By Sharon Atieno

As World Health Organization (WHO) gears up to release the results of the study which enrolled 7,830 women in 12 sites in four countries- Kenya, eSwatini (Swaziland), Zambia and South Africa- in July, many African countries are not well prepared for the possible outcomes of the trial.

The Evidence for Contraceptive Options and HIV Outcomes (ECHO) study is a multicenter, open-label, randomized clinical trial comparing HIV incidence and contraceptive benefits in women using DMPA injectable method (DMPA-IM), levonorgestrel (LNG) implants and copper intrauterine device (Cu IUDs).

Part of the preparation by countries include: holding a country stakeholder workshop and awareness creation on ECHO trial including possible scenarios, having a task team established to oversee the actions prior to and after release of results, having a roadmap or a plan formulated, having policy makers and health providers sensitized as well as having sub-regional plans among others.

East and Southern Africa (ESA) is the region hardest hit by HIV in the world, with 19.4 million people living with the virus. As per the information collected from this region, there is limited preparation for release of the results.

Areas such as scenario planning to ensure swift response to study findings; development of subnational/regional plans to disseminate findings; messaging and media preparation are doing very poorly. So far, only 3 ESA countries have plans in place for actions in the period between ECHO release and the updated WHO recommendations.

In West and Central Africa, no country is part of the ECHO trial. Furthermore, most countries in this region are not even aware of the study and as a result, have not prepared for the outcomes.

“More effort should be put to strengthen country preparedness for ECHO study results and to look at additional mechanisms to fast track this preparedness by countries,” said Dr. Nancy Kidula, Reproductive and women’s health at WHO regional office for Africa during a webinar.

“There should be awareness raising in West and Central Africa, specifically on the ECHO trial and possible results and scenarios to ensure good preparedness and avoid inappropriate reactions,” she added.

The ECHO study was conducted against the background that use of hormonal contraception increased the risk of HIV acquisition. Previous studies have shown mixed results, with progestogen-only injectables (particularly DMPA-IM) being linked to high HIV risk though it is not clear if the association is causal.

While Africa has an unmet burden of modern contraception at 24.2 percent as per WHO, depot-medroxyprogestorone acetate (DMPA) is the most popular contraception method in sub-Saharan Africa.

Dr. James Kiarie, co-ordinator Human Reproduction Team, WHO in a webinar said that: “the study will not address all the issues regarding contraception and HIV but it will provide some evidence.”

While the study will show the comparative HIV incidence in each group (DMPA-IM versus Cu IUD, implant versus Cu IUD, DMPA-IM versus implant), the additional studies embedded in the ECHO study will show possible biologic mechanisms. Moreover, the ECHO study will also give comparative side effects, continuation and pregnancy rates in each group (DMPA-IM versus Cu IUD, implant versus Cu IUD, DMPA-IM versus implant).

Possible scenarios from the ECHO trial include: no difference in HIV risk in all the hormonal contraception tested as well as any of the contraception methods having a high or low risk of HIV acquisition compared to the others.