”.

Dr Nelly Mugo, Head of the Sexual, Reproductive, Adolescent and Child Health Research Programme at the Kenya Medical Research Institute in Nairobi, Southern and East African, said women face the double jeopardy of high HIV prevalence and high maternal-infant mortality from unintended pregnancies.

Tens and millions of women in the region rely on DMPA-IM, which is often the only modern method of contraception available in local family planning clinics,” Mugo said in a statement released by the Echo Consortium.

The open letter, signed by medical doctors, religious leaders, HIV activists, public health educators, and members of the Echo Trial outlines three key requests:

  1. That the WHO provide more time to the GDG, African Health authorities, civil society and scholars to consider the relevance of new epidemiological, and biological evidence, including the recently announced findings from the Echo randomised clinical trial for policy.
  2. That the GDG demand transparency from Echo researchers on their trial. In particular on how a 50% increased risk was determined as an appropriate margin – and by whom. And further that the GDG determine if this margin is still ‘clinically relevant’, and if it ever was? 
  1. That extensive discussion take place at the GDG on what is meant by “high-risk” women to determine how, and if the Echo Trial’s “calculated effect size of potential increased risk of 30%” is valuable enough to inform global guidelines.

Daily Maverick attempted to get comment from WHO’s regional office but was unsuccessful. This story will be updated when comment is received.

Meanwhile, a previously released statement by WHO stated that its updated recommendations will be issued by the end of August 2019. DM

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