IAS 2019 is just ahead, July 21-24 in Mexico City. To help you prepare, read on for a round-up of research and happenings you won’t want to miss, a roadmap to guide you to sessions where HIV prevention is center stage, and how to follow on-site or from afar.

This year’s conference will feature data from late-breakers on highly anticipated research including:

• Data on the first-ever human trial of a new PrEP implant
• Analysis of the need to integrate HIV prevention with sexual & reproductive health in light of the ECHO study results
• Updates from the Discover trial of F/TAF for PrEP
• Findings from a study of same-day PrEP initiation among gay men and other men who have sex with men
• Data from the ASCENT study evaluating an HIV mosaic vaccine

For the full conference program go to the website for IAS 2019, and find your optimal schedule for following HIV prevention with AVAC’s conference roadmap, which can be sorted by timing, intervention or session type (Excel/PDF here).

Consider adding these satellite and conference events below, some hosted by AVAC and partners, to your calendar!

• “Sticky Linkage”: Latest evidence and new strategies
  Sunday 21 July, 8:00-10:00, Palacio de Iturbide 1 y 2

  This session on approaches for improving ART initiation and retention will talk about challenges to the idea that the continuum of care is linear. The agenda includes the results of segmentation research aimed at improving linkage to treatment among South African men.

• Hormonal contraception and HIV risk: Understanding the ECHO trials results, and what’s next for women, providers, policies, and programmes
  Sunday 21 July, 17:00-19:00, Palacio de Valparaíso 2

  Come to this forum to hear a review of the ECHO study results and discussion of their implications for women, providers, policies and programs. Presentations will focus on informed choice for women, the need to expand method mix, and the importance of integrating HIV prevention with sexual and reproductive health.

• An HIV vaccine to prevent HIV acquisition
  Sunday 21 July, 17:00-19:00, Palacio de Valparaíso 1

  Learn more about the newest candidate for a vaccine to be investigated in a trial known as Mosaico. This session will provide an overview of pre-clinical work and next steps for the latest mosaic vaccine strategy.

• Data from six locations inform the future of the HIV response
  Monday 22 July, 14:15-15:00

  This press conference will unveil a new analysis from amfAR, AVAC and Friends of the Global Fight of six case studies of progress toward epidemic control. From the report Translating Progress Into Success to End the AIDS Epidemic, the analysis identifies elements that accelerate the impact of treatment and prevention with implications for program, policy, implementation and advocacy. The press conference will only be open to journalists, but you can watch the livestream and watch for a future Advocates Network with links to the report post-launch.

• Improving prevention choice, while we wait for an HIV vaccine: Prioritizing resources for key population-specific prevention research and implementation
  Tuesday 23 July, 14:30-16:00, Palacio de Valparaíso 1

  For a broad analysis of improving prevention for key populations, check out this presentation, part of a larger session titled, Prevention is more than PrEP.

• High adherence and sustained impact on HIV-1 incidence: Final results of an open-label extension trial of the dapivirine vaginal ring
  Tuesday 23 July, 14:30-16:00, Palacio de Valparaíso 2

  Catch the latest results on the effectiveness of the dapivirine vaginal ring at this session on the findings of the HOPE open-label study.

Following from afar?

AVAC will offer comments and updates on Twitter and Facebook. Use the conference hashtag — #IAS2019.

Get the latest news on the conference at this dedicated page on the IAS 2019 website.

Interested in the events where AVAC is participating? Click here. And watch this space for additional updates.

Maureen is the African Regional Advocacy Advisor at AVAC.

As in-country planning for the Key Population Investment Fund (KPIF), a PEPFAR initiative to fund programs and organizations focused on key populations, key populations (KP) groups should take center stage in the process. Leaving them behind or out of the process would mean proceeding against their will.

In May, AVAC joined Civil Society Organizations (CSOs) in Zambia in the kick-off planning for the KPIF. The experience and lessons from the Zambia meeting provide insights into how to fully engage KP groups in the planning process—and the Zambia experience has ignited interest and enthusiasm among KP groups in different countries who are now more than ever eager to engage at all levels.

