The Coming-of-Age of Subcutaneous Injectable Contraception.

The Stout article describes a variety of different introduction approaches, illustrating the many options a country may consider. Globally, countries tend to co-position DMPA-SC alongside DMPA-IM, transition from IM to SC, or roll out targeted introduction by piloting different approaches. There is no “right” introduction approach; country-level decisions around programming and procurement of contraceptive methods are complex, involve multiple stakeholders, and require thoughtful planning. However the intended outcome should be that more women have voluntary access to this method if it meets their needs. The Box summarizes some of the conditions necessary for successful introduction, many drawn from the Stout and Georges articles. BOX Elements Promoting Successful Introduction of DMPA-SC Policy Encourage strong Ministry of Health leadership. Promote task sharing: Countries can achieve high impact without including task sharing, but policies that allow for community health worker or pharmacist administration and/or self-injection maximize its potential. Service Delivery Use a rapid, cascade approach to provider training. Counsel on all voluntary family planning methods, including those available through referral while ensuring comprehensible information is provided on the method chosen. Counsel on the method's characteristics including bleeding changes as well as the need for simultaneous use of condoms for dual protection to prevent HIV and other sexually transmitted infections. Offer the method through community channels, mobile outreach, and the private sector, supported by extensive demand-generation activities. Integration Integrate with maternal and child health and other health and non-health services. Quickly make DMPA-SC a normal part of commodity planning to increase commodity security and leverage existing distribution systems. Monitoring and Evaluation Disaggregate health information system data by injectable type (IM vs. SC) and collect data more frequently than semiannually. Disaggregate users by age to better understand user dynamics, and by prior contraceptive use to track new users. Share data openly, especially between the public and private sectors. PROGRAMMING UNKNOWNS AND WORDS OF CAUTION AROUND HIV There is evidence of a possible increased risk of acquiring HIV among progestin-only injectable users. Uncertainty exists about whether this is due to methodological issues with the evidence or to a real biological effect.21 Currently there are no epidemiological data available on possible association between DMPA-SC specifically and risk of acquiring HIV. On March 2, 2017, the World Health Organization, in its Medical Eligibility Criteria for Contraceptive Use, changed use of DMPA injectable products among women at high risk of HIV acquisition from category 1 to category 2.22 This means that for women at high risk of HIV, the advantages of using DMPA products generally outweigh the theoretical or proven risk. Women should not be denied progestin-only injectables because of concerns about the possible increased risk of HIV. Rather, women considering progestin-only injectables should be advised about these concerns, about the uncertainty over whether there is a causal relationship, and about how to minimize their risk of acquiring HIV, including correct and consistent use of condoms, antiretroviral therapy initiation for partners living with HIV where appropriate, and pre-exposure prophylaxis where available. A wide range of voluntary family planning methods must be available, and when introducing a new method such as DMPA-SC, consideration should be given to retraining providers on clinical and counseling skills for all contraceptive methods and HIV risks.23,24 Given the inconclusive data, the question of whether DMPA increases women's risk of HIV is a critical public health issue requiring the strongest evidence possible. The ongoing Evidence for Contraceptive Options and HIV Outcomes (ECHO) study is designed to fill this gap and provide robust evidence on the relative risks (HIV acquisition) and benefits (pregnancy prevention) between 3 effective contraceptive methods (DMPA-IM; levonorgestrel implant; copper intrauterine device).25 It is important to note that the study does not include DMPA-SC, but the results may affect the introduction and rollout of DMPA-SC.