The World Health Organization (WHO) has revised its guidance on contraceptive use in view of the new evidence that women at high
risk of HIV can use any form of reversible contraception, including progestogen-only injectables,
implants and intrauterine devices (IUDs), without an increased risk of HIV infection.
However, the guideline emphasizes that correct and consistent use of condoms should be used where there is a risk of STIs, including HIV as these contraceptive methods do not protect against HIV and other sexually transmitted infections (STIs).
WHO also recommends considering offering pre-exposure prophylaxis (PrEP) in settings where the incidence of HIV is above 3%, as appropriate.
The new evidence is largely based on the results of the evidence for contraceptive options and HIV outcomes (or ECHO trial) – a randomized clinical trial that showed no statistically significant differences in HIV acquisition among women using intramuscular depot medroxyprogesterone acetate (DMPA-IM), copper IUDs, or levonorgestrel (LNG) implants.
This new high-quality evidence supersedes the low to low-moderate quality evidence from observational studies that had been previously available to inform WHO’s guidance.
The ECHO study, which was conducted across communities expected to have high levels of HIV prevalence in Eswatini, Kenya, South Africa and Zambia – also revealed concerningly high levels of HIV acquisition and other STIs among women seeking contraceptive services, particularly younger women, irrespective of which of the three contraceptive methods they used.
The global recommendations have particular bearing for sub-Saharan Africa, which has the highest rates of HIV transmission but also some of the biggest challenges in ensuring women have access to a full range of contraceptive options. Currently, a quarter of women aged 15–49 in Africa (24%), who want to delay or prevent having children, have limited access to modern contraception. This is the highest unmet need across all WHO regions.