key: cord-0735714-tqkv9kxs authors: Erausquin, J. T.; Tan, R. K. J.; Uhlich, M.; Francis, J. M.; Kumar, N.; Campbell, L.; Zhang, W.-H.; Hlatshwako, T. G.; Kosana, P.; Shah, S.; Brenner, E. M.; Remmerie, L.; Mussa, A.; Klapilova, K.; Mark, K.; Perotta, G.; Gabster, A.; Wouters, E.; Burns, S.; Hendriks, J.; Hensel, D. J.; Shamu, S.; Strizzi, J. M.; Esho, T.; Morroni, C.; Eleuteri, S.; Sahril, N.; Low, W. Y.; Plasilova, L.; Lazdane, G.; Olumide, A.; Michielsen, K.; Moreau, C.; Tucker, J. D.; consortium, I-SHARE research title: 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 date: 2021-09-27 journal: medRxiv DOI: 10.1101/2021.09.18.21263630 sha: 7abf0f636c894beb10fb974c9c5d8767296c37a5 doc_id: 735714 cord_uid: tqkv9kxs Background: To better understand sexual and reproductive health (SRH) during the initial COVID-19 wave, we organized a multi-country cross-sectional survey. Methods: Consortium 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. Findings: Descriptive 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. Interpretation: The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings. health variables across countries. Our use of online data collection and large reliance on convenience sampling provides both challenges and opportunities. This 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. The COVID-19 pandemic has profoundly disrupted social relationships and health services that are fundamental to sexual and reproductive health. 1 The initial wave of SARS-CoV-2 infections (COVID-19 disease) forced billions of people worldwide to shelter in place, transforming social and sexual relationships. Entrenched gender inequalities that existed prior to COVID-19 may have been exacerbated during the emergency response, 2 placing people at increased risk for intimate partner violence (IPV). At the same time, a wide range of essential sexual and reproductive health services were stopped or re-oriented because of the pandemic. 3 These trends suggest an important question: How have COVID-19 measures impacted sexual and reproductive health outcomes in different settings? Here we define COVID-19 mitigation measures as responses (e.g., non-pharmacological interventions) to slow or halt the spread of the virus within a population, including shelter in place, test and trace, quarantine, and travel restrictions. 4 Although cities, nations, regions, and the entire world have moved together in altering social lives during the COVID-19 pandemic, there has been substantial variation in COVID-19 disease incidence and responses at the national level. Some countries have imposed less stringent lockdown measures, allowing greater movement between and within cities, while others have instituted more unyielding measures. 5 Several countries already had infrastructure in place for decentralized sexual and reproductive health services (e.g., HIV self-testing, telemedicine abortion) which compensated for pandemic-related closures of facility-based services during COVID-19. 6 However, in most countries, COVID-19 further undermined already fragile health infrastructure and health service provision. 7 The lead organization in each country selected networks to disseminate the survey link, and it was primarily distributed through email lists, local partner organizations affiliated with ANSER, other sexual and reproductive health networks, and social media links. The survey took most participants 20-30 minutes to complete. Each country had a research team that led the country's ethical review, translation and survey administration while providing support and organization for the multinational study. The survey was available in the official language of the country and other relevant languages. In total, the survey was translated into 21 languages. In most participating countries, CAPTCHA or other fraud protection methods were included to prevent more than one response from a single IP address. The survey included several potentially sensitive questions including items about sexuality, gender identity, sexual behavior, abortion, and IPV. Participants could stop the survey at any point or leave out questions they did not want to answer. Participating country institutions signed data sharing agreements for cross-country analysis. Resources on country-specific referral pathways for IPV, sexual health services, and reproductive health services were provided at the end of the survey. All data were de-identified before multi-country analyses. Multi-country analysis was undertaken for countries that met specific pre-specified criteria. Each country was required to have obtained Institutional Review Board approval from a local ethics authority, locally translated and field-tested the instrument, described the sampling methodology, and obtained responses from at least 200 participants. A minimum threshold of 200 participants