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Urusan Belum Selesai untuk Akses kepada Kontrasepsi dan Pencegahan HIV

The landmark Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study is the first large-scale randomized clinical trial to investigate the relationship between the use of hormonal family planning methods and the risk of HIV acquisitiona double burden far too many women still face. Although the study’s results have yielded valuable information, our colleagues at FHI 360 explain that there is still plenty of work to do.

Great strides have been made in expanded access to family planning care and HIV prevention services; walau bagaimanapun, women continue to suffer the dual burdens of unintended pregnancy and HIV infection. Concerns that contraception itself might increase the risk of HIV acquisition led to the design and implementation of the landmark ECHO trial. ECHO was a randomized clinical trial comparing HIV incidence, adverse events, and pregnancy rates among 7,829 African women randomized to three licensed contraceptive products: intramuscular depot medroxyprogesterone acetate (DMPA), a copper intrauterine device, and a levonorgestrel implant. The results were presented at a conference in Durban, South Africa in June 2019 dan published in The Lancet. HIV incidence was similar across the three groups and all methods were safe and highly effective. In light of the ECHO results, Pertubuhan Kesihatan Sedunia (WHO) convened an expert group to review the data on contraceptive eligibility for women at high risk for HIV acquisition and issued updated guidance in August 2019, which indicated that all trial methods could be safely used by women at high HIV risk.

The ECHO study identified a very high overall HIV incidence of 3.8 per 100 women-years among the young study participants (median age 23 tahun) seeking contraception in the four study countries: Eswatini, Kenya, South Africa, dan Zambia. This alarming finding among women who were provided HIV prevention services, including STI screening, condoms, and pre-exposure prophylaxis (PrEP) later in the trial, tempered the encouraging news of no difference in HIV risk by contraceptive method. Discussion of this finding led to calls for urgent and aggressive measures to expand women-centric HIV prevention services, including PrEP, for women in family planning programs. The findings also supported expanded access to the full range of contraceptive products for women at high HIV risk. WHO initiated a concerted effort to support country programs, especially in Africa, to act aggressively on the ECHO findings to enhance FP-HIV integration.

DMPA-IM, 2-rod levonorgestrel implant, and the copper IUD. Photo credit: Leanne Gray
DMPA-IM, 2-implan rod levonorgestrel, dan IUD tembaga. Kredit foto: Leanne Gray

Now, dalam 2021, we are confronted with the additional challenge of the COVID-19 pandemic on access to both family planning care and HIV prevention services. With regard to family planning, important steps to maintain access to critical family planning care for women and girls include using telehealth for counseling, screening, peruntukan kaedah, and side effects management; extended use of IUDs and implants; and self-administration of Sayana Press (DMPA-SC). Unfortunately, many programs have seen drops in attendance and early signs of increased pregnancy rates among young women.

The COVID-19 pandemic has also challenged HIV prevention, care, and treatment program. In many areas where women are at greatest HIV risk, scale up of PrEP is still at an early stage. Linking PrEP services with family planning offers a “win-win” opportunity. The recent European Medicines Agency endorsement of the dapivirine vaginal ring for HIV prevention for women in high HIV burden settings should lead to a complementary prevention approach in addition to safer sex practices when women cannot take or do not have access to oral PrEP. Additionally, the HIV Prevention Trials Network recently announced that a trial evaluating the safety and efficacy of long-acting injectable cabotegravir (CAB LA) for PrEP in women in Africa was stopped early by the Data and Safety Monitoring Board when CAB LA was found to be superior to oral PrEP in preventing HIV acquisition. The addition of a long-acting injectable PrEP agent to the prevention toolbox should help mitigate access and adherence challenges. Moreover, the 8-week injection schedule can be synchronized to injectable contraceptive provision. Ongoing research will hopefully yield multipurpose technologies that prevent both pregnancy and HIV.

At the completion of the ECHO study, the greatest fear of study investigators was that the world of family planning and HIV prevention would return to business as usual, and not continue to act on the critically important findings for women’s health. Now, with the triple threats of COVID-19, HIV, and unintended pregnancy, we must move decisively to assure that the fear of returning to business as usual, or even business less than usual, is not realized.


To learn more about how to adapt family planning and contraceptive access in the current pandemic context, check out our COVID-19 content.

Urusan Belum Selesai untuk Akses kepada Kontrasepsi dan Pencegahan HIV
Timothy D. Cikgu, MD, DTM&H

Ketua Pegawai Sains, FHI 360

Timothy D. Cikgu, MD, DTM&H ialah Ketua Pegawai Sains di FHI 360, Durham, Carolina Utara. Beliau juga Profesor Adjung Epidemiologi di Gillings School of Global Public Health, Universiti North Carolina di Chapel Hill. Beliau menyelia penyelidikan FHI 360 dan program berasaskan sains yang dijalankan di Amerika Syarikat dan melalui pejabat FHI 360 di 50 negara di seluruh dunia. Dr. Mastro menyertai FHI 360 dalam 2008 mengikuti 20 tahun dalam jawatan kepimpinan saintifik di Pusat Kawalan dan Pencegahan Penyakit AS (CDC). Kerja beliau telah menangani penyelidikan dan program mengenai rawatan dan pencegahan HIV, TB, STI dan kesihatan reproduktif, termasuk berkhidmat dalam jawatankuasa pengurusan saintifik untuk percubaan klinikal rawak ECHO yang menyiasat risiko dan faedah pemerolehan HIV untuk tiga kaedah kontraseptif di kalangan wanita di Afrika.

Kavita Nanda, MD, MHS

Pengarah Penyelidikan Perubatan, Pembangunan dan Pengenalan Produk, FHI 360

Kavita Nanda, MD, MHS, Pengarah Penyelidikan Perubatan, FHI 360, ialah pakar obstetrik/pakar sakit puan yang telah menumpukan kerjayanya untuk membangunkan dan menambah baik penggunaan kaedah kontraseptif untuk wanita. Beliau adalah penyiasat bersama dan pengerusi jawatankuasa keselamatan kontraseptif untuk Bukti Pilihan Kontraseptif (ECHO) perbicaraan, percubaan rawak berbilang pusat bagi tiga kontraseptif berbeza dan pemerolehan HIV dalam 7,800 Wanita Afrika berisiko tinggi HIV. Dr. Nanda telah berkhidmat sebagai penyiasat utama untuk beberapa FHI 360 pengajian, termasuk menangani keselamatan kontraseptif hormon dalam kalangan wanita dengan pelbagai keadaan perubatan, dan sebagai pengarah perubatan kajian untuk beberapa ujian pencegahan HIV yang besar. Pada masa ini, Dr. Nanda ialah pengarah program untuk membangunkan implan terbiodegradasi baharu untuk kontraseptif yang dibiayai oleh Yayasan Bill dan Melinda Gates.

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