AVAC’s Take on Updated WHO Guidance on Hormonal Contraception and HIV Risk

August 29, 2019

Today, the World Health Organization (WHO) released updated guidance on “Hormonal Contraceptive Eligibility for Women at High Risk of HIV”. The WHO updated guidance shifts DMPA, other progestogen-only injectables and IUDs to a MEC 1 classification, which states that the products can be used without restriction. The updated WHO recommendations follow a thorough review of the latest scientific evidence, including the recent results of the ECHO trial, which evaluated whether the risk of HIV differs with the use of three different safe and effective contraceptive methods: depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as Depo-Provera, the copper intrauterine device (Cu-IUD) or a levonorgestrel (LNG) implant, also known as Jadelle.

About WHO’s Updated Guidance

The WHO updated guidance shifts DMPA, other progestogen-only injectables and IUDs to a MEC 1 classification, which states that the products can be used without restriction. This is a shift from the 2017 MEC 2 categorization of progestogen-only injectables, which states that the benefits of a product outweigh the theoretical or proven risks. From 2012 to 2016, DMPA and other related contraceptives were classified as a MEC 1 with a qualification—that the uncertainty around DMPA and HIV risk meant women at high risk of HIV who chose to use DMPA should receive HIV prevention services and counseling. (Click here for a background document on hormonal contraception and the WHO Medical Eligibility Criteria (MEC) system for contraceptives explains key issues in plain language.)

Now What?: AVAC’s perspective on the new WHO guidance

With this new guidance from WHO, DMPA and other progestogen-only contraceptives have their third distinct MEC classification in seven years. While the classification has changed, the context in which women receive HIV prevention and contraceptives and the number of choices available to them have not.

We are gravely concerned that this guidance will be used to justify a “business as usual” approach in which contraceptive procurement, program design, service delivery and counseling approaches go unchanged. This approach ignores women’s priorities and the clear imperative to transform services so that sexual and reproductive health and HIV concerns are addressed in the same place, at the same time, in a stigma-free environment.

The past seven years saw incremental adjustments in the range of methods available in some countries, but nothing approaching the investment and commitment needed from policy makers, funders and implementers of sexual reproductive health & rights (SRHR) and HIV services. These services continue to exist in vertical programs, even though integration is needed as an emergency response to the soaring HIV epidemic in young women—many of whom are far more concerned about avoiding pregnancy than preventing HIV.

The updated WHO guidance will simplify the messages about specific methods. However, meeting HIV and SRHR needs is a complex issue; so is the science around HIV risk and progestogen-only contraceptives. As the Civil Society Advocacy Working Group on HC-HIV noted, any increase in HIV risk associated with method use is unacceptable and the ECHO trial was not powered to eliminate the possibility of risk, but to detect with confidence a 50 percent increased hazard ratio.

This updated guidance reflects evidence on a level of risk determined by the scientific community to be relevant for public health and individuals; but women in all their diversity will want and need to be able to make their own determinations, which is why informed choice and provision of a full range of contraceptives, including alternatives to DMPA-IM, are essential.

The WHO should, with these guidelines, identify specific, actionable and monitorable ways to expand contraceptive method mix and integration of HIV, STI and SRHR products and services, sending a clear signal that the updated classification is not an excuse to preserve the status quo.

Every woman matters and no woman should have to choose between comprehensive sexual and reproductive health services and HIV prevention. Yet today, women’s access to services is under threat by funders who prioritize ideology over evidence and control over bodily autonomy. We must step up and do the challenging work of implementing women-led and -centered programs. If we don’t, the cost in lives will be even higher.

Additional Information about the ECHO Results

The ECHO trial, which released its results in June 2019, enrolled 7,829 women in eSwatini, Kenya, South Africa and Zambia. The women came from communities with high levels of HIV, but they were not recruited for the trial based on any specific risk factors for HIV. They were sexually active, and sought contraception. All of the women received HIV prevention counseling, condoms, HIV tests; a small number used PrEP, as it became available in their countries. The trial was designed with the statistical power to detect a 50 percent increase in risk associated with any method.

ECHO found no substantial difference in HIV risk among women in the trial arms. Based on the design, a smaller level of increased risk, especially below 30 percent, could not be ruled out. Though no method was associated with increased risk, the rates of HIV were alarmingly high in all groups of women: 3.8 percent across all of the participants. (This HIV incidence rate exceeds WHO’s threshold for defining populations as being at “substantial risk”, as stated in the WHO oral PrEP guidelines.) The ECHO trial also revealed concerningly high levels of other sexually transmitted infections (STIs) among women seeking contraceptive services, particularly younger women. Click here to read AVAC’s Understanding the Results of the ECHO Study.