TheGlobalCondomLandscapePerspectivesonthecontextofcondomprogramminginashiftingenvironmentGlobalCommunityofPractice,IASJuly20242SettingtheStageEpidemiology&TransmissionDynamicsAlthoughincidenceacrosssub-SaharanAfrica(SSA)continuestorapidlydecline…itisnotontracktomeet2025and2030targets.11UNAIDSEpidemiologicalestimates.2023.2Assumingactiveprogramsmaintaincurrenttreatmentandpreventioncontinue:DatapresentedattheHIVModellingConsortium,MIHPSAPhase1,UNAIDSTechnicalConsultation,20-21July2023.SlidesthroughJeffreyImai-EatonIncidenceisexpectedtodecline…butthepaceofdeclinewillslowin2025aswe:CloseinonsaturationofARTandviralsuppressionbasedonsuccessesofthepastdecade.BenefitfromdecreasingHIVprevalenceandcorrespondingdecreasingviremia.NewHIVinfections,global,1990-2022and2025target13Modellingindicatesincidencewilldecline,butataslowerrate-presentingchallengesforpreventionmovingforwardGoalsASM(Age-StructuredModel):AcloserlookatSouthAfricaClusteringofHIVtransmissionsinEuropecomparedwithdiffuseclusterscharacterizingtransmissioninZambia1ZambiaBroadlydiffusetransmissionclustersEurope1JeffreyImai-Eaton[2023].HIVNewProductPlanning&IntroductionandHIVDeliveryAfrica-basedgranteeconvening30November2023;HIVepidemiologytrends:Wherearewe?Whereareweheaded?”,citingAbeler-D?rneretal(2019).inpreparation4SmallandDiffuseHIVTransmissionNetworksinEasternandSouthernAfricaResultinanEpidemicof“ManyWhoInfectFew”IncreasinglyChallengingtoIdentifyPopulationsatHighRiskofContractingHSV-2andHIV1

1JeffreyImai-Eaton[2023].HIVNewProductPlanning&IntroductionandHIVDeliveryAfrica-basedgranteeconvening30November2023;HIVepidemiologytrends:Wherearewe?Whereareweheaded?,citingLouisaRMoorhouseDevelopmentofanHIVrisk-differentiationtoolforuseinroutineHIVtestingservices:ValidationbasedonabilitytopredictHIVandHSV-2acquisitionin12-monthsoffollow-upinyoungmenandwomenineasternZimbabwe–unpublishedmanuscriptcurrentlyunderreview.BaselinePreventiongroupallocation

(n=960women15-24y)Oneyearfollow-upHSV-2/HIVinfections(n=26;1yearfollow-up)

KeyFindingAlthough42%ofinfectionswereamongthe17%of“atrisk”AGYW…42%ofnewinfectionsoccurredinAGYWnotsexuallyactiveatbaselineassessment.Risktoolsarepoorpredictorsofriskand,ultimately,HIVtransmission.Importanttoreachgeneralpopulationswithpreventionmessagingandproductsinhighprevalencesettings—lesttheybemissedbyscreeningmethods.ArecentstudyinZimbabwefound“halfofincidentinfectionsina12-monthperiodoccurredamongpeoplereportingtohaveneverhadsexandweremissedbyriskdifferentiationatbaseline.”1

Adolescentgirlsandyoungwomen(AGYW)infectedtodaywerenotengaginginhigh-risksexjustoneyearago5ProgrammaticImplications6RoleofCondomsintheHIVPrevention,STI,andFPEcosystemCondomsMatter:TheRoleofCondomsinReducingHIVIncidence—ModeledHistoricExperience(1of2)ModelingofhistoricimpactdemonstratesthattheannualnumberofnewHIVinfectionswouldhaveincreasedtonearly11millionby2019ifcondomusehadremainedat1990levels.Anestimated117millioninfectionswereavertedfrom1990–2019duetocondomuse.StoverJ,TengY[2022]TheimpactofcondomuseontheHIVepidemic.GatesOpenRes.2022Feb11;5:91./pmc/articles/PMC8933340/7NumberofnewHIVinfectionswithvaryinglevelsofcondomscale-upArecentanalysisinSouthAfricayieldedinsightsontherelativeroleofvariousinterventionsonincidence,holdingHIVtestingconstant.Declinesincondomuseof15%and30%fromexistinguserates—andafterdiscontinuingotherinterventions—resultinsignificantincreasesinincidence.ContinuecurrentpreventionDiscontinuePrEP(femaleSW[FSW],MSM,higherriskAGYW)DiscontinuePrEP&VMMCCondomusereducesby15%(+discon.PrEP,VMMC)Condomusereducesby30%(+discontinuationPrEP,voluntarymedicalmalecircumcision[VMMC])1JeffreyImai-Eaton[2023].HIVNewProductPlanning&IntroductionandHIVDeliveryAfrica-basedgranteeconvening