Different groups in different countries are now reaching out to their KPIF lead agencies to get more details and demand their seat at the table. (See AVAC’s Activist Guide to Influencing and Monitoring KPIF Rollout to see which agency is lead in your country and more.) Malawi is a case in point. KP-led CSOs in Malawi reviewed the contents of a KPIF proposal for Malawi in June. AVAC, joining as an observer, was on hand offering background information and lessons from the experience in Zambia. The result was a set of recommendations that helped key populations to participate meaningfully in the process of implementing the KPIF.

Background

Key populations in Malawi remain at highest risk of HIV infection. Due to high levels of stigma and discrimination both in the community and at facility level, access to HIV prevention and treatment services remain low among this group. More effort to improve service delivery will only yield results if the structural barriers to services are addressed. The KPIF funding can be leveraged to do just that—dismantle structural barriers. Following the news of the $100 million KPIF investment from PEPFAR, KP groups have been pushing to allocate funds to close gaps in implementation and address the dire needs that stem from them.

How are the key populations CSOs engaging with the process in Malawi?

In May, Malawi’s KP groups, led by the Centre for the Development of People, formed a coalition known as the Diversity Forum, to coordinate and unite KP voices around issues affecting them. Members have since used this forum to engage stakeholders on issues that affect key populations in Malawi.

In June, the Diversity Forum took part in a gathering of the KP Technical Working Group (KP TWG) where USAID presented a fully developed KPIF proposal. KP CSOs in the room felt they were left out of the initial process for developing the proposal and asked for time to review and provide feedback. Within days the Diversity Forum had facilitated a process that resulted in beefed-up coordination and a draft statement outlining current implementation gaps and key recommendations for the KPIF implementation.

The recommendations include:

• CEDEP, the Secretariat of the Diversity Forum, should be named the host organization/grant manager for KPIF funds. CEDEP possesses the capacity to manage these funds, and has demonstrated long, sustained, meaningful engagement of LGBTQI+ and key populations. CEDEP maintains positive working relationships with all other LGBTQI+-led organizations, namely those with membership in the Diversity Forum. The Diversity Forum endorses CEDEP as host for the funds.
• The Diversity Forum should be consulted at every stage of planning, proposal writing, implementation, monitoring and evaluation of KPIF-related activities and projects.
• The Diversity Forum members should be present at all PEPFAR meetings and consultations pertaining to KPIF in Malawi; PEPFAR should issue formal invitations to the members of the Forum on these occasions.
• PEPFAR should work to develop the technical capacity and ability to provide services of all the organizations that comprise the Diversity Forum.
• PEPFAR should not lose sight of the role of the advocacy and activism undertaken by the organizations of the Diversity Forum in improving service uptake and delivery, mandates at the core of KPIF.

The Diversity Forum will follow up on the statement. The Forum also remains open to further engagement on its content, but the interest of Malawi’s civil society and all advocates working on behalf of key populations will not waver. The KPIF represents a vital resource in the struggle against discrimination and inequity. We can’t afford to see it squandered.

Kenneth is the Advocacy and Networking Officer at HEPS-Uganda.

In 2016, the Key Population Investment Fund (KPIF) was announced by PEPFAR leader Ambassador Deborah Birx at the UN High-Level Meeting. It took two years before this commitment materialized, and at the AIDS 2018 conference in Amsterdam, Ambassador Birx announced that the funds would finally be disbursed to selected awardees through PEPFAR agencies to existing cooperative agreements. The $100M (split between CDC and USAID) is meant to support scale-up of key population-led community approaches to expand and enhance HIV services. In Uganda, the $10m envelope of funding for KPIF is being implemented by CDC through existing implementing partners like The AIDS Support Organization (TASO) and Baylor.

Since the announcement, advocates and key population (KP) representatives have been at the forefront of planning for KPIF implementation, advocating that the fund must serve its primary purpose—expanding demand for and access to quality, effective HIV prevention, care, and treatment services for key populations; addressing structural barriers, reducing stigma, discrimination, and violence; promoting regular and meaningful engagement of KPs; promoting human rights without distinction; and supporting collection and analysis of epidemiologic data on KP subpopulations. Ugandan civil society representatives have kept a keen eye on every stage of the KPIF planning and implementation thus far.

