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BACKGROUND: Instructions for what women should do when they miss oral contraceptive pills are complex and vary according to the quantity and the timing of missed pills. METHODS: A randomized controlled trial was conducted to assess the comprehensibility of four types of instructions rendered in both 21- and 28-day versions, as well as in graphic and text formats. Interviews were conducted with 864 current and past pill users in Kingston, Jamaica. Each was provided with scenarios of missed pills and one version of the instructions; they were then asked what they should do to avoid pregnancy. RESULTS: More than 60% of respondents knew what to do when one pill was missed, but most did not give correct answers for missing two or more pills in a row, regardless of the instruction type. CONCLUSION: Women generally do a poor job of identifying steps to take when multiple pills are missed. Graphic instructions are easier to understand than text-only instructions and less information is better. Findings suggest that rendering missed pill instructions in graphic format while scaling back on the breadth of medical information results in better comprehension. [ABSTRACT FROM AUTHOR]

Background: Condom use among young people in South Africa has declined in recent years and adolescent girls and young women continue to bear the highest incidence of HIV in the country. Young women who have dropped out of school may be more at risk because of traditional gender norms that create substantial power imbalances and a lack of power to negotiate condom use with their male partners, especially when using alcohol and other drugs., Methods: This study presents an analysis of baseline data provided by 500 adolescent girls and young women (AGYW) from Cape Town communities between November 2016 and November 2018 who were reached for a cluster-randomised trial conducted to assess the efficacy of an evidence-based, young woman-focused intervention seeking to reduce HIV risk and substance use behaviours. The analysis focuses on associations between binge drinking, condom use, and sexual negotiation, including impaired sex (any substance use at last sex)., Results: AGYW who reported frequent condom negotiation with their partners were 8.92 times (95% CI: [4.36, 18.24]) as likely to use a condom when alcohol or other drugs were not used at last sex and 5.50 times (95% CI: [2.06, 14.72]) as likely when alcohol or other drugs were used at last sex (p < 0.05). AGYW who reported frequent binge drinking in the past month (n = 177) had significantly reduced odds of condom use at last sex, irrespective of whether the sex was impaired (OR 0.60, 95% CI: [0.49, 0.73]) or not impaired (OR 0.69, 95% CI: [0.60, 0.81])., Discussion: The findings highlight the need for interventions that reach AGYW in South Africa by specifically aiming to educate AGYW about the effect of binge drinking on negotiating power in their relationships, thus providing them with the knowledge and skills to increase agency regarding condom use., Trial Registration: ClinicalTrials.gov Identifier: NCT02974998 (recruitment completed). 29/11/2016., (© 2023. The Author(s).)