was used because small samples may be more likely to be biased and have higher heterogeneity. We examined the effect of including all data empirically using a sensitivity analysis. We did not weight our estimates because most countries did not use a probability sample. We conducted descriptive meta-analysis to assess the effect of study characteristics and setting and more accurately estimate the prevalence of our key outcomes across multiple countries. First, we ran descriptive statistics on using the main data set of 25 countries to assess patterns in respondent sociodemographic characteristics and to assess the primary outcomes prior to and during COVID-19 measures. We used the Oxford indices to assess the stringency of COVID-19 measures in each country, based on the mean value across the days when the survey was open. We used the Appraisal Tool for Cross-Sectional Studies (AXIS) to assess risk of bias. 15 Second, we conducted a meta-analysis for all 30 countries on the prevalence of reported hindered access to HIV/STI testing, IPV during COVID-19 measures, and decreased condom use with casual partners. We used meta-analysis because this provided a mechanism to assess risk of bias of individual studies and consider the strength of the evidence. Tests for heterogeneity were applied using I 2 statistics. 16 We also adopted the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework to rate the quality of evidence presented in our metaanalysis. 17 Furthermore, we conducted sensitivity analyses that separated primary outcomes based on country income level (low and middle-income countries compared to high-income countries), sample size (less than 200 or more), and sampling strategy (convenience compared to online panel or population-representative). All analyses were carried out using Stata version 14, and missing data were treated by pairwise deletion (available-case analysis). position of the household relative to others in their country, with most participants (38.4%) indicating that their household was in the 5 th or 6 th highest income group out of 10 in their country. Nearly three-quarters (74.0%) of participants reported living in an urban or semi-urban area. The lower panel of Table 1 presents relationship status and sexual frequency, and sexual satisfaction in the three months before and during COVID-19 measures. There were a variety of relationship types reported, with 43.4% in a cohabiting relationship. Among sexually experienced participants, most (75.2%) were not pregnant and not trying to become pregnant. Among those with a steady partner, 37.6% reported having sex with that partner 2-4 times a month, and another 29.9% reported 2-3 times a week. Among those with a casual partner, the most commonly reported frequency of sex with that partner was monthly or less (15.4%). Most participants (75.6%) reported being somewhat satisfied or very satisfied with their sex life before COVID-19, but this proportion had fallen (to 59.4%) during COVID-19 in the same participants. In terms of compliance with COVID-19 measures (Supplemental Table 5 ), 58.9% of participants reported they had followed measures a lot. The majority (76.6%) had never been in isolation due to their own symptoms or close contact with someone with COVID-19, and two-thirds (66.2%) had never been tested for COVID-19. Although 62.2% of participants said that their household socioeconomic status stayed the same during the COVID-19 pandemic, about one-third (32.0%) reported their household economic situation worsened. Table 2 shows our key study outcomes before and during COVID-19. Condom use "always" or "most of the time" with steady partners (62.5%) and with casual partners (63.8%) was relatively high prior to COVID-19 measures. Although most participants perceived their condom use stayed the same during COVID-19 measures (74.4% with casual partners and 86.9% with steady partners), 14.1% of participants with casual partners (and 10.4% of those with steady partners) reported their condom use with those types of partners decreased during COVID-19 measures. Regarding physical or sexual violence, 9.3% reported experiencing one or more types of violence prior to COVID-19, and a slightly lower proportion (7.0%) reported experiencing these types of violence during COVID-19 measures. Additional analyses showed that among those reporting no prior physical or sexual violence from a partner, 1.4% reported experiencing violence during COVID-19 measures; among those who did report prior physical or sexual violence from a partner, 67.9% reported experiencing violence during COVID-19 measures. For sexual and reproductive health care access, we first examined condom access. About 9% of participants indicated that COVID-19 measures made it more difficult to access condoms. A slightly smaller proportion (7.5%) reported that COVID-19 measures stopped