Scaling pleasure-based sexual and reproductive health: an impact and economic modelling study in 99 low- and middle-income countries.

INTRODUCTION: Pleasure is a key reason why people have sex. Yet many sexual and reproductive health (SRH) programmes do not consider the fundamental role of pleasure, focusing primarily on the prevention of pregnancy and sexually transmitted infections. Moreover, there is limited policy-ready evidence on pleasure-based sexual and reproductive healthcare (PBSRH), including implementation guidance, costs, impacts and return on investment at scale. METHODS: We conducted semi-structured interviews with nine PBSRH providers to characterise the incremental activities required to implement PBSRH relative to conventional SRH. Using activity-based costing, we estimated the costs of integrating pleasure principles into existing SRH programmes for 15-24-year-olds in 99 low- and middle-income countries (LMICs) over 2026-2035. We focused on a narrow behavioural pathway - increased condom use - and projected its effects on (1) Unintended pregnancies, abortions, maternal and child mortality using methods consistent with Guttmacher's Adding it Up approach and (2) HIV outcomes using the Goals-Spectrum application. We undertook a prospective, societal benefit-cost analysis to estimate global, regional and country-level return on investment. RESULTS: Eighteen incremental activities are commonly undertaken when integrating pleasure into SRH programmes. The estimated incremental cost of these activities for 15-24 year olds in LMICs is $1.6 billion (95% CI $1.1 to $2.2) over 10 years. This is expected to lead to 30.7 million (95% CI 17.8 to 41.1) additional years of condom use, averting 4.3 million pregnancies (95% CI 2.1 to 6.7) and 2.1 million abortions (95% CI 1.1 to 3.4). PBSRH integration would avert 92 318 deaths by 2050 (95% CI 47 965 to 139 835), ~80% relating to women and children. The expected return on investment is $22.9 (95% CI $13.8 to $37.6) in benefits per $1 of incremental cost. The largest benefits and returns are in Sub-Saharan Africa and Latin America and the Caribbean. CONCLUSION: PBSRH is a cost-effective and high-return intervention to support global SRHR and HIV/AIDS goals for young people in LMICs.