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Context: Improving contraceptive method choice is a goal of international family planning. Method mix-the percentage distribution of total contraceptive use across various methods-reflects both supply (availability of affordable methods) and demand (client preferences). We analyze changes in method mix, regional contrasts, and the relationship of the mix to contraceptive prevalence., Methods: We use 789 national surveys from the 1960s through 2019, from 113 developing countries with at least 1 million people and with data on use of 8 contraceptive methods. Two measures assess the "evenness" of the mix: method skew (more than 50% use is by 1 method), and the average deviation (AD) of the 8 methods' shares from their mean value. Population weighted and unweighted results are compared because they can differ substantially., Results: Use of traditional methods has declined but still represents 11% of all use (population weighted) or 17% (unweighted country average). Vasectomy's share was historically low with the exception of a few countries but is now even lower. The previous trend toward greater overall evenness in the mix has slowed recently. Sub-Saharan Africa shows a hormonal method progression from oral contraceptives to injectables to implants in a substantial number of countries. In some countries with high HIV prevalence, the condom share has increased. The leading method's share differs by region: female sterilization in Asia (39%) and in Latin America (31%), the pill in the Middle East/North Africa (32%), and the injectable in sub-Saharan Africa (36%). Method skew persists in 30% of countries. "Evenness" of mix is not related to contraceptive prevalence., Conclusion: The marked diversity in predominant methods underscores the conclusion that no single method mix is ideal or appropriate everywhere. But that diversity across countries, coupled with the persisting high degree of extreme skewness in many of them, argues for continued concerted efforts for programs to increase method choice., (© Bertrand et al.)

Context: Method mix-the percentage distribution of contraceptive users in a given country, by method-is one measure that reflects the availability of a range of contraceptive methods. A skewed method mix-one in which 50% or more of contraceptive users rely on a single method-could be cause for concern as a sign of insufficiency of alternative methods or provider bias. Shifts in method mix are important to individual countries, donors and scholars studying contraceptive dynamics., Methods: To determine current patterns and recent changes in method mix, we examined 109 low- and middle-income countries. A variety of statistical methods were used to test four factors as correlates of skewed method mix: geographic region, family planning program effort index, modern contraceptive prevalence rate and human development index. An assessment of changes in reliance on female and male sterilization, the IUD, the implant and the injectable was conducted for countries with available data., Results: Of the 109 countries included in this analysis, 30% had a skewed method mix-a modest decrease from 35% in a 2006 analysis. Only geographic region showed any correlation with method skew, but it was only marginally significant. The proportion of users relying on female sterilization, male sterilization or the IUD decreased in far more countries than it increased; the pattern was reversed for the injectable., Conclusion: Method mix skew is not a definitive indicator of lack of contraceptive choice or provider bias; it may instead reflect cultural preferences. In countries with a skewed method mix, investigation is warranted to identify the cause.

Because public health must operate at scale in widely diverse, complex situations, randomized controlled trials (RCTs) have limited utility for public health. Other methodologies are needed. A key conceptual backbone is a detailed "theory of change" to apply appropriate evidence for each operational component. Synthesizing patterns of findings across multiple methodologies provides key insights. Programs operating successfully across a variety of settings can provide some of the best evidence. Challenges include judging the quality of such evidence and assisting programs to apply it. WHO and others should shift emphasis from RCTs to more relevant evidence when assessing public health issues.

Reduced mortality has been the predominant cause of the marked global population growth over the last 3/4 of a century. While improved child survival increases motivation to reduce fertility, it comes too little and too late to forestall substantial population growth. And, beyond motivation, couples need effective means to control their fertility. It is an inconvenient truth that reducing child mortality contributes considerably to the population growth destined to compromise the quality of life of many, particularly in sub-Saharan Africa. Vigorous child survival programming is of course imperative. Wide access to voluntary family planning can help mitigate that growth and provide many other benefits.