Background: Diagnosis of invasive candidiasis (IC) relies on insensitive cultures; the relative utility of fungal biomarkers in children is unclear., Methods: This multinational observational cohort study enrolled patients aged >120 days and <18 years with concern for IC from 1 January 2015 to 26 September 2019 at 25 centers. Blood collected at onset of symptoms was tested using T2Candida, Fungitell (1→3)-β-D-glucan, Platelia Candida Antigen (Ag) Plus, and Platelia Candida Antibody (Ab) Plus assays. Operating characteristics were determined for each biomarker, and assays meeting a defined threshold considered in combination. Sterile site cultures were the reference standard., Results: Five hundred participants were enrolled at 22 centers in 3 countries, and IC was diagnosed in 13 (2.6%). Thirteen additional blood specimens were collected and successfully spiked with Candida species, to achieve a 5.0% event rate. Valid T2Candida, Fungitell, Platelia Candida Ag Plus, and Platelia Candida Ab Plus assay results were available for 438, 467, 473, and 473 specimens, respectively. Operating characteristics for T2Candida were most optimal for detecting IC due to any Candida species, with results as follows: sensitivity, 80.0% (95% confidence interval, 59.3%-93.2%), specificity 97.1% (95.0%-98.5%), positive predictive value, 62.5% (43.7%-78.9%), and negative predictive value, 98.8% (97.2%-99.6%). Only T2Candida and Platelia Candida Ag Plus assays met the threshold for combination testing. Positive result for either yielded the following results: sensitivity, 86.4% (95% confidence interval, 65.1%- 97.1%); specificity, 94.7% (92.0%-96.7%); positive predictive value, 47.5% (31.5%-63.9%); and negative predictive value, 99.2% (97.7%-99.8%)., Conclusions: T2Candida alone or in combination with Platelia Candida Ag Plus may be beneficial for rapid detection of Candida species in children with concern for IC., Clinical Trials Registration: NCT02220790., Competing Interests: Potential conflicts of interest. B. T. F. receives funding from the Food and Drug Administration, Pfizer, and Merck and serves as a paid chair of a data and safety monitoring board (DSMB) for Astellas. R. H. serves on advisory boards for Quidel and Inflammatix; receives ASM Press book royalties (personal payments); and serves as a member of the board of directors for the Clinical Laboratories Standards Institute and as immediate past president for the Pan-American Society for Clinical Virology (both unpaid). T. E. Z. provides consultant services for T2 Biosystems and Nabriva Therapeutics. D. E. Y.’s institution receives funding from Merck, Astellas, Marion Merrel Dow Fund, Viracor-Eurofins (laboratory testing services to institution for investigator-initiated research), and Chimerix. D. E. Y. is now employed by the National Institute of Allergy and Infectious Diseases, NIH, which has paid for conference registration and fees, but this research was conducted while he was employed by Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine. D. E. Y. also reports serving as unpaid technical advisor to nonprofit organizations Cover the Globe and Maipelo Trust, which provide human immunodeficiency virus services to migrant or displaced children and families in Botswana. A. R. H. has patent 10,160,974 issued (Engineered cytokine- and chemokine-expressing Candida albicans strains and methods of use; no royalties collected); reports grant support from the NIH (grant K08DE026189 from the National Institute of Dental and Craniofacial Research and NIH pass-through via Duke grants [DOMINIC]); and reports serving on the Central Review Board for Non-Invasive Diagnosis of Pediatric Pulmonary Invasive Mold infections (DOMINIC) (unpaid). L. D. I. received institutional support for contracted clinical research from Astellas, Merck, Takeda, Ansun Biopharma, and Viracor-Eurofins; is a paid consultant for Takeda and paid chair of a DSMB for Merck; and serves as president of The International Society for Heart and Lung Transplantation. W. J. M. receives support from Adagio Therapeutics, Ansun Biopharma, Astellas, AstraZeneca, Eli Lilly, Enanta Pharmaceuticals, Janssen, Karius, Merck, Genentech, Gilead, Moderna, Melinta, Nabriva, Tetraphase, and Seqirus; reports consulting fees from Seqirus (to institution), the US Attorney’s Office, Southern District of Illinois (to self), McQuade Blasko Law Offices (to self), Finley Law Firm (to self), Doherty & Progar (to self), Phelan, Tucker, Mullen, Walker, Tucker, Gelman (to self), and Bailes, Craig, Yon & Sellards (to self); and reports participation on DSMB or advisory boards for Adagio Therapeutics and ProventionBio (payments to self). E. R. receives funding from Merck Sharp & Dohme (MSD), Merck, Pfizer, and Gilead; reports consulting fees from MSD and Pfizer (paid to institution); reports honoraria for lectures paid to their institution from Pfizer, MSD, and Gilead; reports travel support/payment of registration from Vianex, Pfizer, and MSD; and reports participation on advisory board(s) for MSD and Pfizer. P. K. S. reports grants from Astellas and Merck (to institution for work as clinical trial site). D. B. was a consultant for Teleflex. D. B. reports consulting fees from Precision Health (consulting agreement as of August 2021), for providing advice on the selection of polymerase chain reaction panels for outpatients in long-term care facilities and educating the Medical Science Liason team on their use) and Karius Diagnostics (where D. B. has been employed full time since 28 June 2021, as medical director in the Medical Affairs Division); Karius offers metagenomic next-generation sequencing for pathogens from plasma). As a full-time Karius employee, D. B. has the option to purchase stocks in the future during the initial public offering (the timing of the initial public offering is not yet known). D. B. continue to have a faculty appointment at Johns Hopkins All Children’s Hospital and hospital privileges (per diem). N. H. was a consultant for Moderna; receives funding from NIH, the Centers for Disease Control and Prevention, Quidel, and Sanofi; and serves as a Pediatric Infectious Diseases Society board member. G. M. receives funding from Astellas. P. S. P. receives support from Pfizer (research grant), Grifols, CSL Behring, Takeda, and Gilead (education and research grants); reports payment/honoraria from Pfizer and Gilead and payment for expert testimony from Gilead; reports participation on DSMB or an advisory board for Pfizer. C. M. S. reports receiving an NIH grant for the BIOPIC study, during the conduct of the study. M. G. reports NIH funding, outside the submitted work; receives royalties for being a textbook editor for Elsevier; reports personal consulting fees from ITB-Med; reports a personal honorarium for a lecture from Medscape; reports personal payments for serving on an advisory board for ATARA Biotherapeutics; and serves on the DSMB and as a consultant for Bristol Myers Squibb. S. B. H. reports honoraria for lectures on coronavirus disease 19 in Texas and office infection control from the Centers for Disease Control and Prevention. W. J. S. serves on the scientific advisory board of Sfunga (personal payments). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Introduction: In Senegal, discontinuation due to sides effects of long-acting, reversible contraceptives (LARCs) is relatively low; 5% of new implant acceptors and 11% of new IUD acceptors stop using in their first year because of health or side effect concerns. This study investigated factors associated with LARC discontinuation in the first 12 months of use in Senegal and explored how LARC users cope with side effects., Methods: This mixed-method study involved quantitative interviews at five time points with LARC acceptors recruited from three service channels between February 2018 and March 2019. Qualitative interviews were conducted in August 2018 with a subset of those who experienced side effects. Logistic regression models identified factors associated with discontinuation due to side effects and discontinuation for any reason. Twelve-month discontinuation rates due to side effects were also estimated using a cumulative incidence function (CIF) approach to account for time to discontinuation., Results: In logistic models, method choice (IUD or implant) [OR = 3.15 (95% CI: 1.91-5.22)] and parity [OR = 0.81 (95% CI: 0.7-0.94)] were associated with discontinuation due to side effects; IUD users and women with fewer children were more likely to discontinue. Results for all-cause discontinuation were similar: method choice [OR = 2.39 (95% CI: 1.6-3.58)] and parity [OR = 0.86 (95% CI: 0.77-0.96)] were significant predictors. The 12-month side effect CIF discontinuation rate was 11.2% (95% CI: 7.9-15.0%) for IUDs and 4.9% (95% CI: 3.5-6.6%) for implants. Side effect experiences varied, but most women considered menstrual changes the least acceptable. No statistically significant differences across services channels were observed., Conclusions: In this study in Senegal, the choice between implants and IUDs had a significant impact on continuation, and women with more children continued LARC methods longer, despite side effects., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chin-Quee, Diadhiou, Eichleay, Youssef, Chen, Bernholc and Stanback.)

