Obstetrics & Gynaecology Forum Volume 29 | Issue 3 | 2019

O&G Forum 2019; 29: 1 - 2 EDITORIAL Stopping the spread of HIV and reducing the unmet need for con- traception are global health priorities. South Africa (SA) and in particular the province of KwaZulu-Natal, is the epicenter of the HIV epidemic. In the last decade, through political will and huge financial investment, the country has seen a decreasing trend in HIV incidence and deaths. Globally, 40% of pregnancies are unin- tended. 1 Accessible safe and effective contraception is a key pub- lic health tool. Barrier contraception (male and female condoms) remains the only form of contraception that prevents unintended pregnancies, HIV and sexually transmitted infections (STIs). SA boasts almost 100% knowledge about contraception and a 60% con- traceptive prevalence rate yet the unmet need for contraception in sexually active women remains 19%. 2 Sub-Saharan Africa including SA is also unique because the injectable contraceptive, depot medroxyprogesterone acetate (DMPA) is the most popular method of contraception used. Al- though DMPA is an effective contraceptive method, there have been observational, epidemiological and biological research that showed it may increase the risk of HIV acquisition by as much as 40%. 3, 4 This has created obvious concern among policy makers, service providers and civil society. The World Health Organisation (WHO) reviews evidence as it becomes available and formulates guidelines to best provide safe and effective contraceptive methods to women who might be at high risk of HIV acquisition. SA draws on these recommendations to guide policy and practice. With this accumulation of evidence that together became com- pelling, global organizations, including WHO, governments, sci- entists and users realized the need for more conclusive data. A consortium led by FHI 360, University of Washington, Wits Re- productive Health and HIV Institute and the WHO conducted a multi-center, open label randomized clinical trial, the “Evidence for Contraceptive Options and HIV Outcomes” (ECHO) trial com- paring HIV incidence and contraceptive benefits in women using DMPA, LNG implant and copper IUD. ECHO enrolled 7,829 wom- en at 12 sites across Swaziland, Kenya, SA and Zambia. Of note, 9 of the 12 sites were in SA. ECHO aimed to inform of the incidence of HIV in each group, a possible biological mechanism, and contin- uation and failure rates of each method. It will not be able to make conclusions about HIV risk compared to no method as there was no control group and risk with other methods beside the ones used in the study. 5 The much anticipated results were released online and at the South African Aids conference on 13 June 2019. In summary, the ECHO study concluded that the three methods used were safe and highly effective and there was no substantial difference in the HIV risk among users of the three methods of contraception [DMPA-IM vs IUD HR = 1.04 (96% CI = 0.82-1.33, p = 0.72); DMPA-IM vs LNG implant HR = 1.23 (96% CI = 0.95-1.59, p = 0.097); IUD vs LNG implant HR = 1.18 (96% CI = 0.91-1.53, p = 0.19)]. 6 The high retention rate (93.6%) proves high satisfaction on method and 99.4% of women accepted their randomized meth- od proving that women find various methods acceptable and do not necessarily prefer DMPA. 6 There was low condom use and HIV incidence was high despite comprehensive HIV prevention package provision (3.81% per year (95% CI = 3.45-4.21). 6 STI prevalence at baseline was also high; 18% C. trachomatis, 5% N. gonorrhoeae and 38% HSV 2 infection. 6 HIV and Contraception- Two inextricable public health priorities that have called South Africa to action M. Panday 1 , HM Sebitloane 1 1 Discipline of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Correspondence M Panday email: mala.panday@kznhealth.gov.za OBSTETRICS & GYNAECOLOGY FORUM 2019 | ISSUE 3 | 1