| | Region | Epidemiology | Priorities, opportunities, challenges for
MPT development |
| | Sub-Saharan Africa (SSA) | Contraception
(i) SSA lags behind global trends for increasing contraceptive prevalence and fertility decline, with high rates of unintended pregnancy and maternal mortality
(ii) The region is not homogeneous: faster evolution in Southern and Eastern Africa. Demand for contraception now reaching 50% of married women, but only accessible to 20% [14–16]
(iii) Method preferences also vary: unmarried women throughout SSA mainly rely on male-controlled condoms; pills, and injectables used predominantly by married women, rarely with additional protection against STIs [17]. Female condom is underutilized and comparatively expensive, with 50 million distributed annually by UNFPA [18]
STI protection
(i) Women on HIV antiretroviral therapy often do not use modern contraception, or forgo additional condom use [19]. In southern and eastern Africa, where a sizable proportion of HIV-positive women use injectable hormonal contraception [20]
(ii) Syndromic management has reduced rates of bacterial STIs such as syphilis and chancroid [21], rates of the other dominant viral (STIs, HSV, HPV) extremely high, with prevalence rates up to 70% for HSV [4], between 20 and 33% HPV [22] in some cohorts
(iii) Prevalence of bacterial vaginosis (BV), associated with increased risk of HIV-1 acquisition, reaches rates of 16–50% of women [23–25].
| Priorities
(i) STI prevention targets dictated by prevalence, that is, HIV, HSV, BV, trichomonas vaginalis (TV), and HPV.
(ii) Strong regional preference for injectable products, but barrier methods and vaginal products also highly acceptable.
Opportunities
(i) Contraceptive uptake could increase by expanding method mix, moving toward low-dose hormonal products (and IUDs), addressing health concerns through expanded user education, focusing on populations with a high unmet need
(ii) Increasing pressures for integration of services for HIV prevention, testing, PMTCT and care, and family planning services
Challenges
(i) Method needs differ for married and unmarried women, and preference varies across the region
(ii) MPTs with and without a contraceptive component required for women at risk for STIs and wishing to become pregnant
(iii) Given current popularity of injectable contraceptives, concern about impact of progestins on HIV acquisition is high [26].
(iv) Health interventions in low-resource and middle-income countries often experience slow uptake, necessitating interventions with long-term horizons |
| India
| Contraception
(i) Population growth main concern, but total fertility rate showed dramatic decline over last few decades, to total fertility rate of 2.6 [15, 27]. Decreasing significant rate of unintended pregnancies [28] instrumental in reaching replacement level fertility, a critical requirement to prevent doubling current population within next 50 years [15, 29]
(ii) Only 7% of sexually active young women have ever used condoms for premarital sex; 25% of women are pregnant or mothers by age 18 [30]
(iii) Current contraceptive prevalence just under 50% [15]; method mix consists primarily of female sterilization, IUDs, male condoms, and oral contraceptives; injectables and female condoms rarely used [31]
STI protection
(i) HIV prevalence in India estimated at 0.31% (2.39 million people), concentrated in high-risk groups (female sex workers, migrant workers, men who have sex with men, intravenous drug users)
(ii) HIV acquisition is primarily through heterosexual sex and 39% of all infections occur in women [32]
(iii) Bacterial STI prevalences overall below 10%; candidiasis and HSV-2 reach low double digits; bacterial vaginosis reported as high as 63% [33]
(iv) Regions with low HIV prevalence (e.g., Bihar, Orissa, Uttar Pradesh) also have low rates for other STIs, but lead national statistics with the worst maternal mortality rates, highest fertility rates, and lowest rates of use of modern contraceptive methods [34] | Priorities
(i) The Indian market for MPTs would be driven by priority for a contraceptive indication
Challenges
(i) Cultural factors such as women's often limited ability to act as decision-maker for own health, husband’s support (as well as varying comfort levels with administration of vaginal products) will all influence uptake of MPTs |