Early on, key population and civil society representatives were involved in a consultative priority-setting meeting in October 2018. These KPIF priorities were echoed at the 2019 Regional Planning Meeting (annual meetings to make plans, set targets and define approaches for Country Operational Plans (COP)) and they were incorporated into the Strategic Direction Summary (a country-specific document that describes investments, targets and program strategy for the COP).

Furthermore, Sexual Minorities Uganda (SMUG) spearheaded the formation of the Uganda Key Population’s Consortium, and under the banner of the consortium, civil society and KP representatives of the PEPFAR core committee led nationwide popularization of the KPIF.

After the Regional Planning Meeting in March 2019, KPs and civil society representatives have continued to monitor the implementation of the KPIF. After CDC’s implementing partners sent out the first calls for application, advocates and some KP representatives set up a technical working group team that supported local community-based KP organizations to review applications and help strengthen the proposed interventions.

During this process, advocates observed that there were needlessly stringent requirements and that there was minimal dissemination of the call, which was contrary to the objectives of the KPIF. Additional issues raised by KP representatives and advocates included lack of experience by some of CDC’s implementing partners in working with KPs, blatant homophobia and the requirement that groups be fully registered with strong financial systems, which disqualified many community-based KP organizations (which the fund is ideally supposed to strengthen).

Advocates were able to successfully advocate for a formal advisory group, which includes civil society and key population representatives, to oversee the implementation of the fund. And in the meantime, CDC has halted the sub-granting process to address some of the issues raised by CSOs. Watch this space for further developments!

In-country planning for the Key Population Investment Fund (KPIF), a PEPFAR initiative to fund programs and organizations focused on key populations, has finally begun. AVAC and a number of our partners have been working with KP-led organizations in KPIF countries to help them engage in and influence the ongoing country-level processes. AVAC has developed a new resource and documented some of its work to-date to help inform ongoing advocacy and action. Read on for more!

Activism in Action: Malawi, Uganda and Zambia

Lessons learned from the engagement experiences in Malawi, Uganda and Zambia are required reading for advocates and key population groups looking to make an impact during the in-country KPIF planning process.

In Zambia, KP-led CSOs came together to demand their space and put forward their recommendations on what should be included in the KPIF. In Malawi, the Diversity Forum, a newly established KP coalition, demanded accountability and transparency in the KPIF processes. And in Uganda, a formal advisory group, which includes civil society and key population representatives, was established to oversee implementation of the fund. These experiences, documented on the P-Values blog, highlight lessons learnt and next steps, which other civil society and KP groups can look to replicate or adapt.

KPIF Guide

An Activist’s Guide to Influencing and Monitoring KPIF Rollout, is designed to guide advocates as they engage with KPIF planning and implementation. The guide points to specific components of the KPIF and key things to watch out for in the coming months.

The Guide also includes a link to a survey for KP-led organizations in KPIF countries to assist in providing timely information and support on engagement. If this applies to you or your organization, please fill it out here!

A new report, What we know and don’t know about adolescent girls and young women and HIV prevention in sub-Saharan Africa: Mapping findings across completed, ongoing and planned projects, analyzes data from 49 projects in 20 countries to identify steps that will advance HIV prevention awareness, uptake and adherence by adolescent girls and young women (AGYW). Among the findings is the existence of a robust body of knowledge that explores young women’s attitudes about HIV prevention. But the field knows far less about the effect of communities on attitudes and behaviors related to prevention, even though that support is thought to be crucial to the uptake of HIV prevention. These and other findings in the report can inform implementers and policy makers now, and they also point to where more research is needed.

Adolescent girls and young women (AGYW) comprise the majority of new HIV infections in sub-Saharan Africa. According to UNAIDS, young women between the ages of 15 and 24 in sub-Saharan Africa are twice as likely to be living with HIV than young men of the same age, and 75 percent of all new infections in 15- to 19-year-olds are found in AGYW. Responding to the needs of AGYW is critical to ending the epidemic in the region. Many programs have implemented HIV prevention interventions aimed at AGYW, with varying success, as they confront the unique challenges, concerns and vulnerabilities faced by AGYW.

Oral PrEP is one such HIV prevention option, which is US FDA-approved, WHO-recommended, and demonstrated to be very effective in research studies. But, in many settings, implementers have faced challenges rolling out PrEP, a reminder that the efficacy of a product alone is not a predictor of real-world success. When people do not like a product, face structural or social barriers to accessing it, or have difficulty incorporating it into their daily lives—and thus don’t use it—efficacy by itself cannot overcome that.

