Long-acting Reversible Contraception (LARC) David Hubacher, PhD Senior Epidemiologist FHI

Outline of Talk Description of long-acting reversible contraception (LARC) Worldwide use of long-acting Advantages and Disadvantages Service delivery factors Comparison to short-acting reversible

Characteristics of Long-acting Reversible Contraception (LARC) Device is inserted Products lasts from 3 to 10+ years Removal is required at some point Simple clinic environment for services Nurse practitioners can insert/remove

Two body locations, three products Intrauterine contraception Copper IUD: ParaGard® - 10+ years T-shaped plastic frame with copper attached Non-hormonal

ParaGard – Copper intrauterine device (IUD) How it works: Prevents fertilization by creating intrauterine environment hostile to sperm Copper ions enhance anti-sperm action

Two body locations, three products Intrauterine contraception Copper IUD: ParaGard® - 10+ years T-shaped plastic frame with copper attached Non-hormonal Intrauterine system (IUS): Mirena® - 5 years T-shaped plastic frame with reservoir to release progestin (levonorgestrel) Levonorgestrel absorbed in genital tract

Mirena

Intrauterine Contraception Since 1930s The first long-acting reversible In US, nine major products used over 50 yrs Wide variety of shapes/sizes in other countries

Two body locations, three products Intrauterine contraception Copper IUD: ParaGard® - 10+ years Intrauterine system (IUS): Mirena® - 5 years Subdermal implant – upper arm Implanon ® - 3 years Match-stick sized rod that releases progestin

Mostly by preventing ovulation Implanon How it works: Mostly by preventing ovulation

Implants Developed in 1960s First came Norplant (6 rods), then Jadelle (2), Implanon (1), Sino-implant (2) Countries with highest use: Indonesia

Worldwide LARC Use Varies tremendously Information from national surveys Limitation: most data sheets do not list implants separately because use is low IUD is only LARC method reported

Countries with High IUD Use 20-29% Tunisia, Mongolia, Tajikistan, Israel, Jordan, Syria, Turkey, Belarus, Moldovia, Russia, Finland, Latvia, Norway, Slovenia, France 30-39% Egypt, Kyrgyzstan, Kazakhstan, Turkmenistan, Estonia, Cuba 40+ % China, Dem PR Korea, Uzbekistan, Vietnam

IUD Use in Other Countries Brazil 1% India 2% South Africa 1% Mexico 12% Nigeria 1% USA 5%

IUD Use in the US: 45 Years of Change

Disadvantages of LARC Invasive insertion procedure Requires removal procedure Thus more difficult to stop using it Less control over fertility Side effects like all methods but different

Advantages of LARC One procedure/clinic visit Easy to use Nothing to remember Discrete use Return to fertility is very rapid Most effective reversible strategy

WHO Classification of Methods

Program Advantages of LARC Fewer commodities needed More cost effective More effective at preventing unintended pregnancy One visit One LARC insertion = 39 to 65 to 130 packs of pills…or 9 to 20 to 30 injections More LARC  fewer stock-outs of methods

Service Provision Requirements Trained personnel Equipment and supplies Autoclave for sterilizing equipment Clinic needs electricity supply Contraceptive commodities

Cost of LARC Cost varies tremendously ParaGard copper IUD: Mirena: $1 for international donors but $800 in US Mirena: $850 in US, $200 in Kenya, limited donations Jadelle and Implanon implants $25 to international donors Sino-implant (II) $8 to international donors

LARC vs. Short-acting Methods Injectables and Oral Contraceptives Great methods if used consistently and correctly 40-60% of users stop within 12 months For variety of reasons, not always by choice This can lead to unintended pregnancy

Cumulative Probability of Discontinuation months

Some obstacles to perfect use Commodity stock-outs at public sector clinics Cost at pharmacies/private facilities Ambivalence toward contraception/pregnancy Motivation can wane over time Great effort required Abstinence episodes Partner opposition Side effects: who wants another dose? The FP queue: who wants to be seen there?

Risk of Unintended Pregnancy

Estimating Impact * 18M users of injectable/orals in sub-Saharan Africa If 20% switched to implant If apply regular discontinuation patterns Prevent 1.8M unintended pregnancies in 5 yr * Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception 2008;78(1):73-78.

Conclusions Long-acting reversible contraception Underused in many countries Women need more choices Expanded use could have tremendous benefit Essential components: Voluntary uptake and removal on demand