Introduction: The recent availability of efficacious prevention interventions among stable couples offers new opportunities for reducing HIV incidence in sub-Saharan Africa. Understanding the dynamics of HIV incidence among stable couples is critical to inform HIV prevention strategy across sub-Saharan Africa., Methods: We quantified the sources of HIV incidence arising among stable couples in sub-Saharan Africa using a cohort-type mathematical model parameterized by nationally representative data. Uncertainty and sensitivity analyses were incorporated., Results: HIV incidence arising among stable concordant HIV-negative couples contribute each year, on average, 29.4% of total HIV incidence; of those, 22.5% (range: 11.1%-39.8%) are infections acquired by one of the partners from sources external to the couple, less than 1% are infections acquired by both partners from external sources within a year and 6.8% (range: 3.6%-11.6%) are transmissions to the uninfected partner in the couple in less than a year after the other partner acquired the infection from an external source. The mean contribution of stable HIV sero-discordant couples to total HIV incidence is 30.4%, with most of those, 29.7% (range: 9.1%-47.9%), being due to HIV transmissions from the infected to the uninfected partner within the couple. The remaining incidence, 40.2% (range: 23.7%-64.6%), occurs among persons not in stable couples., Conclusions: Close to two-thirds of total HIV incidence in sub-Saharan Africa occur among stable couples; however, only half of this incidence is attributed to HIV transmissions from the infected to the uninfected partner in the couple. The remaining incidence is acquired through extra-partner sex. Substantial reductions in HIV incidence can be achieved only through a prevention approach that targets all modes of HIV exposure among stable couples and among individuals not in stable couples.

Behavior is crucial throughout global health interventions. The discipline of behavior change offers distinct expertise needed across 6 different domains of behavior. Such expertise is in short supply, however. We will not have effective and sustainable health systems, nor achieve our ambitious global health goals, without seriously addressing behavior change.

GHSP aims to improve how programs function at scale, targeting implementers who actually support and carry out programs across all of global health. Thus, we emphasize specific implementation details, using a crisp, accessible, interactive style.

Objective: To estimate the contribution of HIV-1 sero-conversions among stable HIV sero-discordant couples (SDCs) to total HIV population-level incidence in sub-Saharan Africa., Design and Methods: We constructed a mathematical model, grounded in nationally representative demographic and epidemiological data, that estimates the annual number of HIV-1 transmissions from the infected partners to the uninfected partners among established SDCs, and compares its value to an estimate for the overall HIV population-level incidence in 20 countries in sub-Saharan Africa. We defined identifiable HIV-1 transmissions among SDCs as those that a hypothetical screening and intervention program would have the potential to avert. Uncertainty and sensitivity analyses were incorporated to assess the robustness of the findings., Results: Across the 20 countries, an average of 29% (range: 10-52%) of new HIV-1 infections occurred in which one partner in an identifiable SDC infected the other. The percentage of total HIV new infections in a country that occurred within such identifiable SDCs tended to be lower in countries with larger general population HIV epidemics. For most countries, HIV-1 incidence among SDCs is unlikely to exceed 50% of new HIV infections in the whole population., Conclusion: Only a fraction of HIV-1 heterosexual transmissions occur within identifiable SDCs. Prevention within SDCs at scale requires a series of potentially challenging programmatic requirements to be met. Despite the importance of prevention programs aiming at protecting the sero-negative partner in an SDC, a wider strategy utilizing the full range of prevention modalities, which would limit the original generation of SDCs, is also needed.

Contraceptive prevalence has been central to family planning research over the past few decades, but researchers have given surprisingly little consideration to method mix, a proxy for method availability or choice. There is no 'ideal' method mix recognized by the international community; however, there may be reason for concern when one or two methods predominate in a given country. In this article method skew is operationally defined as a single method constituting 50% or more of contraceptive use in a given country. Of 96 countries examined in this analysis, 34 have this type of skewed method mix. These 34 countries cluster in three groups: (1) sixteen countries in which traditional methods dominate, most of which are in sub-Saharan Africa; (2) four countries in which female sterilization predominates (India, Brazil, Dominican Republic and Panama); and (3) fourteen countries that rely on a single reversible method (the pill in Algeria, Kuwait, Liberia, Morocco, Sudan and Zimbabwe; the IUD in Cuba, Egypt, Kazakhstan, Kyrgyz Republic, Moldova, Turkmenistan and Uzbekistan; and the injectable in Malawi). A review of available literature on method choice in these countries provides substantial insight into the different patterns of method skew. Method skew in some countries reflects cultural preferences or social norms. Yet it becomes problematic if it stems from restrictive population policies, lack of access to a broad range of methods, or provider bias.