So, what do AGYW need and want from a prevention product or program? What program features or social factors will galvanize them to use a product or participate in a program, continue with that intervention and ultimately champion it with their peers and communities? The report, produced by the the HIV Prevention Market Manager and Clinton Health Access Initiative (CHAI) and funded by the Bill & Melinda Gates Foundation, explores these questions, drawing from 49 projects focusing on AGYW in sub-Saharan Africa, for which HIV prevention is a primary objective. It examines 308 individual key findings reported by these projects to highlight what approaches have worked best and why, and where data gaps exist in the field. (Through the HIV Prevention Market Manager, AVAC has also undertaken human-centered design research in South Africa to better understand the factors that encourage or discourage AGYW’s engagement with HIV prevention.)

The report’s analysis maps the findings along two continuums, the social ecological model and behavior change framework. The number of findings along either of these continuum point to stronger or weaker areas of knowledge in the field. For instance, most findings focus on the individual and the initial “awareness” stage of behavior change, an indication that many AGYW are not yet using prevention methods and fewer have begun championing them with others.

There will be no issue next week. The NewsDigest will return on July 12, 2019. Happy Independence Day to those celebrating and a wonderful week to all!

In the days since the leaders of the ECHO Study announced their findings, AVAC has produced a number of resources to inform advocacy and action.

Px Pulse

Tune in to a special episode of AVAC’s podcast, Px Pulse. The ECHO Trial Results: Time to Act features two veteran women’s advocates from Kenya and South Africa, Jaqueline Wambui and Yvette Raphael, who talk about what the high rates of HIV in the trial mean for advocacy now. Helen Rees and Nelly Mugo, members of the ECHO trial leadership team, explain the results and their implications, and James Kiarie of WHO shares the importance of the WHO guidelines and more. (And for background on the trial, you can also check out our pre-results podcast – The ECHO Trial: Preparing for Action.)

For the full podcast episodes, highlights and resources, visit avac.org/px-pulse. Subscribe on Apple Podcasts to catch every episode.

Understanding Results

AVAC has published a comprehensive guide to interpreting the results of the trial in Understanding the Results of the ECHO Study. You’ll find concise information on the trial’s background, design and results, and a full section on next steps such as the WHO process for updating its guidelines and what you can do to get involved.

Webinar: What do the ECHO Study results mean for African women?

In case you missed it, AVAC and ICW-EA hosted a webinar on June 27th with Jared Baeten and Tim Mastro from the ECHO Consortium, and James Kiarie from WHO. In a discussion moderated by ICW-EA’s Lillian Mworeko, speakers discussed implications of the findings and took questions from members of the ECHO Global Community Advisory Group and other women’s health advocates.

Use these tools and find more at www.avac.org/echotrial to join the movement demanding informed-choice and expanded, integrated options for HIV prevention and sexual and reproductive health.

[UPDATE: Recording and slides from the webinar are now available below. And a link to Understanding the Results of the ECHO Study is now available as well.]

Please join women and our allies for a global webinar, Thursday, June 27, 9-10am EDT / 3-4pm SAST / 4-5pm EAT, on shaping the post-ECHO agenda for comprehensive sexuality and reproductive health and rights. This emerging agenda will inform an upcoming WHO meeting on this critical subject. Please join the leaders of the Civil Society Working Group on HC-HIV, members of the ECHO Global Community Advisory Group and young women advocates for this discussion with WHO and the ECHO Consortium Management Team members.

Click here to register.

On June 13, the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study released its results. The study was designed to evaluate the risk of acquiring HIV among HIV-negative women who used one of three contraceptive methods: depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as Depo-Provera, a copper intrauterine device (Cu-IUD), and a levonorgestrel (LNG) implant, also known as Jadelle. The study found that there was no substantial difference in HIV risk among women using any of these three methods. These results mark an important step for women’s health—the findings provide evidence that WHO and national ministries of health will hopefully use as they develop policies and programs that directly impact women’s lives.

What do the ECHO study results mean for African women: A webinar organized by the Civil Society Working Group on HC-HIV (co-convened by AVAC and ICW-EA) — Thursday, June 27

Recordings & Slides: YouTube / Jared Baeten and Tim Mastro’s Slides / James Kiarie’s Slides.