| | China | Contraception
(i) At almost 85% of married women, one of world’s highest rates of contraceptive use [35]
(ii) Contraceptive method mix dominated by IUDs (40%) and female sterilization (almost 30%); condom use has increased with urbanization and increased income
(iii) Availability of oral contraception, implants, and injectables still limited, partly due to lack of government funding and substantial regulatory approval processes, discouraging to private enterprise
STI protection
(i) Overall HIV prevalence low, almost 80% concentrated in Guangzi, Guangdong, Henan, Sichuan, Xinjian, Yunnan provinces; overall HIV prevalence estimated at 780,000, with 48,000 new HIV infections in 2011
(ii) More than 75% of HIV transmission is heterosexual; 28.6% of all HIV infections in China are in women. In economically developed provinces, for example, Dongguan, Guangdong, many new HIV cases are among migrant workers [36, 37]
(iii) Due to expanded reproductive health care in government facilities, STI prevalence in China declined over past two decades, but prevalence in underserved rural areas remains high [38]
(iv) STI epidemic in China is changing: while gonorrhea and HPV were main infections in past decades, nongonorrheal urethritis (NGU) and syphilis surged over last 20 years
(v) Today, syphilis is the dominant STI, mainly among young migrant workers and female sex workers in richer coastal regions; chlamydia, gonorrhea, HPV, non-gonococcal urethritis (NGU), and HPV are widely distributed [39–41] | Priorities
(i) MPT development will be driven by the need to respond to the STI epidemic, including HIV, as well as by expansion of contraceptive method mix toward a larger proportion of short-term methods
|
| | Developed Countries | Contraception
(i) Nearly half of all pregnancies in 29 US states are unintended [42], especially in young women age 15–19 (over 80%) [43]: more than half of American women experience an unintended pregnancy, and 30% undergo an abortion [44]
(ii) While unintended pregnancy rates have improved overall, socioeconomic disparities remain. Between 1994 and 2006, rate of unintended pregnancy among US higher-income women fell by 29%, while that rate among lower-income women rose by 50% [45]. Even though national teen pregnancy rate is now the lowest in 40 years, rates among Hispanic and black teens are 2 to 3 times higher than those of non-Hispanic white teens [46]
STI protection
(i) In 2007, CDC reported 1.1 million cases of chlamydia (3-fold in women compared to men), and 356,000 cases of gonorrhea (5-fold among women age 15–24 compared to women overall) [47]
(ii) CDC estimates that 20% of adolescents and adults have had a genital herpes infection [48] and about 7.4 million new cases of trichomoniasis occur each year [49]
(iii) Despite regulatory approval and availability of HPV vaccines, HPV continues to infect 6.2 million Americans each year [50].
(iv) Each year about 47,000 new HIV infections occur in the US [51]. In 2010, women accounted for 23% of all diagnoses and for growing majority of all heterosexual transmissions [51]; in 2010, black women accounted for 64% of new AIDS diagnoses among women, Latinas for 17%, a rate 22 times and 5 times higher, respectively, than for white women [52] | Priorities
(i) Developed countries were found to place highest emphasis on MPTs that would serve both as contraception and be active against selected STIs, notably HSV and HPV.
(ii) HIV largely seen as issue for specific subpopulations | | | (v) Approximately 20% of US HIV-positive individuals unaware of their status [51, 53]
(vi) HIV and high rates of other STIs burden many European countries. In 2009, almost 344,000 cases of chlamydia and almost 30,000 cases of gonorrhea reported from EU/EEA Member States [54]
(vii) Chlamydia affects more women than men, and both chlamydia and gonorrhea disproportionately affect young people in this region, where 15–24 year-olds account for 75% and 40% of reported infections, respectively
(viii) In 2010, close to 120,000 cases of HIV were reported by 51 European countries, 76% of those in the East [54, 55], with heterosexual contact remaining a main route of transmission, at 43% of reported HIV cases [55] | |
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