Background: Given the role that continued use of family planning (FP) by current users plays in increasing contraceptive prevalence rates (CPR), this research aims to measure method-specific continuation rates for fixed-site and community-based program interventions and to document reasons for discontinuation.  Methods: This research compared discontinuation rates for clients initiating family planning through two types of strategies-services provided at existing health centers that provided regular, ongoing services, and "one-off" outreach services in communities.  Data collectors surveyed consenting clients who were initiating a modern method, or reinitiating after a break of at least six months, and conducted a follow up survey after seven months.  Results: Long acting reversible contraception (LARC) was more commonly initiated through outreach strategies than through fixed sites. LARC made up 65% of methods initiated through the outreach setting and 47% of those initiated through a fixed-site strategy. Continuation rates varied from 99% for intrauterine devices (IUDs) to 77% for injectables and were very similar between outreach and fixed-site strategies, with the exception of oral contraceptive pills (OCPs). Only 65% of outreach initiators continued using OCPs, compared to 84% of fixed-site initiators. Top reported reasons for discontinuation were side effects and little or no sexual relations. Conclusions: Project interventions allowed most women to continue with their chosen method of FP for the seven-month duration of the study whether initiated through fixed site or outreach strategies, showing promise in helping Senegal to increase its CPR. It is feasible to offer both LARC and short acting methods through outreach strategies.  Further research into the sensitivity of demand to the price charged is needed., Competing Interests: No competing interests were disclosed.

