Quantifying the potential market for new contraceptive technologies: global projections of 2040 contraceptive needs and preferences.

Background: Despite a wide range of contraceptive methods, unmet need persists. New contraceptive technologies (CTs) have the potential to improve uptake and continuation. CT development has a long-time horizon; products will be introduced into markets that look very different than today. Identifying viable investments requires an understanding of these future markets. For this work the 2040 potential contraceptive market is described utilizing seven market segments based on marital status, fertility preferences, and patterns of sexual activity outside of marriage.  Methods: Market size estimates are developed by country for all countries in the world for a current market (2020) and a future market (2040). United Nation's (UN) population projections of the number of women of reproductive age (WRA) form the basis of this work. WRA are then segmented into market segments based on marital status, fertility intentions, and patterns of sexual activity outside of marriage.  Each segment is further subdivided by contraceptive use versus non-use.  Segmentation draws from UN projections, household surveys, census data, and modeling techniques developed for this work. Results: The largest market increases will be seen in Africa; most notably among the segment of married women wanting no more children. By contrast, Asia will see declines across all three married segments, coupled with increases among sexually active unmarried segments.  Levels of contraceptive use are projected to vary widely by segment, with differential patters across regions. Conclusions: This analysis projects the impact of demographic changes, evolving fertility preferences, shifts in sexual activity outside of marriage and increased utilization of contraceptives in shaping the contraceptive market of 2040. Results show that there is not one global market, but distinct markets that vary in size and shape across the world. This diversity suggests that a range of different new CTs could have potential for uptake.

Using the Demographic Health Survey wealth index to create family planning market segments based on absolute income levels.

Family planning market segmentation approaches typically include analysis by wealth, particularly when considering whether individuals can afford out-of-pocket expenses in the private sector. Most commonly, this is done using the Demographic and Health Survey (DHS) wealth index, which uses a relative approach by summing household asset questions and categorising respondents into five groups from poorest to wealthiest within a country. In addition, the use of absolute measures, such as segmenting populations based on whether one lives below or above the International Poverty line, defined by the World Bank as US$1.90 per person per day, may provide further useful insights when designing strategies to ensure access to family planning. While such measures are not readily available in the DHS, a simple approach can be used to combine the wealth index and World Bank poverty lines to generate an absolute measure for an additional perspective when conducting family planning market segmentation. Family planning market size estimates were made for 24 low-income countries using wealth quintiles and World Bank poverty lines. The results show large variations in market size based on what measure is used, particularly for countries with a high density of poverty. Looking at both types of measures and understanding the reasons for the differences in market size estimates between the approaches can help lend a more nuanced understanding of the distribution of wealth and income in a country, leading to improved family planning market segmentation and ultimately to ensure more women have access to a method of their choice.

Modelling impact and cost-effectiveness of oral pre-exposure prophylaxis in 13 low-resource countries.

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) provision is a priority intervention for high HIV prevalence settings and populations at substantial risk of HIV acquisition. This mathematical modelling analysis estimated the impact, cost and cost-effectiveness of scaling up oral PrEP in 13 countries. METHODS: We projected the impact and cost-effectiveness of oral PrEP between 2018 and 2030 using a combination of the Incidence Patterns Model and the Goals model. We created four PrEP rollout scenarios involving three priority populations-female sex workers (FSWs), serodiscordant couples (SDCs) and adolescent girls and young women (AGYW)-both with and without geographic prioritization. We applied the model to 13 countries (Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Mozambique, Namibia, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe). The base case assumed achievement of the Joint United Nations Programme on HIV/AIDS 90-90-90 antiretroviral therapy targets, 90% male circumcision coverage by 2020 and 90% efficacy and adherence levels for oral PrEP. RESULTS: In the scenarios we examined, oral PrEP averted 3% to 8% of HIV infections across the 13 countries between 2018 and 2030. For all but three countries, more than 50% of the HIV infections averted by oral PrEP in the scenarios we examined could be obtained by rollout to FSWs and SDCs alone. For several countries, expanding oral PrEP to include medium-risk AGYW in all regions greatly increased the impact. The efficiency and impact benefits of geographic prioritization of rollout to AGYW varied across countries. Variations in cost-effectiveness across countries reflected differences in HIV incidence and expected variations in unit cost. For most countries, rolling out oral PrEP to FSWs, SDCs and geographically prioritized AGYW was not projected to have a substantial impact on the supply chain for antiretroviral drugs. CONCLUSIONS: These modelling results can inform prioritization, target-setting and other decisions related to oral PrEP scale-up within combination prevention programmes. We caution against extensive use given limitations in cost data and implementation approaches. This analysis highlights some of the immediate challenges facing countries-for example, trade-offs between overall impact and cost-effectiveness-and emphasizes the need to improve data availability and risk assessment tools to help countries make informed decisions.

Evaluating the potential impact and cost-effectiveness of dapivirine vaginal ring pre-exposure prophylaxis for HIV prevention.

BACKGROUND: Expanded HIV prevention options are needed to increase uptake of HIV prevention among women, especially in generalized epidemics. As the dapivirine vaginal ring moves forward through regulatory review and open-label extension studies, the potential public health impact and cost-effectiveness of this new prevention method are not fully known. We used mathematical modeling to explore the impact and cost-effectiveness of the ring in different implementation scenarios alongside scale-up of other HIV prevention interventions. Given the knowledge gaps about key factors influencing the ring's implementation, including potential uptake and delivery costs, we engaged in a stakeholder consultation process to elicit plausible parameter ranges and explored scenarios to identify the possible range of impact, cost, and cost-effectiveness. METHODS AND FINDINGS: We used the Goals model to simulate scenarios of oral and ring pre-exposure prophylaxis (PrEP) implementation among female sex workers and among other women ≤21 years or >21 years with multiple male partners, in Kenya, South Africa, Uganda, and Zimbabwe. In these scenarios, we varied antiretroviral therapy (ART) coverage, dapivirine ring coverage and ring effectiveness (encompassing efficacy and adherence) by risk group. Following discussions with stakeholders, the maximum level of PrEP coverage (oral and/or ring) considered in each country was equal to modern contraception use minus condom use in the two age groups. We assessed results for 18 years, from 2018 to 2035. In South Africa, for example, the HIV infections averted by PrEP (ring plus oral PrEP) ranged from 310,000 under the highest-impact scenario (including ART held constant at 2017 levels, high ring coverage, and 85% ring effectiveness) to 55,000 under the lowest-impact scenario (including ART reaching the UNAIDS 90-90-90 targets by 2020, low ring coverage, and 30% ring effectiveness). This represented a range of 6.4% to 2.2% of new HIV infections averted. Given our assumptions, the addition of the ring results in 11% to 132% more impact than oral PrEP alone. The cost per HIV infection averted for the ring ranged from US$13,000 to US$121,000. CONCLUSIONS: This analysis offers a wide range of scenarios given the considerable uncertainty over ring uptake, consistency of use, and effectiveness, as well as HIV testing, prevention, and treatment use over the next two decades. This could help inform donors and implementers as they decide where to allocate resources in order to maximize the impact of the dapivirine ring in light of funding and implementation constraints. Better understanding of the cost and potential uptake of the intervention would improve our ability to estimate its cost-effectiveness and assess where it can have the most impact.