Evidence for Contraceptive Options and HIV Outcomes

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Evidence for Contraceptive Options and HIV Outcomes
Publication Date: 04/02/2019

Results from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study that compares the risks of HIV acquisition between women randomised to DMPA-IM, levonorgestrel (LNG) implant, or copper-releasing IUD, are expected to be published in mid-July 2019. Once the results are published, WHO will rapidly convene a Guideline Development Group to review the evidence and to update, as needed, the Medical Eligibility Criteria for Contraceptive Use guideline with regard to women at high risk of HIV. It is expected that the Guideline Development Group will convene at the end of July 2019. All information on the guideline development process will be published here together with a WHO statement that will be issued in response to the results that will provide guidance until publication of the updated medical eligibility criteria guideline.



WHO Medical eligibility criteria


On 1 June 2015, WHO released the fifth edition of the Medical eligibility criteria for contraceptive use (MEC). This guidance contains more than 2000 recommendations for 25 different contraceptive methods and addresses more than 80 medical conditions or personal characteristics. WHO carefully monitors the publication of new research evidence to keep this guideline up to date and guidance is updated as new evidence emerges.

Since 1991, there has been mixed evidence as to whether the use of hormonal contraceptive methods is associated with an increased risk of a woman acquiring HIV. In response, WHO commissioned an update of a 2014 systematic review, to include new data. Based on this update, published in 2016, WHO convened a consultation to determine whether a revision of the guidance was needed. The consultation considered new scientific evidence from recently published studies and concluded that the cumulative body of scientific evidence available continued to indicate an association with an increased risk of acquiring HIV among progestogen-only injectable users (DMPA and NET-EN). The consultation concluded that it was unknown whether the associations seen in observational studies were due to a true biological effect, or because of limitations of the observational studies, such as bias or confounding.


2017 Revised recommendation


In 2017, WHO issued revised guidance on hormonal contraceptive eligibility for women at high risk of HIV. The updated guidance determined that women at high risk of HIV infection may use DMPA because the benefits outweigh the possible risks, The guidance upgraded the category of risk from a 1 to a 2. Previously the recommendation had been a category 1 with a clarification, meaning there was no restriction for the use of the contraceptive method but women should be informed that progestogen-only injectables may or may not increase risk of HIV acquisition. This revised guidance placed greater emphasis on the importance of shared decision making and the need for counselling on concerns that progestogen-only injectables might increase the risk of HIV infection.

The World Health Organization also determined that more research was needed on whether or not progestogen-only injectables do or do not increase the risk of HIV acquisition. Data on whether use of contraceptive implants or IUDs affects HIV risk were also limited and therefore warranted additional research as well. Except for condoms, no contraceptive method protects against HIV or other sexually transmitted infections, and thus women at risk of HIV infection who are using contraception should also be advised to use condoms.


Medical eligibility criteria (MEC) categories for contraceptive use


Categories   Eligibility
Category-1 A condition for which there is no restriction for the use of the contraceptive method
Category-2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
Category-3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method
Category-4 A condition which represents an unacceptable health risk if the contraceptive method is used



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