Vasectomy is a highly effective and safe contraceptive method for couples who want to stop childbearing, but only 2.4% of men around the world use this method. We conducted an extensive review of the vasectomy research literature and programmatic reports, published between April 2005 and April 2015, to synthesize barriers and facilitators to vasectomy adoption. Of the more than 230 documents initially retrieved in our search, we ultimately included 75 documents in our review and synthesized the findings according to the Supply-Enabling Environment-Demand (SEED) Programming Model. Regarding promoting demand for vasectomy services, we found there was a general lack of awareness about the method among both men and women, which often fueled erroneous assumptions about how vasectomy affects men. Several types of programmatic activities directly addressed knowledge gaps and negative misperceptions, including community-based and mass media communications, employer-based promotion, and group counseling. For supply of services, the lack of or inaccurate knowledge about vasectomy was also prevalent among providers, particularly among community-based health workers. Programmatic activities to improve service delivery included the use of evidence-based vasectomy techniques such as no-scalpel vasectomy, whole-site trainings, task shifting, cascade training, and mobile outreach. Finally, programmatic approaches to building a more enabling environment included engagement of governments and other community and religious leaders as well as campaigns with gender transformative messaging that countered common myths and encouraged men's positive engagement in family planning and reproductive health. In summary, a successful vasectomy program is comprised of the mutually reinforcing components of continual demand for services and access to and supply of well-trained providers. In addition, there is an underlying need for enabling policies within the cultural and gender environments that extend beyond vasectomy and include men not just as default partners of female family planning clients but as equal beneficiaries of family planning and reproductive health programs in their own right. Accelerating progress toward meaningful integration of vasectomy into a comprehensive contraceptive method mix is only possible when political and financial will are aligned and support the logistical and promotional activities of a male reproductive health agenda., (© Shattuck et al.)

Background: Task shifting from higher cadre providers to CHWs has been widely adopted to address healthcare provider shortages, but the addition of any service can potentially add to an already considerable workload for CHWs. Objective measures of workload alone, such as work-related time and travel may not reflect howCHWs actually perceive and react to their circumstances. This study combined perception and objectivemeasures of workload to examine their effect on quality of services, worker performance, and job and clientsatisfaction., Methods: Three hundred eighty-three CHWs from control and intervention districts, where the intervention group was trained to provide contraceptive resupply, completed diaries of work-related activities for one month. Interviews were also conducted with a subset of CHWs and their clients., Results: CHW diaries did not reveal significant differences between intervention and control groups in time spent on service provision or travel. Over 90% of CHWs reported workload manageability, job satisfaction, and motivation to perform their jobs. Clients were highly satisfied with CHW services and most stated preference for future services from CHWs., Conclusion: The study demonstrated that adding resupply of hormonal contraceptives to CHWs' tasks would not place undue burden on them. Accordingly, the initiative was scaled up in all 30 districts in the country.

Background: Private-sector drug shops are often the first point of health care in sub-Saharan Africa. Training and supporting drug shop and pharmacy staff to provide a wide range of contraceptive methods and information is a promising high-impact practice for which more information is needed to fully document implementation experience and impact., Methods: Between September 2010 and March 2011, we trained 139 drug shop operators (DSOs) in 4 districts of Uganda to safely administer intramuscular DMPA (depot medroxyprogesterone acetate) contraceptive injections. In 2012, we approached 54 of these DSOs and interviewed a convenience sample of 585 of their family planning clients to assess clients' contraceptive use and perspectives on the quality of care and satisfaction with services. Finally, we compared service statistics from April to June 2011 from drug shops, community health workers (CHWs), and government clinics in 3 districts to determine the drug shop market share of family planning services., Results: Most drug shop family planning clients interviewed were women with low socioeconomic status. The large majority (89%) were continuing family planning users. DMPA was the preferred contraceptive. Almost half of the drug shop clients had switched from other providers, primarily from government health clinics, mostly as a result of more convenient locations, shorter waiting times, and fewer stock-outs in drug shops. All clients reported that the DSOs treated them respectfully, and 93% trusted the drug shop operator to maintain privacy. Three-quarters felt that drug shops offered affordable family planning services. Most of the DMPA clients (74%) were very satisfied with receiving their method from the drug shop and 98% intended to get the next injection from the drug shop. Between April and June 2011, clinics, CHWs, and drug shops in 3 districts delivered equivalent proportions of couple-years of protection, with drug shops leading marginally at 36%, followed by clinics (33%) and CHWs (31%)., Conclusion: Drug shops can be a viable and convenient source of short-acting contraceptive methods, including DMPA, serving as a complement to government services. Family planning programs in Uganda and elsewhere should consider including drug shops in the network of community-based family planning providers., (© Akol et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/10.9745/GHSP-D-14-00085.)