or hindered contraceptive access. Nearly one-third (30.7%) of participants who reported needing abortion services during COVID-19 reported that COVID-19 measures stopped or hindered them from seeking or obtaining this service. In addition, 38.2% of participants that needed HIV/STI testing reported that COVID-19 measures stopped or hindered them from accessing HIV or STI testing. Meta-analyses using data from all 30 countries indicated substantial heterogeneity at the country level for all outcomes, including hindered access to HIV/STI testing (P=.000, I 2 =89.9%), IPV experienced during COVID-19 measures (P=.000, I 2 =95.5%), and condom use during COVID-19 measures (P=.000, I 2 =95.5%). Pooled estimates suggest that 32.3% (95% CI 23.9 -42.1%) of people needing HIV/STI testing had hindered access to HIV/STI testing (Supplemental Figures 1-3) . Risk of bias assessment for the studies in I-SHARE indicated that, in general, study procedures of all studies were largely justified, appropriate, and adequately described (Supplemental Table 5 ). The convenience sampling methods used by most countries introduced bias. In addition, response rates raised concerns about non-response bias and information about non-responders was not available. The GRADE framework was used to assess the quality of evidence for each of the three metaanalysis outcomes (Supplemental Table 6 ). Each of the three main findings was associated with a moderate certainty of evidence. Observational studies in general begin at a low quality of evidence; while there were risks of bias due to convenience sampling, we rated the quality of our evidence upwards due to the large effect size for the outcome of hindered access to HIV/STI testing, and the large sample size of the study across all outcomes. Our study findings provide important insights into sexual and reproductive health during the initial COVID-19 wave in diverse global settings. Our data suggest that condomless sex with casual partners did not substantially change with the introduction of COVID-19 measures. Experiences of intimate partner violence may have decreased during COVID-19 measures compared to prior to the pandemic. Among the health services we examined, there were marked decreases in access to HIV/STI testing and abortion services. We found that condomless sex was similar during COVID-19 measures compared to the pre-COVID-19 period for many respondents. Approximately 74-87% of people reported that condom use with a steady and/or casual partner stayed the same during these two periods. Maintenance of pre-COVID-19 condom use behavior is consistent with observational studies from sex workers and ethnic and racial minority groups. 18, 19 Given that COVID-19 introduced many new infectious disease risks, some individuals may have been less likely to engage in risky sexual behaviors. 20 Only 8.7% of the sample noted problems accessing condoms. The COVID-19 environment did not appear to substantially alter individual decisions about whether to use a condom. Our results suggest a modest decrease in sexual and physical partner violence during COVID-19 measures compared to the pre-COVID period. Although there was concern about COVID-19 exacerbating intimate partner violence, 2 data on intimate partner violence during the pandemic have been mixed. Some studies suggest increased intimate partner violence during COVID-19 measures, 21, 22 while others found decreases. 23 Other research has shown that IPV may increase . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; after a natural disaster, 24 indicating a need for follow up studies to see if IPV worsened as the COVID-19 pandemic continued beyond the initial wave that we examined in this study. Our study also indicates that COVID-19 measures interrupted access to HIV/STI testing and abortion services. This finding is consistent with other studies observing interruptions in HIV/STI testing 25,26 and abortion services. 27 Decentralized testing approaches using STI selfcollection and HIV self-testing 28 have alleviated some of the gaps in diagnostic service provision during COVID-19. However, despite strong evidence that telemedicine is safe and effective for providing medical abortion services, several countries further restricted abortion services during the initial wave of the COVID-19 pandemic. 29 More research and advocacy are needed to support abortion services during pandemics and similar circumstances. Our study has several limitations. First, this was an online survey organized during COVID-19 measures, introducing risk for selection bias. Although there is no guideline for conducting online surveys, we used several strategies to limit bias, including the use of online panels, partnerships with organizations for sample recruitment, review of analytics, and prespecified analysis plans. 