The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Cross-Sectional Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave

BackgroundTo better understand sexual and reproductive health (SRH) during the initial COVID-19 wave, we organized a multi-country cross-sectional survey. MethodsConsortium research teams conducted online surveys in 30 countries. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. FindingsDescriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses. Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed steady for 3374 (74.4%); 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) than before (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. InterpretationThe initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings. FundingUnited States National Institutes of Health, Latvia National Research Programme to Lessen the Effects of COVID-19 Research in context Evidence before this studyIn 2020, the COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 undercut already precarious health infrastructure and health service provision. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of SARS-CoV-2 infections (COVID-19 disease). Most studies have focused on high-income countries, rather than examining broader regional and global trends. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium. Consortium research teams in 30 low, middle, and high-income countries collaboratively developed the survey instrument using existing measures and items adapted for COVID-19. Topics included sociodemographic characteristics; compliance with COVID-19 mitigation measures; couple and family relationships; sexual behavior; contraceptive use and barriers to access; access to reproductive healthcare; abortion; sexual violence and intimate partner violence (IPV); HIV/STI testing and treatment; and optional sections including female genital cutting and early marriage; mental health; and food insecurity. This multi-country, cross-sectional study aimed to better understand SRH prior to and during the first wave of the COVID-19 pandemic in participating countries. Added value of this studyThis study was conducted in thirty diverse settings during a pandemic. In addition to providing needed evidence about SRH during COVID-19 across low-, middle-, and high-income countries, the study demonstrates the feasibility and utility of a new framework for global health collaboration. Using an inclusive open science approach, we were able to harmonize key sexual health variables across countries. Our use of online data collection and large reliance on convenience sampling provides both challenges and opportunities. Implications of all the available evidenceThis multi-country study provides detailed sexual and behavioral data across diverse global settings. Our findings suggest that COVID-19 measures during the initial wave of the COVID-19 pandemic impacted sexual and reproductive health behaviors and access to services worldwide. In particular, our findings show a sizable proportion of people needing SRH services including HIV/STI testing and abortion reported that their access to these services was limited due to COVID-19 measures. These results suggest the need for expanded use of decentralized SRH interventions that can be implemented in emergency settings, such as self-testing, self-collection, and telemedicine.