International Women’s Day seems like an appropriate time to remind ourselves that clinical trials are only the beginning of something, not the end. Researchers seeking to answer some of the thorniest questions about women’s health are most interested in data. Advocates are looking for tools to advance their work on behalf of women and girls. Governments seek solutions to issues that prevent their citizens from achieving their potential. And women and girls are most interested in improving their lives and that of their families.
One clinical trial recently captured the attention of stakeholders working on issues related to HIV and family planning. The Evidence for Contraceptive Options and HIV Outcomes (ECHO) clinical trial enrolled 7,829 women in eSwatini, Kenya, South Africa, and Zambia from 2015 to 2018, randomly assigning them to receive either DMPA-IM, a copper intrauterine device (IUD), or a hormonal contraceptive implant. The goal was simple: to determine if any of the three contraceptive methods increased risk of HIV acquisition among women already at high risk. But little in public health is simple.
In June 2019, researchers concluded that the women who received DMPA-IM were not significantly more likely to acquire HIV than the women who received the other two contraceptive methods. Good news on the data side. But as one HIV advocate from South Africa reminded the FP2020 Reference Group, even before the ECHO trial results came out, “There is not one woman who wants contraception and one who wants HIV prevention. We are the same woman.”
Many public health professionals, advocates, and funders were troubled by findings that didn’t make the initial headlines.
Why were so many of the women living in those countries primarily using DMPA-IM?
Are women in Africa truly making informed choices about contraception if one method is heavily used over all others?
Are they receiving options and enough information to make informed choices?
And is women’s need for pregnancy prevention taking priority over their need for HIV prevention?
With an unexpectedly high HIV transmission rate of 3.8% per year across all three methods, what are the implications for women not enrolled in a clinical trial who receive much less counseling and information than trial participants did? And what are the non-biological factors – violence against women, issues of empowerment or lack thereof, poverty, and stigma – that may also affect women’s and girls’ vulnerability to both HIV and unwanted pregnancy?
In the months since the ECHO trial results were released, both the HIV and family planning communities have taken these questions seriously. In fact, it is often the questions that resonate more than the answers. It is also critical to remember that we are talking about the lives of women and girls whenever we discuss supply chains, method mix, service delivery, and HIV/family planning integration. We lose focus on women and girls at our own peril, and theirs.
While quality of care and client-centered approach to care are not new words in the family planning lexicon, it seems they are being used more regularly post-ECHO. Equally important is ensuring that the words rights-based are more than aspirational. Clinical trials are clearly important – as demonstrated by the ECHO findings – but so is ensuring that women and girls have the right and ability to decide how to protect themselves from HIV and unwanted pregnancy, no matter where they live.
In the case of ECHO, we must push for greater integration of family planning and reproductive health with other issues of vital importance to women and girls. Systems, funding, intractability, and pride of ownership must never get in the way of meeting the needs of those who rely on access to information and products that are lifesaving. Let’s ask the right questions, and then come together across sectors to answer them. It’s an appropriate resolution for International Women’s Day and for the other 364 days of the year.