The maximum contraceptive prevalence 'demand curve': guiding discussions on programmatic investments

Demand creation for HIV testing services: A systematic review and meta-analysis

BACKGROUND

HIV testing services (HTS) are the first steps in reaching the UNAIDS 95-95-95 goals to achieve and maintain low HIV incidence. Evaluating the effectiveness of different demand creation interventions to increase uptake of efficient and effective HTS is useful to prioritize limited programmatic resources. This review was undertaken to inform World Health Organization (WHO) 2019 HIV testing guidelines and assessed the research question, "Which demand creation strategies are effective for enhancing uptake of HTS?" focused on populations globally.

METHODS AND FINDINGS

The following electronic databases were searched through September 28, 2021: PubMed, PsycInfo, Cochrane CENTRAL, CINAHL Complete, Web of Science Core Collection, EMBASE, and Global Health Database; we searched IAS and AIDS conferences. We systematically searched for randomized controlled trials (RCTs) that compared any demand creation intervention (incentives, mobilization, counseling, tailoring, and digital interventions) to either a control or other demand creation intervention and reported HTS uptake. We pooled trials to evaluate categories of demand creation interventions using random-effects models for meta-analysis and assessed study quality with Cochrane's risk of bias 1 tool. This study was funded by the WHO and registered in Prospero with ID CRD42022296947. We screened 10,583 records and 507 conference abstracts, reviewed 952 full texts, and included 124 RCTs for data extraction. The majority of studies were from the African (N = 53) and Americas (N = 54) regions. We found that mobilization (relative risk [RR]: 2.01, 95% confidence interval [CI]: [1.30, 3.09], p < 0.05; risk difference [RD]: 0.29, 95% CI [0.16, 0.43], p < 0.05, N = 4 RCTs), couple-oriented counseling (RR: 1.98, 95% CI [1.02, 3.86], p < 0.05; RD: 0.12, 95% CI [0.03, 0.21], p < 0.05, N = 4 RCTs), peer-led interventions (RR: 1.57, 95% CI [1.15, 2.15], p < 0.05; RD: 0.18, 95% CI [0.06, 0.31], p < 0.05, N = 10 RCTs), motivation-oriented counseling (RR: 1.53, 95% CI [1.07, 2.20], p < 0.05; RD: 0.17, 95% CI [0.00, 0.34], p < 0.05, N = 4 RCTs), short message service (SMS) (RR: 1.53, 95% CI [1.09, 2.16], p < 0.05; RD: 0.11, 95% CI [0.03, 0.19], p < 0.05, N = 5 RCTs), and conditional fixed value incentives (RR: 1.52, 95% CI [1.21, 1.91], p < 0.05; RD: 0.15, 95% CI [0.07, 0.22], p < 0.05, N = 11 RCTs) all significantly and importantly (≥50% relative increase) increased HTS uptake and had medium risk of bias. Lottery-based incentives and audio-based interventions less importantly (25% to 49% increase) but not significantly increased HTS uptake (medium risk of bias). Personal invitation letters and personalized message content significantly but not importantly (<25% increase) increased HTS uptake (medium risk of bias). Reduced duration counseling had comparable performance to standard duration counseling (low risk of bias) and video-based interventions were comparable or better than in-person counseling (medium risk of bias). Heterogeneity of effect among pooled studies was high. This study was limited in that we restricted to randomized trials, which may be systematically less readily available for key populations; additionally, we compare only pooled estimates for interventions with multiple studies rather than single study estimates, and there was evidence of publication bias for several interventions.

CONCLUSIONS

Mobilization, couple- and motivation-oriented counseling, peer-led interventions, conditional fixed value incentives, and SMS are high-impact demand creation interventions and should be prioritized for programmatic consideration. Reduced duration counseling and video-based interventions are an efficient and effective alternative to address staffing shortages. Investment in demand creation activities should prioritize those with undiagnosed HIV or ongoing HIV exposure. Selection of demand creation interventions must consider risks and benefits, context-specific factors, feasibility and sustainability, country ownership, and universal health coverage across disease areas.

Elevating Social and Behavior Change as an Essential Component of Family Planning Programs

The global family planning community has made significant progress towards enabling 120 million more women and girls to use contraceptives by 2020, though we enter the decade ahead with a long road yet to travel. While investment in strong health systems and supply chains is still needed, the supply‐driven approach dominant in family planning fails to address the individual, relational, and social barriers faced by women and couples in achieving their reproductive intentions and desired family size. Overcoming these barriers will require a better understanding of behavioral drivers and the social environment in which family planning decisions are made, and an increased investment in the proven, yet underutilized, approach of social and behavior change (SBC). We make the case that a more intentional focus on the science of human behavior in family planning can help advance the achievement of global, regional, and national goals while also calling for strategic and sustained investment that reflects the critical importance and proven impact of SBC approaches.

The Maximum CPR Model: a demographic tool for family planning policy

The Maximum CPR Model (MCM) allows demographers, policy makers, and family planning advocates to determine a country’s highest potential contraceptive prevalence rate (CPR), based on an ideal number of children, demographic life events, and population structure. Understanding the highest potential level of CPR achievable under current circumstances in a population leads to realistic expectations and appropriate policy implementation. Countries with a large gap between current CPR and maximum CPR can focus on removing blocks to contraceptive use, while countries where the maximum potential CPR is near the actual CPR may need to shift their focus to demand generation or postpartum family planning programs. With a focus on equality of access to family planning, MCM produces CPR for all women, regardless of marital status. This paper details the mathematical construction of the MCM. A version of the model is available online for easy use by non-technical audiences in English and French.

The Maximum CPR Model: a demographic tool for family planning policy

The Maximum CPR Model (MCM) allows demographers, policy makers, and family planning advocates to determine a country’s highest potential contraceptive prevalence rate (CPR), based on an ideal number of children, demographic life events, and population structure. Understanding the highest potential level of CPR achievable under current circumstances in a population leads to realistic expectations and appropriate policy implementation. Countries with a large gap between current CPR and maximum CPR can focus on removing blocks to contraceptive use, while countries where the maximum potential CPR is near the actual CPR may need to shift their focus to demand generation or postpartum family planning programs. With a focus on equality of access to family planning, MCM produces CPR for all women, regardless of marital status. This paper details the mathematical construction of the MCM. A version of the model is available online for easy use by non-technical audiences in English and French.