In the name of science: Ethical violations in the ECHO randomised trial

African voices in global health: Knowledge, creativity, accountability

In this article we offer an introduction to a special issue of Global Public Health on the theme of 'African Voices in Global Health: Knowledge, Creativity, Accountability'. This special issue explores Africans' self-understood roles - and voices - in global health (as both researchers and interlocutors in relation to various global health institutions/policies). We argue that the special issue's focus on African voices in global health is critical in view of the legacies of colonial medicine and public health for contemporary narratives, discourses, and practices. It is important to acknowledge that Africans continue to address the structural injustices facing them in relation to global health policies and practices on the continent. In the face of this they have demanded that donors, NGOs, governments, and intergovernmental organisations be politically, fiscally, and ethically accountable to the people they serve on the continent. As the special issue highlights, critical scholars of global health based in Africa are increasingly offering challenges to the frequent positioning of African patients and study-participants as either invisible, or disempowered, in understanding and shaping their own lived experiences of health in a transnational context.

HIV, progestins, genital epithelial barrier function, and the burden of objectivity†

Contributions from a diverse set of scientific disciplines will be needed to help individuals make fully informed decisions regarding contraceptive choices least likely to promote HIV susceptibility. This commentary recaps contrasting interpretations of results from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial, a study that compared HIV risk in women using the progestin-only injectable contraceptive depot medroxyprogesterone acetate (DMPA) vs. two other contraceptive choices. It also summarizes results from basic and translational research that establish biological plausibility for earlier clinical studies that identified enhanced HIV susceptibility in women using DMPA.

Is the Injectable Contraceptive Depo-Medroxyprogesterone Acetate (DMPA-IM) Associated with an Increased Risk for HIV Acquisition? The Jury Is Still Out

Intramuscular depo-medroxyprogesterone acetate (DMPA-IM) is the most widely used hormonal contraceptive in sub-Saharan Africa. Previous meta-analyses of observational studies found a significant 40%–50% increased risk associated with DMPA-IM use, relative to no contraception or infrequent condom use. This raised substantial concerns, although these studies had important limitations. Consequently, the open-label randomized Evidence for Contraceptive Options and HIV Outcomes trial was conducted, designed primarily to detect a 50% or greater difference in HIV risk between DMPA-IM, the levonorgestrel (LNG) implant, and the copper-intrauterine device. The ECHO study, published in July 2019, concluded that there is no substantial difference in HIV risk among the methods evaluated, and that all three methods are safe and highly effective. In response, the WHO relaxed the Medical Eligibility Criteria for DMPA-IM use among women at high HIV risk in August 2019. However, two of the three comparisons in the ECHO trial could rule out neither a 50% increase nor no change in HIV risk for one contraceptive compared with another. The study had limitations and the results contained considerable uncertainty. They also did not inform on associated HIV risk for any one of the individual methods due to the absence of a control group such as no contraception or only infrequent condom use. The HIV risks associated with LNG implant and copper-IUD relative to no contraception or infrequent condom use are unknown and these cannot be seen as controls, nor did the authors claim them to be. The results will be discussed in the context of their limitations, what they add to the body of work to date on contraception and HIV acquisition, and the implications of the findings and reports thereof for future research and contraceptive choice.