Context: Little is known about the frequency and patterns of use of emergency contraceptive pills among women in urban Kenya and Nigeria., Methods: To recruit women who had used emergency contraceptive pills, individuals aged 18-49 were intercepted and interviewed at shopping venues in Nairobi, Kenya, and Lagos, Nigeria, in 2011. Information was collected on 539 Nairobi and 483 Lagos respondents' demographic and behavioral characteristics, attitudes toward the method, and frequency of use. Multinomial logistic regression analyses were used to identify associations between these characteristics and frequency of pill use., Results: Eighteen percent of the women interviewed in Nairobi and 17% in Lagos had ever used emergency contraceptive pills. On average, these respondents had used the pills less than once per month, but greater use and acceptance were seen in Lagos. In multivariate analysis, women who had sex at least once in a typical week were generally more likely than others to have used the pills 2-5 times in the last six months, rather than once or never, or to have used them six or more times. Furthermore, Lagos respondents who said their main contraceptive method was the condom, the pill or injectable, or a natural method were generally less likely than those who did not report these methods to have used the emergency pills multiple times in the last six months., Conclusions: Repeated use of emergency contraceptive pills was not common in this sample.

Introduction: Emergency contraceptive pills (ECPs) were developed and marketed with the emergency aspect firmly in mind, but research and anecdotal evidence indicate that some women use them as a form of regular contraception, spurring efforts in the reproductive health community to explore the development of a coitally-dependent oral contraceptive pill., Methods: We asked women of reproductive age in Nairobi, Kenya and Lagos, Nigeria how likely they would be to use a hypothetical pericoital pill and why., Results: Bivariate logistic regressions indicated that women aged 18-35 years, with secondary education or higher, and who had ever used condoms or short-acting methods, were more likely to say that they would use this hypothetical pill. Women who had ever used a family planning method or ECPs were also more likely to say they would use this pill. The likely adopters reported that they would use the pericoital method if it prevented pregnancy with little or no health problems and was convenient and easy to use., Conclusion: The findings suggest that should a safe and effective pericoital hormonal pill become available then a significant number of women would adopt this method., (Published by the BMJ Publishing Group Limited.)

Background: A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. One way to fill this gap is for community health workers (CHWs) to provide injectable contraceptives, an intervention for which there is growing evidence and international support. In 2009, with approval from the Government of Zambia (GoZ), FHI 360 collaborated with ChildFund Zambia to design and implement such an intervention as part of its existing CHW family planning program., Methods: The safety of CHW provision of injectable DMPA (depot medroxyprogesterone acetate) was measured by client reports and by a 21-item structured observation checklist. Feasibility and acceptability were measured by interviews with CHWs and a subset of DMPA clients. The impact of adding DMPA to pill and condom provision was assessed by family planning uptake among the clients of trained CHWs from February 2010 to February 2011. Costs were documented using spreadsheets over the period November 2009 to February 2011., Results: Scores were high on all measures of safety, feasibility, and acceptability. Couple-years of protection (CYP, protection from pregnancy for 1 year) was provided to 51 condom clients, 391 pill clients, and 2,206 DMPA clients. Of the 1,739 clients new to family planning, 85% chose injectable DMPA, while 13% chose pills and 2% chose condoms. Continuation rates were also high, at 63% after 1 year as compared with 47% for pill users. Incremental costs per couple-year were US$21.24 if 50% of users continue with CHW-provided DMPA., Conclusion: The study affirms that the provision of injectable contraceptives by CHWs is safe, acceptable, and feasible in the Zambian context, with very high rates of uptake in hard-to-reach areas. High continuation rates among clients mean that costs of the intervention can be low when added to an existing community-based distribution program-a finding that is relevant to program replication (now underway in Zambia).