Prepare for the discussion with resources available on www.avac.org/echotrial, which are also highlighted below:

• 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— The Lancet
• How Should We Listen to ECHO? — The Lancet commentary
• Watch the presentation of the ECHO study results from the SA AIDS Conference
• FP2020 and AVAC held a webinar, A Roadmap for Results: Understanding the ECHO Study Results, with the ECHO team following the results announcement. The webinar explained the trial, provided topline results, outlined next steps, and offered key advocacy messages to help all stakeholders understand the findings. Watch here.
• Visit the ECHO page for a statement from the Civil Society Working Group on HC-HIV on the study results, as well as a range of other public statements on the results and their implications.

In the coming days, AVAC will release Understanding the Results of the ECHO Study, a document designed to help advocates understand some of the issues related to the ECHO trial, the questions it was designed to answer, its findings and next steps. AVAC will also release the next episode of our Px Pulse podcast, where you will hear from members of the ECHO Trial team and leading women’s advocates discuss what they think about the results, so be on the lookout!

Stay tuned for more updates, and find the latest at www.avac.org/echotrial.

Today at a satellite symposium at the South African AIDS Conference linked to a publication in The Lancet, the ECHO trial of contraceptive use and impact on HIV risk released its results. The Evidence for Contraceptive Options and HIV Outcomes Study, or ECHO, was designed to evaluate the risk of acquiring HIV in HIV-negative women who used the copper intrauterine device (Cu-IUD), a levonorgestrel (LNG) implant (Jadelle) and depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as Depo-Provera.

The topline finding: There was no substantial difference in HIV risk among women using DMPA-IM, the LNG implant or the copper IUD. These are long-awaited data from the most rigorous trial of HIV and contraceptive interactions in history. They are an urgent call to action at a time when women’s reproductive health and rights are under threat in many countries, and the mobilization by and for women’s lives is vibrant and strong.

As AVAC and the women advocates who have led this work in Africa have said in the months and years prior to the result: ECHO must prompt action. Now is the time for investment in woman-centered programs that offer a full range of contraceptive choices and HIV prevention strategies at the same site and in the context of a true informed-choice approach. The ECHO results tell us this is the case. The women who made the trial possible deserve nothing less.

Find the AVAC press release here and commentary from Yvette Raphael in an op-ed on the results in the South African Mail & Guardian’s Bhekisisa health journalism center. And we hope you’ll read on and join us in the fight!

This update provides:

• Basics on the data release
• What are the topline trial findings?
• What do the results mean – including core messages coming from the HC-HIV Civil Society Advocacy Working Group, the Africa-based women’s network led by ICW EA, with AVAC
• Who should act—and how?
• Trial background

ECHO Data: The basics

What are the topline the trial findings?

The ECHO trial did not find any significant difference in HIV risk among women using the three methods studied: DMPA-IM, LNG implant and the copper IUD. Not very many women used pre-exposure prophylaxis, or PrEP, for HIV prevention during the trial; women who used DMPA-IM reported more condom use and fewer partners. These choices don’t seem to have made a difference in HIV risk.

All of the contraceptive methods tested were safe, effective and acceptable; the majority of women stayed on the method that they were assigned to use. Very few became pregnant while they were using the method.

There were high HIV incidence rates in all three arms of the trial. This does not mean that the methods increased women’s risk. These incidence rates are comparable to those seen in young women in these countries in other trials and contexts. What is notable, though, is that many trials with comparable incidence rates recruited women with specific HIV risk factors, such as numbers of partners, commercial sex work, sexually transmitted infections, etc. In ECHO, HIV risk factors were not part of enrollment criteria. The participants were sexually active young women looking for contraception. ECHO gives a stark picture of the risk facing these young women. HIV prevention services must meet them where they are—in contraceptive clinics and other related services.

What do the results mean?

The results are a clear call for contraceptive programs that offer more method choices, including DMPA-IM for women who want to start or continue it, along with comprehensive HIV prevention interventions. The new information from ECHO should be used to improve counseling, expand method choices and rapidly and urgently integrate HIV prevention and treatment with contraceptive programs. The level of HIV risk among eSwatini, Kenyan, South African and Zambian women in the trial was profoundly high. The majority of the participants were under 25, who were not identified as at high risk for HIV—but were simply sexually active and seeking contraception.

