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PrEP Halves New HIV Rate When Offered in Contraceptive Trial
  AIDS 2020: 23rd International AIDS Conference Virtual, July 6-10, 2020
Mark Mascolini
In the ECHO trial comparing HIV incidence with three contraception methods, offering women on-site PrEP halved the new-infection rate at South African study sites [1]. ECHO researchers propose making PrEP part of the standard prevention package in future HIV prevention trials.
ECHO, which ended in October 2018, compared HIV incidence in 7829 African women randomized to one of three highly effective contraception methods [2]. Every 3 months participants received a comprehensive HIV prevention package, including PrEP when it became available. All South African sites offered on-site PrEP between March and June 2018, the last year of the trial.
This analysis did not directly assess HIV incidence in women who started PrEP. Instead, the ECHO team measured overall HIV incidence after participants were offered on-site PrEP. Among the 2043 South African women who had follow-up time after PrEP became available, 543 (27%) started PrEP.
Researchers tried to limit confounding of PrEP access and calendar time in two ways: (1) a study visit method included only study visits with on-site PrEP access, and (2) a calendar time method included only follow-up time within 6 months of on-site PrEP access. By both methods 25% of South African women began PrEP when it became available at trial sites.
By the study visit method, HIV incidence was 4.65% before PrEP access and 2.16% during on-site PrEP access, meaning PrEP approximately halved HIV incidence (incidence rate ratio [IRR] 0.45, 95% confidence interval [CI] 0.25 to 0.81, P = 0.0076). In an analysis adjusted for age, a new sex partner, and condomless sex plus partner having other partners, the incidence rate ratio remained 0.45 (95% CI 0.25 to 0.82, P = 0.0085). By the calendar time method, HIV incidence fell from 5.0% before PrEP access to 2.29% during on-site PrEP access to yield an adjusted IRR of 0.43 (95% CI 0.22 to 0.84, P = 0.014).
The ECHO investigators propose that offering on-site PrEP as part of the standard HIV-prevention package in prevention trials may lower new-HIV rates in those trials. They add that these findings "are some of the only data providing a rigorous assessment that offering PrEP to women in Africa is associated with a substantial decrease in HIV incidence."
1. Donnell D, Beesham I, Welch JD, et al. Incorporating PrEP into standard of prevention in a clinical trial is associated with reduced HIV incidence: evidence from the ECHO trial. AIDS 2020: 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OAC0105.
2. Onono M, Nanda K, Heller KB, et al. Comparison of pregnancy incidence among African women in a randomized trial of intramuscular depot medroxyprogesterone acetate (DMPA-IM), a copper intrauterine device (IUDs) or a levonorgestrel (LNG) implant for contraception. Contracept X. 2020 May 28;2:100026. doi: 10.1016/j.conx.2020.100026.