Objective: To estimate the accuracy of self-screening for contraindications to combined oral contraceptive pills (COCs) and to estimate the proportion of women with contraindications to hormonal methods among those using drug shops in Tanzania., Methods: Trained nurses interviewed 1651 women aged 18-39 years who self-screened for contraindications to COCs with the help of a poster at drug shops in Tanzania. Nurse assessment of the women served as the gold standard for comparison with self-assessment. Blood pressure was also measured onsite., Results: Nurses reported that 437 (26.5%) women were not eligible to use COCs, compared with 485 (29.4%) according to self-report. Overall, 133 (8.1%) women who said that they were eligible were deemed ineligible by nurses. The rate of ineligibility was artificially high owing to participant and nurse assessments that were incorrectly based on adverse effects of pill use and cultural reasons, and because of the sampling procedure, which intercepted women regardless of their reasons for visiting the drug shop. Adjusted rates of ineligibility were 8.6% and 12.7%, respectively, according to nurse and participant assessment. Both nurses and women underestimated the prevalence of hypertension in the present group., Conclusion: Self-screening among women in rural and peri-urban Tanzania with regard to contraindications to COC use was comparable to assessment by trained nurses., (© 2013.)

Background: As emergency contraceptive pills (ECPs) become increasingly available through pharmacies, concerns about potential overuse of this product have emerged. In response, bridging women from ECPs to ongoing contraception was advanced as a solution., Study Design: We collected information in Ghanaian pharmacies on ECP users' sexual activity, use of contraceptive methods and reasons for buying ECPs. Further, two behavioral indicators were examined to determine whether a woman should consider using an ongoing contraceptive method: how often she has sex and how she uses ECPs., Results: Of the four types of ECP users, stratified by those two indicators, only women who have sex frequently and use ECPs as their main contraceptive method would be appropriate for, but not necessarily amenable to, bridging., Conclusions: The challenges of bridging to meet the contraceptive needs of women are discussed in light of the characteristics of emergency contraceptive users and suggest that bridging is not as straightforward as initially conceived., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Methods: Emergency contraceptive pills (ECPs) are becoming more popular, yet little is known about the contraceptive preferences of women who take ECPs. Women purchasing ECPs were recruited from pharmacies in Accra, Ghana. A total of 24 semi-structured, qualitative interviews were conducted in May 2008., Results: Nearly all participants preferred ECPs to other contraceptive methods. Although fear of side effects from oral contraceptive pills (OCPs), intrauterine devices and injectables were deterrents to use of those methods, side effects from ECPs were acceptable to this small and highly self-selected group of ECP users. Participants had little knowledge about how other contraceptive methods work and expressed a strong distrust and dislike of condoms., Discussion and Conclusion: Study participants loved their ECPs, despite minor discomforts like bleeding, and most had no concerns about repeated use, though these findings may not apply to women outside Accra or women who obtain ECPs from non-pharmacy settings. Future interventions should work to dispel myths about OCPs, condoms and other modern methods, and focus on basic contraception education.

Background: Despite World Health Organization and International Planned Parenthood Federation recommendations to provide multiple pill cycles to new users, many programs in developing countries still give only one pill cycle to new acceptors., Study Design: To compare provision of a single versus multiple packs of pills, new pill users in 20 matched public sector clinics in Jamaica were assigned to one of two pill regimens in which they received either one (then subsequently three) or four pill cycles at method initiation. The primary outcome was the proportion of women who used pills beyond 4 months., Results: Among 655 women, those receiving one cycle of pills at initiation, followed by counseling and a three-pack resupply, were no more likely to be using pills after 4 months than women who received four packs at initiation (odds ratio=1.33; 95% confidence interval=0.88-2.0). In both pill regimen groups, returning late to the clinic for resupply was a problem. However, more women in the 1+3-pack regimen group returned late to study clinics to obtain their fifth cycle of pills than their counterparts in the 4-pack regimen group (53% vs. 28%)., Conclusion: Our findings support the recommendation that pill users should be given more than one cycle to start, because an extra visit for resupply contributes to clinic and provider costs. Moreover, providing more pill cycles at initiation would decrease the likelihood that women experience a gap in pill use between cycles.