The HC-HIV Civil Society Working Group says:

The ECHO results are not “good news”. The women in the trial did not have any specific HIV risk criteria. They recruited women who wanted contraception and were sexually active. It is a wake-up call to put HIV prevention on site at every family planning clinic including PrEP and female condoms with peer support, trained providers.

A key question about DMPA-IM has been answered, but that does not mean the method can continue to dominate women’s contraceptive programs in East and Southern Africa. We don’t believe that DMPA-IM should continue to be the only long-acting method available. Black and brown women in East and Southern Africa want choices, dislike side effects and deserve equity with the high-quality contraceptive programs often available in high-income countries.

ECHO shows method mix is possible. Women use many things. Make it happen.

Women need strategies to prevent pregnancies and HIV infection at the same sites, from the same providers, in a rights-based, woman-centered context. Throughout ECHO, the risks of unplanned pregnancy and HIV were pitted against each other by scientists and normative agencies. Now is the time for integration. This has to include investigation—more research on how to deliver services that meet contraceptive and HIV needs well, what is driving HIV risk and how to address it, and more.

Click here for the full statement.

Who should act—and how?

• WHO should follow through on its commitment to rapidly convene a Guidelines Review Group (GRG), issuing a clarifying statement for countries in the interim. This GRG should include African women who have led advocacy on this effort for nearly a decade.

• Every east and southern African country must now make or implement, with full funding, a plan—with milestones—for expanding contraceptive method mix and uptake, and integrating HIV prevention into contraceptive service points.

• The upcoming WHO meeting in Zambia prompted by the ECHO results should generate a declaration of commitment to this, along with a commitment from funders to put money into this work and revisit the key milestones across the regions and in countries in one year’s time. This review could be guided by the method mix and choice indicators developed by FP2020 and the integration index piloted by the US group CHANGE.

• This review must be validated by “ground forces”—women who live and work and love in the places where this trial happened. There is nothing for us without us, nothing that can call itself a “woman-centered approach” with a straight face if it does not have women, especially young women, in the lead.

Trial background

The Evidence for Contraceptive Options and HIV Outcomes Study, or ECHO, was designed to evaluate the risk of acquiring HIV in HIV-negative women who used the copper intrauterine device (Cu-IUD), a levonorgestrel (LNG) implant (Jadelle) and depot medroxyprogesterone acetate-intramuscular (DMPA-IM), also known as Depo-Provera. The trial also compared pregnancy rates among women using these methods, documented rates of method discontinuation and switching, and provides a valuable body of evidence about acceptability of these methods among African women.

Many women¹ at risk for HIV are also concerned about avoiding or postponing pregnancy. Some observational studies have suggested that specific injectable contraceptives (e.g., DMPA-IM)² can increase women’s risk of acquiring HIV, while other studies have not suggested this link between DMPA-IM and HIV risk. Before ECHO, very little was known about other methods and their relationship to HIV risk—no other randomized trial had been conducted on the relationship between HIV risk and a contraceptive method. ECHO was designed to gather high-quality information about how different methods affected risk—whether increasing or possibly decreasing it. One key goal for the trial was to gather information that could be used to shape the WHO classification of and, by extension, the service-delivery approaches for the three methods. In the past years, WHO has used its Medical Eligibility Criteria system for evaluating contraceptives to signal the theoretical possibility that DMPA and similar methods might increase HIV risk. This complex classification hasn’t translated into action in terms of women being informed about risks and benefits, or into procurement of additional alternative methods in most settings. ECHO was also designed to help understand acceptability of methods not widely used in the trial countries.

¹ Throughout this document, “women and girls” refers specifically and exclusively to cisgender women and girls in all their diversities. Data on transgender women, hormonal contraception and HIV risk are not available.
² The World Health Organization (WHO) identifies this “theoretical or possible risk” in its current classification of three products: DMPA-IM, NET-EN (another injectable that uses a different hormone from DMPA) and DMPA-Subcutaneous, also known as DPMA-SC and Sayana Press, which contains the same hormone as DMPA-IM but uses a different, simpler injectable delivery method.