13 Second, although we were able to capture data from different times during the COVID-19 epidemic, this was a series of retrospective cross-sectional studies, and we did not capture how sexual behaviors and access evolved over the course of the pandemic. A follow-up survey in selected countries is now underway. Third, our sample included more women, people with higher education, and people living in high-income countries compared to populations in respective countries. At the same time, data from one of the convenience samples included in this analysis suggested that the convenience sample included similar proportions of adults within subnational geographic areas compared to census data. 30 Fourth, our study had fewer studies from low-income countries which may have been due to later COVID-19 initial waves and less capacity for research alongside the pandemic. At the same time, our main findings were robust when stratifying based on country income level. Although COVID-19 measures made it more difficult to obtain population-representative samples, we organized a multi-country analysis of data from 30 countries. Several studies have noted that online surveys may be particularly useful for collecting information about sensitive sexual behaviors compared to in-person survey methods. 13 Strengths of this study include the inclusive open science approach, the harmonization of key sexual health variables across countries, and the geographic diversity. The use of meta-analysis methods was a key factor in mitigating risks of bias in our study. Pooled estimates of key outcomes reported in this study generated through meta-analysis provided more conservative estimates of our key study outcomes than our descriptive findings, thus mitigating bias in the varying sampling strategies across countries. Sensitivity analyses revealed differences in proportions based on country income level and sample size for experiencing IPV during the COVID-19 measures, while differences in proportions based on country income level and sampling strategy were observed for decreased condom use during COVID-19 measures. Differences in country-level income and sampling strategies do not have any bearing on the presentation of our descriptive findings but offer insight into country-level variations for these outcomes. However, because we omitted countries with sample sizes of less than 200 in our descriptive sample, and those countries omitted had a generally lower level of IPV experienced during COVID-19 measures compared to other countries in the sample, our pooled estimate for the proportion of individuals experiencing IPV may overestimate this outcome. This study has implications for research and policy. From a research perspective, this underscores the need for sexual behavior, IPV, and reproductive health service access research in emergency settings. Given the heterogeneity in study outcomes, multi-national studies should consider using methods that account for clustering (e.g., multilevel modeling). From a policy perspective, our data suggest the need for expanded use of decentralized sexual and reproductive health interventions that could be implemented in emergency settings (e.g., self-testing, selfcollection, telemedicine abortion). The results from country-level data have already helped to inform COVID-19 related sexual and reproductive health policies in several countries, including Latvia, Czech Republic, Panama, Singapore, Uruguay, and Portugal. Finally, the open science methods used in this study point towards new frameworks for global health collaboration. We organized a survey in thirty diverse settings during a pandemic, despite not having a central funding source or a COVID-19-specific organizational remit. This suggests the feasibility of grounds-up organized multi-country studies focused on sexual and reproductive health. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; 100 *This included individuals whose sex at birth was not a male or female.** Oxford Stringency Index: a measure to record the strictness of lockdown policies based on indicators such as school and workplace closure, and travel bans, rescaled to a value from 0 to 100 (100 = strictest). Note: Household socioeconomic status and relationship status were not mutually exclusive and participants could choose more than one. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. w o r k 5 I w o r k o n r e d u c e d t i m e 6 I l o s t m y j o b / w o r k / b u s i n e s s 7 I a m t e m p o r a r i l y u n e m p l o y e d 8 I c h a n g e d w o r . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; . d y o u h a v e a d r i n k c o n t a i n i n g a l c o h o l ? 1 N e v e r 2 M o n t h l y o r l e s 3 2 -4 t i m e s a m o n t h 4 2 -3 t i m e s a w e e k 5 4 o r m o r e t i m e s a w e e k 1 D e c r e a s e d a l o t 2 D e c r e a s e d a b i t 3 S t a y e d t h e s a m e 4 I n c r e a s e d a b i t 5 I n c r e a s e d a l o t 3 . . D i d y o u h a v e a s t e a d y p a r t n e r i n t h e t h r e e m o n t h s b e f o r e t h e C O V I D -1 9 c i r c u i t b r e a k e r ? 