Reflections on the anniversary of the ECHO study
Lindsey Miller, FP2030 Consultant

In June 2019, the results of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) study revealed that women, and especially adolescent girls, remain highly at risk of acquiring HIV infection and other sexually transmitted infections (STIs), and their comprehensive health needs are not being met. Despite having access to a comprehensive package of HIV prevention services, women aged younger than 25 years were associated with a higher incidence of HIV, and STIs were common in the study population at baseline. The results of the study elevated a long-standing call for the integration of services for HIV, STIs, and pregnancy prevention that works for adolescents and young people and upholds their right to comprehensive health care.

After the ECHO study, the global health community was again mobilized to prioritize expanding access to comprehensive sexual and reproductive health (SRH) services, but there is still much to be done to fully realize a future where women and girls everywhere have the freedom and ability to lead healthy lives. Women who live in high HIV incidence areas not only have a high lifetime risk of HIV infection, but usually also have a high unmet need for comprehensive SRH services. To that end, our commitment to expanding a rights-based, client-centered approach to comprehensive SRH health care must be sustained, country-led, funded, measured, and supported by national SRH policies and guidelines. Two years after ECHO, we must maintain momentum despite the serious challenges posed by COVID-19, which themselves have laid bare the urgent need for health care service delivery systems that meet women and adolescents where they are and mitigate exacerbating existing inequalities.

Through the FP2030 Commitments process, governments and other stakeholders have an opportunity to formalize investments to support a future where women and girls everywhere make their own informed decisions about using contraception and having children and participate as equals in society and its development. Donors should reduce funding barriers to ensure resources are allocated as efficiently as possible and in line with the needs and preferences of women and girls. Civil society and advocates should continue efforts to maintain, and ideally expand, the availability of SRH services, including demanding investments in SRH programs, procurement of critical health commodities, metrics that reflect new models of service delivery (e.g., self-care, differentiated service delivery [DSD]), and provider training and program designs that reflect a client-centered, informed-choice approach, including comprehensive sexuality education and emerging evidence-based approaches such as adolescent-responsive contraceptive services.

The ECHO study findings remain a stark reminder of the urgent need to expand access to prevention, diagnosis, and treatment services for HIV and other STIs, especially among women living in high HIV incidence areas, and prioritize the expansion of HIV prevention methods and services among women seeking family planning services. Integrated service provision promotes a rights‐based approach to health service provision and is supported by leading global health organizations such as the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and United States Agency for International Development (USAID) because of its potential to contribute to the achievement of critical development goals. As countries consider making rights-based family planning commitments, now is the time to reaffirm their support for services for integrated family planning, HIV/STI, and cervical cancer — all of which are essential to comprehensive SRH service provision — that are grounded in rights-based principles and responsive to the needs of all clients, regardless of age, HIV status, marital status, or parity.