More than 150 million women worldwide use modern methods of contraception for family planning. By enabling women to avoid high-risk pregnancies, these contraceptive methods help prevent hundreds of thousands of maternal and infant deaths every year.

As the HIV epidemic spread, it became important to explore risk factors for HIV, including whether there was an association between use of specific contraceptives and HIV acquisition. There is evidence from observational studies that use of progestogen-only injectable methods — particularly depo-medroxyprogesterone acetate (DMPA) — is associated with an increased risk of acquiring HIV infection, but uncertainty remains about whether DMPA use actually causes increased risk.

The World Health Organization has determined that women at high risk of HIV infection may use DMPA because the benefits outweigh the possible risks, but that more research is needed. Data on whether use of contraceptive implants or IUDs affects HIV risk are also limited. Except for condoms, no contraceptive method protects against HIV or other sexually transmitted infections, and thus women at risk of HIV infection who are using contraception should also be advised to use condoms.

Given the widespread use of DMPA in areas of high HIV incidence, the question of whether DMPA increases women’s risk of HIV is a critical public health issue requiring the strongest evidence possible. Women need to know whether using DMPA or other methods affects their risk of acquiring HIV so they can make informed choices about contraception.

The Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study is designed to fill this critical knowledge gap. An open-label randomised clinical trial among 7 800 women in four countries, the ECHO Study will compare three highly effective, reversible methods of contraception (including a non-hormonal method) to evaluate whether there is any difference in the risk of acquiring HIV infection among users of these methods. The trial also provides an opportunity to compare pregnancy rates and women’s patterns of use across the study contraceptives. ECHO will deliver high-quality information about contraceptive risks and benefits that women can use in making contraceptive decisions, healthcare providers will use for contraceptive counselling, and policy-makers will use to inform their decisions about contraceptive procurement and guidance.

The Evidence for Contraceptive Options and HIV Outcomes (ECHO) Study