1 a s t h i s c h a n g e d d u r i n g t h e C O V I D -1 9 c i r c u i t b r e a k e r ? O n l y f o r t h o s e r e s p o n d i n g 2 t o 4 . 2 1 M u c h l e s s s u p p o r t t h a n b e f o r e 2 A b i t l e s s s u p p o r t t h a n b e f o r e 3 A b o u t t h e s a m e a m o u n t o f s u p p o r t t h a n b e f o r e 4 A b i t m o r e s u p p o r t t h a n b e f o r e 4 2 -3 t i m e s a w e e k 5 4 o r m o r e t i m e s a w e e k 4 I n c r e a s e d a b i t 5 I n c r e a s e d a l o t 5 . 7 a U s e d a c o n d o m w h e n y o u h a d s e x w i t h a c a s u a l p a r t n e r ? 1 N e v e r 2 R a r e l y 3 S o m e t i m e s 4 M o s t o f t h e t i m e 5 A l w a y s 1 D e c r e a s e d a l o t 2 D e c r e a s e d a b i t 3 S t a y e d t h e s a m e 4 I n . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 27, 2021. ; . A c c e s s t o R e p r o d u c t i v e H e a l t h s e r v i c e s , a n t e n a t a l c a r e , p r e g n a n c y a n d m a t e r n a l a n d c h i l d h e a l t h ( o n l y w o m e n r e s p o n d i n g y e s t o . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint o y o u p l a n t o g i v e b i r t h a t h o m e ? 1 I a m c o n c e r n e d a b o u t t h e r i s k o f C O V I D -1 9 i n h e a l t h f a c i l i t i e s 2 T is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 27, 2021. ; o n l y w o m e n ) -P O S S I B L Y O P T I O N A L F O R C O U N T R I E S W H E R E A B O R T I O N I S F O R E B I D D E N , T H O U G H P R E F E R R E D T H A T T H I S I S A S K E D A N Y W A Y T O A S S E S S U N S A F E A B O R T I O N S W o m e n o n l y -M i n 1 -M a x 6 8 . 1 . D u r i n g t h e C O V I D -1 9 c i r c u i t b r e a k e V I D -1 9 s o c i a l d i s t a n c i n g m e a s u r e s 2 G e n e r a l p r a c t i t i o n e r 3 O t h e r p r i v a t e s p e c i a l i s t c l i n i c s 4 P o l y c l i n i c 5 G o v e r n m e n t h o s p i t a l 6 O n l i n e s e r v i c e s 7 T e l e p h o n e s e r v i c e s 8 O v e r t h e c o u n t e r s e r v i c e s ( p h a r m a c y ) 9 T r a d i t i o n a l h e a l e r 1 0 S e l f -m e d i c a t i o n 1 1 A b o r t i o n c l i n i c 1 2 T h r o u g h a n o n -g o v e r n m e n t a l o r g a n i z a t i o n o r c i S e l f -m e d i c a t i o n 1 0 A b o r t i o n c l i n i c 1 1 T h r o u g h a n o n -g o v e r n m e n t a l o r g a n i z a t i o n o r c i v i l s o c i e t y o r g a n i z a t i o n f o r a b o r t i o n 1 2 O t h e r . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; . 7 . D i d y o u e x p e r i e n c e a n y d e l a y s i n o b t a i n i n g a b o r t i o n c a r e ? 1 N o 2 Y e s , a f e w d a y s 3 Y e s , 1 -2 w e e k s 4 Y e s , 3 -4 w e e k s 5 Y e s , m o r e t h a n 4 w e e k s . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; . S e x u a l a n d g e n d e r -b a s e d v i o l e n c e M i n 1 0 -m a x 1 4 9 . 1 I n y o u r e v e r y d a y l i f e , i n t h e t h r e e m o n t h s b e f o r e t h e C O V I D -1 9 s i t u a t i o n , h o w v u l n e r a b l e d i d y o u f e e l f o r s e x u a l h a r a s s m e n t o r s e x u a l , p h y s i c a l , o r e m o t i o n a l a s s a u l t b y s o m e o n e w h o d o e s n o t l i v e i n y o u r h o u s e ? 1 N o t v u l n e r a b l e a t a l l 2 L i t t l e v u l n e r a b l e 3 N e u t r a l 4 Q u i t e v u l n e r a b l e 5 V e r y v u l n e r a b l e 9 . 2 I n y o u r e v e r y d a y l i f e , d u r i n g t h e C O V I D -1 9 s i t u a t i o n , h o w v u l n e r a b l e d i d y o u f e e l f o r s e x u a l h a r a s s m e n t o r s e x u . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; . 2 . I f y e s o n a n y o f t h e d u r i n g / a f t e r C O V I D -1 9 q u e s t i o n s : D i d y o u e v e r t a l k t o s o m e o n e a b o u t t h e v i o l e n c e e x p e r i e n c e s y o u h a d d u r i n g t h e C O V I D -1 9 c i r c u i t b r e a k e r m e a s u r e s ? ( m u l t i p l e r e s p o n s e s p o s s i b l e ) 1 N o 2 Y e s , t o a r e l a t i v e 3 Y e s , t o a f r i e n d 4 Y e s , t o a p h o n e o r o n l i n e h e l p l i n e 5 Y e s , t o t h e s o c i a l s e r v i c e s 6 Y e s , t o t h e p o l i c e 7 Y e s , t o a n a s s o c i a t i o n 8 Y e s , o t h e r … 9 . O p t i o n a l : F e m a l e g e n i t a l m u t i l a t i o n / c u t t i n g a n d e a r l y / f o r c e d m a r r i a g e M i n 2 -M a x 1 0 1 0 . 1 . D o e s e a r l y m a r r i a g e ( m a r r i a g e b e f o r e t h e a g e o f 1 8 y e a r . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; 3 I a m n o t a b l e / a l l o w e d t o l e a v e t h e h o u s e 4 D o c t o r / h e a l t h p r o f e s s i o n a l n o t a v a i l a b l e 5 P h a r m a c y / d i s p e n s a r y c l o s e d 6 I c a n n o l o n g e r a f f o r d i t 7 H e a l t h c e n t r e / c l i n i c h a s l o n g q u e u e s o r i s n o t . