Council Commentary

Examining the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study

The Population Council welcomes publication of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study. We congratulate the trial organizers and appreciate the more than 7,800 women in four countries in East and Southern Africa whose participation in the trial advances our understanding of women’s needs and choices in contraception and HIV prevention.

This rigorous, large-scale study compared three highly effective reversible contraception products–the depot medroxyprogesterone acetate injection (DMPA-IM), the progestogen implant Jadelle®, and the non-hormonal copper intrauterine device (IUD)—to determine whether the use of any of these methods increases a woman’s chance of acquiring HIV infection, compared to use of the other two methods.

The study found that none of these contraceptive products increased a woman’s risk of acquiring HIV as compared to one another. While some previous observational studies indicated a possible link between DMPA use and increased HIV acquisition, this study provides welcome and reassuring news for the millions of women worldwide who want and need safe, effective and reliable contraceptive options.

ECHO confirmed that women in many parts of East and Southern Africa continue to have high rates of HIV and sexually transmitted infections (STIs).  It found an HIV incidence rate of 3.8 percent per year among all women in the study; women under age 25 had an even higher annual incidence rate.

These findings underscore important issues that the Population Council has been working to address for decades, including the urgent need to ensure that women and girls have the knowledge and tools they need to make informed decisions about their sexual and reproductive health, including contraception and HIV prevention. 

ECHO also found that women’s acceptance and continued use of each of the three contraceptive methods was very high, suggesting that women were satisfied with each of the methods used in the study.

Together, these findings demonstrate a clear need to determine how to better integrate contraceptive, HIV and STI services, and to ensure that all women have access to expanded and new contraceptive options, including the more than 214 million women in low- and middle-income countries who want to avoid a pregnancy but are not using modern contraception. The results also illustrate the need for better woman-centered HIV and STI prevention services and tools; including options that combine HIV prevention and contraception in a single delivery system.

The Population Council continues to work, through its offices and biomedical laboratories, to ensure greater choice and access to sexual and reproductive health services and supplies and calls for more equitable access to high-quality provisions worldwide. Our scientists and researchers are working to:

Better understand the sexual and reproductive health needs of women

  • Exploring contraception and HIV prevention and treatment counseling protocols and identifying the most effective ways to communicate with women about their HIV risk. 
  • Assessing women’s experiences with contraceptives to better understand what women may want in a product to simultaneously prevent HIV, STIs and unintended pregnancy.
  • Understanding women’s motivations for contraceptive switching and discontinuation, including how health care providers can better prepare women for what to expect with a new contraceptive method and provide higher quality services.

Develop and introduce improved contraceptive and HIV and STI prevention methods

  • Working to develop an oral contraceptive and HIV-prevention method in a single pill that combines the two drugs now used in oral HIV pre-exposure prophylaxis (PrEP) with a widely available combined oral contraceptive.
  • Expanding contraceptive options, including the newly FDA-approved Annovera™ (segesterone acetate and ethinyl estradiol vaginal system), which was developed by the Population Council and is the first and only contraceptive that provides an entire year of protection against unintended pregnancy while fully under a woman’s control.
  • Introducing the progesterone vaginal contraceptive ring, developed by the Population Council as a contraceptive method safe for use by breastfeeding mothers. It is currently being used in Latin America and being introduced in countries in Africa and in India.Investigating a non-antiretroviral-based multipurpose technology (MPT) to prevent HIV and other STIs.
  • Studying the underlying biological factors that could increase a women’s susceptibility to HIV and STI infections.

Provide evidence to promote healthcare that is more responsive to the needs of women and young people

  • Ensuring that women can access contraceptive methods in a variety of settings that move beyond public health clinics through task-shifting and task-sharing implementation science research.
  • Documenting the varying contraceptive needs of women throughout their reproductive lives, with special attention to adolescents. 
  • Showing the effectiveness of the inclusion of gender and power in comprehensive sexuality education programs on sexual and reproductive health outcomes.

The Population Council thanks the donors, investigators and the thousands of women who participated in the ECHO study, who made a critical contribution to enhancing our understanding of women’s sexual and reproductive healthcare needs. These results reinforce the need to ensure women and young people have a wide choice of contraceptives and all available HIV prevention options, delivered in a respectful setting that empowers them to make truly informed decisions about their lives and health.