Depot contraception and HIV: an exercise in obfuscation

In June this year, the Lancet published results of a randomised trial by the Evidence for Contraceptive Options and HIV Outcomes (ECHO) consortium.1 The main purpose of this trial, according to the consortium, was to settle the long controversy over whether girls and women using intramuscular depot medroxyprogesterone acetate as a contraceptive are at increased risk of HIV infection.

The open label trial, conducted in South Africa, Kenya, Zambia, and Eswatini (Swaziland), compared the risk of HIV associated with three contraceptive methods: depot medroxyprogesterone, a copper intrauterine device (IUD), and a levonorgestrel subdermal implant.2 The authors noted that throughout the trial, HIV incidence, the primary endpoint of the study, was “alarmingly high.” Yet, because the differences were not judged statistically significant—taken in this study as P<0.04—the authors concluded that there was “no link between HIV and the methods tested.”3

In keeping with this interpretation, the World Health Organization’s guideline development group recommended that intramuscular depot medroxyprogesterone be placed in category 1 of its medical eligibility criteria: “safe for …