title: Contraceptive sales in the setting of the Zika virus epidemic.
abstract: Has there been any influence of the Zika virus (ZIKV) outbreak on the sales of contraceptive methods in Brazil?
  
  
  
  Contraceptive sales in the 24 months of evaluation showed little variation and no significant change has been observed since the ZIKV outbreak.
  
  
  
  Transmission of ZIKV is primarily by Aedes aegypti mosquitoes; however, sexual transmission has also been described. The association of several birth defects and the ZIKV infection during pregnancy has been established, and it was estimated in Bahia, Brazil that the infection rate could range from 10% to 80%. The World Health Organisation (WHO) declared the cluster of microcephaly cases and other neurological disorders a health emergency on 1 February 2016. The Brazilian government also made recommendations for women who were planning to become pregnant and who reside in ZIKV-affected areas to reconsider or postpone pregnancy.
  
  
  
  The objective of this study was to assess the sales of contraceptive methods in Brazil, tracking it from before and through the ZIKV outbreak. We obtained information from all pharmaceutical companies based in Brazil and from the manufacturers of long-acting reversible contraceptives (LARCs), including the copper-intrauterine device (IUD), the levonorgestrel-releasing intrauterine system (LNG-IUS) and implants, about contraceptives sales in the public and private sectors between September 2014 and August 2016.
  
  
  
  We analyzed the data for: (i) oral contraceptives, i.e. combined oral contraceptives (COC) and progestin-only pills (POP), and vaginal and transdermal contraceptives, (ii) injectable contraceptives, i.e. once-a-month and depot-medroxyprogesterone acetate, (iii) LARCs and (iv) emergency contraceptive (EC) pills.
  
  
  
  Monthly sales of COC, POP, patches and vaginal rings represent the major sales segment of the market, i.e. 12.7-13.8 million cycles/units per month (90%). The second largest group of sales was injectables, representing 0.8-1.5 million ampoules per month (9.5%). Following this, are LARC methods with sales of 37 000-41 000 devices per month (0.5%). It is important to note that although the peak months of sales were different for each group of contraceptives, there were no significant differences overall between the months of observation. The EC pill sales were between 1.0 million and 1.3 million of pills per month.
  
  
  
  Although the use of contraceptive methods was already high and no change was noted, the ZIKV outbreak may have changed the pregnancy intentions of Brazilian women. Consequently, the number of women planning pregnancy may be lower than that recorded. The contraceptive sales figures did not include condoms. Since condoms might not only prevent pregnancies, but also sexual transmission of ZIKV, this lack of information is a limitation.
  
  
  
  The results from this assessment showed that the sales of contraceptives presented little variation during the ZIKV outbreak in Brazil. Furthermore, it is possible that access to LARC methods was limited. Although we did not investigate the reason for low LARC uptake, we suspect that it is due to lack of availability of LARC in the public sector, the high cost of the methods and the incomplete insurance coverage on contraception for women. Projections estimate millions of additional cases of ZIKV transmission. Thus, a coordinated response is needed to ensure access to a wide range of contraceptive methods for women during the ZIKV outbreak. In conclusion, this assessment of contraceptive sales in Brazil identifies challenges in contraceptive access, especially for LARC methods, and represents an alternative source of data to help us understand the trends in demand for contraception in ZIKV-affected areas.
  
  
  
  This study received partial financial support from Fundação de Apoio à Pesquisa do Estado de São Paulo (FAPESP) award # 2015/20504-9 and from an anonymous donor. The funding sources did not play a role in the study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication. The authors declare no conflict of interest associated with this study.
  
  
  
  N/A.
authors.affiliation: Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Caixa Postal 6181, 13084-971 Campinas, SP, Brazil bahamond@caism.unicamp.br.
authors.forename: Luis
authors.initials: L
authors.lastname: Bahamondes
authors.affiliation: Department of Reproductive Health and Research, World Health Organisation, Avenue Appia 20, 1211 Genève 27, Switzerland.
authors.forename: Moazzam
authors.initials: M
authors.lastname: Ali
authors.affiliation: Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Caixa Postal 6181, 13084-971 Campinas, SP, Brazil.
authors.forename: Ilza
authors.initials: I
authors.lastname: Monteiro
authors.affiliation: Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Caixa Postal 6181, 13084-971 Campinas, SP, Brazil.
authors.forename: Arlete
authors.initials: A
authors.lastname: Fernandes
mesh_terms: D000328:Adult; D001938:Brazil; D003132:Commerce; D003267:Contraception / Q000191:economics*; D003270:Contraceptive Agents / Q000191:economics*; D005260:Female; D006801:Humans; D011247:Pregnancy; D000071244:Zika Virus; D000071243:Zika Virus Infection
chemical_list: D003270:Contraceptive Agents
keywords: Brazil; Zika virus; contraception; long-acting contraceptive methods; unintended pregnancies