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. O p t i o n a l : M e n t a l h e a l t h S i n c e t h e l a s t w e e k : 1 2 . 2 . I g e t a n g r y f r e q u e n t l y w i t h s l i g h t p r o v o c a t i o n . T o t a l l y a g r e e A g r e e A g r e e n o r d i s a g r e e D i s a g r e e T o t a l l y d i s a g r e e . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. D i s a g r e e T o t a l l y d i s a g r e e 1 2 . 1 3 . I e x p e r i e n c e o b s e s s i v e o r c o m p u l s i v e b e h a v i o r s w i t h r e g a r d s t o h a n d w a s h i n g . T o t a l l y a g r e e A g r e e A g r e e n o r d i s a g r e e D i s a g r e e T o t a l l y d i s a g r e e 1 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; o e s t h i s h a p p e n m o r e o r l e s s s i n c e t h e s t a r t o f t h e l o c k d o w n ? A l o t m o r e M o r e A b o u t t h e s a m e L e s s A l o t l e s s . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; Observational studies start at low quality. While risk of bias due to largely convenience sampling may further negatively impact certainty, quality of evidence was rated upwards due to a large sample size . It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. LMIC = low / middle income countries. HIC = high income countries. CI = confidence interval. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. Fewer participants reported hindered access to HIV/STI testing during COVID-19 measures in studies that that employed population-based sampling (n=2) than those that did not (n=29) (P=.000). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note. Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. There was a difference in the proportion of respondents who reported exposure to IPV during the pandemic between studies conducted in HICs (n=16) and LMICs (n=14) (P=.013). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. More respondents reported higher prevalence of IPV during the pandemic in studies with at least 200 participants (n=26) versus studies with fewer than 200 participants (n=4) (P=.001). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note. Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. There was a difference in the proportion of respondents who reported reduced condom use between studies conducted in HICs (n=16) and LMICs (n=14) (P=.000). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Note: Effect sizes are expressed as proportions. Studies are represented by symbols whose area is proportional to the study's weight in the analysis. CI = confidence interval. Fewer participants reported reduced condom use in studies that did not use convenience sampling (n=4) than those that did (n=26) (P=.000). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 27, 2021. ; Centring sexual and reproductive health and justice in the global COVID-19 response Surviving in place: The coronavirus domestic violence syndemic Disruption in HIV, Hepatitis and STI services due to COVID-19 How will country-based mitigation measures influence the course of the COVID-19 epidemic? Variation in government responses to COVID-19. Blavatnik school of government working paper 2020 HIV self-testing partially filled the HIV testing gap among men who have sex with men in China during the COVID-19 pandemic: results from an online survey Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage Sexual health (excluding reproductive health, intimate partner violence and gender-based violence) and COVID-19: a scoping review Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from populationbased national or regional cohort surveys Modelling COVID-19 transmission in Africa: countrywise projections of total and severe infections under different lockdown scenarios Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health In Low-and Middle-Income Countries International Sexual Health And REproductive health (I-SHARE) survey during COVID-19: study protocol for online national surveys and global comparative analyses Online health survey research during COVID-19 Using a crowdsourcing open call, hackathon and a modified Delphi method to develop a consensus statement and sexual health survey instrument Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS) Measuring inconsistency in metaanalyses Grading quality of evidence and strength of recommendations Potential reduction in female sex workers' risk of contracting HIV during Covid-19 The authors would like to thank the I-SHARE research consortium. This research was supported by the NIH (UG3HD096929 and NIAID K24AI143471). In Latvia, this research was supported by the National Research Programme to Lessen the Effects of COVID-19 (VPP-COVID-2020/1-0011).