30November2023;HIVepidemiologytrends:Wherearewe?Whereareweheaded?,Citing:

StefanPRautenbach,etal.(2023).FutureHIVepidemictrajectoriesinSouthAfricaandlong-termconsequencesofreductionsingeneralHIVtesting:Amathematicalmodellingstudy.MedRxiv,203300231./10.1101/203300231“Changesinsexualriskcouldsubstantiallyincreaseinfectionsanddeathsovertime.Maintainingcurrenttestingrates,reducedcondomuseby14%resultedinanadditional~3.7millioninfectionsand~346,000deathsbetween2025–2075,comparedwiththestatusquo.”18CondomsMatter:TheRoleofCondomsinFutureIncidenceReduction—ModeledScenarios(2of2)1ModeledimpactofdiscontinuationofspecificinterventionswithHIVtesting&treatmentatexistingrates(SouthAfrica,2023)1.JohnStover[2023].UNAIDSTechnicalConsultation,20-21July2023[Unpublished]Condomsweremodeledtocontributetomorethan40%ofHIVinfectionsaverted—ifinterventionsreachedtheambitiousscale-uptotoglobaltargets.Thesignificantcontributionofcondomsisindicativeof:Theeffectivenessofcondomsasinterventions.TherelativelylargeexistinggapbetweencurrentuseandambitioustargetsModelingbasedonscalingupcondomstoreachtargetsof:90%useinkeypopulations(KP)andinnon-KP95%useamongmaleclientsofFSW

70%amongthosewithmultiplepartnersinthelastyear50%amongthosewithonepartnerinthelastyear.ThischartmodelstherelativecontributionofinterventionstoachievingglobaltargetsassumingtheyscaletoGlobaltargets.-JohnStoverofAvinerhealth.19ThePotentialContributionofCondomstoReducingFutureInfectionsinEastandSouthernAfrica1CSE:comprehensive

sexualityeducationEE:PMTCT:preventionofmother-to-childtransmissionAcompilationofthelatestrelevantepidemiologicaldataandmodeling1laysoutaclearerpathforwardtosupportcontinuedreductionsintheincidenceofHIV.NewcasesofHIVwillbeavertedby:10Bringingittogether:EvolvingEpidemiologyandBehaviouralinsightsbringchallenges&opportunitiestoHIVPrevention1JeffreyImai-Eaton[2023].HIVNewProductPlanning&IntroductionandHIVDeliveryAfrica-basedgranteeconvening30November2023;HIVepidemiologytrends:Wherearewe?Whereareweheaded?”,andemergentdatafromUNAIDSTechnicalConsultations.3BigChallengesConfrontingPreventionAslowingintherateofdeclineofincidencemeansitwillbemorechallenging,andmoreexpensive,foreverynewHIVinfectionavertedDiffuseclustersoftransmissioncharacterizingtheAfricaepidemichindersourabilitytousetargeted,‘clusterbustingapproaches.Risktoolsdon’tworksowelltoidentifyindividualfactorsthatarepredictorsofinfection.Weneedtoreachmorepopulationsatmoderateriskwithlow-costpreventionapproaches.Pairedwithbehavioralinterventions,Condomsarethemosteffective,low-costpreventiontooltoreachmorepopsBehavioralTrends11WorrisomeDropsinCondomUseinCountrieswithRecentData1DemographicandHealthSurveys;[AccessedDecember2023]/en/2UNAIDS[2023]https:///indicator/condom-use-last-high-risk-sexProportionofmen30-39usingacondomatlastNMNCsexhasdecreasedsincethelastroundofdatacollection.=AllfourcountriesanalyzedwithrecentDHSdatademonstratesignificantdropsintheuseofcondomsduringsexwithanon-regularpartner.

Thedroprangedfrom6%to15%,andaveragesnearly10%acrossthe4countries

CondomuseatlastNMNCsex:Overallamongmenages30-391121USAID.DemographicandHealthSurvey.[AccessedDecember2023].2SouthAfrican

National

HIV

Prevalence,Incidence,BehaviourandCommunication

Survey.[AccessedDecember2023].

SABSSNV,VICondomuseduringNMNCsex1,213Useisdeclininginyoungerpopulations….CondomuseatlastNMNCsexamongyoungpeopleinZambia,Kenya,andTanzaniahasdroppeddramatically,likelydriveninpartbyanewergenerationmissingoutontherobustcondominterventionsandcampaignsofthepast.1ICAP.Population-basedHIVImpactAssessment[AccessedDecember2023]./CondomusewithNMNCpartnersamongyoungpeopleages15-24remainslowinmanycountries,withwomenconsistentlyusingcondomslessfrequentlythantheirmalepeers.InRwanda,Tanzania,Uganda,andZambia,condomuseamongwomenages15-24isextremelylow,at<40%ofwomen.14AgainstapersistentgendergapProcurementandSupplyTrends15TotalestimatedglobalcondomdistributioninLMICdeclinedanaverageof27%-37%frompeakprocurementin2011.ThedeclineindistributionoccurredasthepopulationinAfricangrewby400m,or40%,since2010.Privatesectorcontributions,whichvaryatanestimated~5-10%+oftotaldistributioninSSA,arenotestimatedhere.DonorsincludeUNFPA,UNFPAThirdPartyProcurement(TPP),USG,andGlobalFund.Datafordonorsareglobalprocurement;condomsmaynotbedistributedinthatfiscalyear.Dataforsocialmarketingorganizations(SMOs)arereporteddistributionandperDKTsocialmarketingstatisticsreport.MaybemissingdomesticfundedcondomsnotprocuredundertheTPP(asidefromRSA).WhiledistributionbySMOsdeclinedbyabout47%overthesameperiod,(from~3.5billioncondomsin2011to~1.8billionin2022),SMOsstillaccountfornearlyhalfofcondomsdistributedinLMIC.Muchofthatdeclinecanbeattributedtosocialmarketersdistributingfewerfreecondoms.16DecliningProcurementSupplySocialmarketing(allorgs)MajordonorfundingSouthAfrica(RSA)Annualprocurementdown27%USGShiftingfundingstrategiesinplayUFFPA/UNFPAThirdPartyProcurementNewpoliciestoallowsaleofcommoditiesGlobalFundFundingandprocurementtrendsTop10Countries:CondomsprocuredthroughtheCondomFund(FY22&23)Program-matichighlightsAbout75%ofUSGprocurementispaidforfromtheCondomFund(CF).ThependingsunsetoftheCFcouldpresentasignificantdisruptionasUSAIDmissionshavegrownaccustomedtorelyingonprocurementoutsidetheirconstrainedcountrybudgets.AnewpolicyallowingUNFPA-procuredcommoditiestobesoldwillbepilotedin6-8countriesin2024.Theaimofthisinitiativeistofurthersegmentthemarketandcomplementtheshifttosustainableprogramming.TheTPPmechanismcontinuestoplayanimportantroleintheprovisionofcondoms.Investmentincondomprogrammingincreased163%fromGC4,evenconsideringpartialcohortforGC7*.RecentinvestmentintheCondomStrategicInitiativeprovidedvaluablelessonslearnedonwhatmodestinvestmentsinprojectmanagementcanyield(includedassectionofthisreport).The“big3”condomdonorsarechallengedbyshiftingfundingandepidemiologydynamics,andareworkingtobringalignmentonacommonstrategicapproachtosupportcondomdelivery,demand,anduse.17Snapshotof