PRB

Method Could be Critical in Reducing HIV Rate for Married Women

(November 2005) As the AIDS pandemic has become globalized and feminized (see figure), women in developing countries have become more at risk for HIV infection—including married women. Rates of HIV infection among married women or those in committed partnerships are increasing rapidly worldwide: In sub-Saharan Africa, where women have been hardest hit by the AIDS pandemic, 57 percent of those who test positive for HIV are women, and at least one-third of these women are married.¹

Percent of Adults (15-49) Living With HIV Who Are Female, 1985-2004

Source: UNAIDS and WHO, Women and AIDS (2004).

Yet the vast majority of married women at risk are not using any barrier method during sex. According to UNAIDS, only 4.9 percent of married women worldwide use condoms, including only 1.3 percent in sub-Saharan Africa.² Given this context, many analysts think the female condom should become an important tool for HIV prevention, especially for married women.

Currently, the female condom is the only alternative to the male condom as a means of protection against both sexually transmitted infections (STIs) and pregnancy. Introduction studies in more than 45 countries have confirmed the method’s acceptability among both women and men.³ And research shows that, with practice and support, women can overcome the common difficulties with inserting and using this device.⁴ (Organizations including PATH, an international health NGO, are developing improved female condoms that will ease insertion difficulties.)

Yet studies also find that female condoms are used predominantly by women who already feel comfortable with a barrier method and who prefer to alternate its use with that of the male condom.⁵ Its practical use by married women—who do not generally meet these criteria—has not been well-studied to date, largely because married women have not been targeted as a group at high risk for contracting HIV.

The female condom faces three obstacles to its widespread use: a lack of research on its effectiveness in preventing STIs; the challenges of male involvement in its use; and its cost. Policymakers and the health community need to aggressively pursue overcoming these obstacles—which are detailed below—in order to give all women another line of protection against HIV infection.

Uncertain Effectiveness as a Prevention Tool

Introduced in 1993, the female condom was originally intended as a female-controlled barrier device to provide “dual protection”—protection against STIs and unintended pregnancy. While recent unpublished studies funded by the World Health Organization (WHO) validate the effectiveness of female condoms against unintended pregnancy, few small-scale studies find evidence of its effectiveness against STIs and HIV.

One laboratory study and three field studies—in locations ranging from an STI clinic in the United States to brothels in Thailand and agricultural communities in Kenya—have shown the female condom to be at least as effective as the male condom in preventing STIs.⁶ But even with this evidence, the initial enthusiasm for the method has not translated into universal access. The amount of female condoms available globally is less than 0.5 percent that for male condoms.⁷ While increasing a community’s range of contraceptive choices generally boosts that community’s level of protection against STIs, the question of whether the female condom increases levels of protected intercourse has yet to be sufficiently evaluated.

Some research, however, has provided an affirmative answer. One study concluded that introduction of the female condom led to an increase after three months in the percentage of protected sex without decreasing the level of male condom use.⁸ Other studies that looked at long-term use of the female condom among high-risk populations showed small to modest increases in the levels of protected sex.⁹ But policy and program decisionmakers need additional research to show the effectiveness of the female condom for STI and HIV prevention.

The Importance of Male Involvement

Effective use of the female condom also depends on a variety of factors, including male involvement in the decision to use it. Program planners and advocates now refer to the female condom as a female-initiated method, underscoring that the increased participation of men is important for its future success. And research has revealed that a man’s reaction to the female condom is often an important factor in whether his female partner uses the method.¹⁰

Some studies have found men amenable to the female condom. A study in Zimbabwe found that, although women initiate the dialogue about using the method, both partners jointly decide to use it.¹¹ Indeed, married women often resort to strategies other than direct negotiation to convince their partner to use the female condom, such as telling their partner that sex will be more enjoyable or that it will be possible during menstruation.

Social marketing campaigns have also shown that, in certain settings, marketing the female condom for its contraceptive purposes increases its acceptability for both partners.¹² Finally, partner satisfaction with the method has been associated with repeated use, and women who find the female condom easy to use frequently cite lack of partner objection.¹³

However, other research has found that men’s objections to the method are decisive in women’s decisions not to use it. In South Africa, where the female condom has been incorporated into the national family planning program, partner objection was the leading obstacle causing women to abandon use of the method.¹⁴ Other analysts have found that some men may believe the female condom and other female-controlled methods give women too much control over sex.¹⁵ These objections can mean that sex is often unprotected: In the Zimbabwe study, nearly 25 percent of women reported their partner opposed female condom use, and about 50 percent of those women ended up having unprotected sex.

Clearly, the implications of male influence are important for the future of the female condom, particularly for married women. While targeting men has been shown to be an effective way to improve overall acceptability for the method, more work is needed to understand how sexual negotiations in different contexts affect the female condom’s use rates.¹⁶

A Leading Constraint Is Cost

Finally, the current cost of the female condom is prohibitive for the majority of women at risk of HIV infection as well as health program directors with tight budgets. Its unit price to developing country governments ranges from 57 cents to 70 cents, compared with between 3 cents and 5 cents for the male condom.¹⁷ This high cost affects programming, which in turn affects use rates. Donors spend only an estimated 5 cents on purchasing female condoms for every dollar they spend on male condom programming.¹⁸

The Female Health Company, the leading manufacturer of female condoms, recently announced that it will offer a large-volume discount on its second-generation female condom, the FC2. However, the volume purchased must be quite large to qualify for the discount: 60 million to 120 million at 38 cents each, and fewer than 60 million at 60 cents each. (In 2003, between 10 million and 12 million female condoms were sold.)

Another option—reuse after disinfecting the female condom with a bleach and water solution—could decrease the method’s overall cost, but the practice may not be practical in the situations where most women live.¹⁹ Meanwhile, some agencies are exploring the development of cheaper female condom products that use latex instead of polyurethane and involve lower production costs.

The short-term costs of the female condom have to be compared with the long-term costs to economies and societies of women contracting HIV. Showing policymakers the projected savings from a leveling off or a decrease in the incidence of HIV among women might compel more investment in the female condom.

Moving Forward to Increase Access

Despite the obstacles outlined above, key players are moving to make female condoms more widely available. In late September, PATH convened a “Global Consultation on the Female Condom” attended by researchers, women’s health advocates, ministry of health officials, officials from UNAIDS, and representatives from sponsor organizations such as the United Nations Population Fund (UNFPA); USAID; the Bill & Melinda Gates Foundation; the William and Flora Hewlett Foundation; and the U.K. Department for International Development.²⁰ These parties committed to a plan of action focusing on:

• Global leadership through promoting the case for countries to invest in the female condom;
• “Making the case” by gathering compelling evidence for the female condom’s effectiveness;
• Information sharing through training, monitoring, and evaluation tools, web-based resource sharing, and other mechanisms;
• Research efforts that look at devising strategies for overcoming provider bias against the female condom, heightening women’s capacity to negotiate for safer sex, and promoting the method’s use to men; and
• Product development through a timeline for new products and a developers’ group that can facilitate exchange of technical information and address regulatory issues.

With its final commitment—to advocate for full incorporation of the female condom into HIV prevention programming—the global consultation underscored the urgency of the AIDS crisis for women. Although more robust evidence is needed to demonstrate the protective effect of female condoms against STIs and HIV, the accelerating HIV pandemic among women—particularly married women—warrants increasing access to and information about the female condom worldwide.

Heidi Worley is a senior policy analyst at the Population Reference Bureau.

References

1. Joint United Nations Programme on HIV/AIDS (UNAIDS), UN Population Fund (UNFPA), and United Nations Development Fund for Women (UNIFEM), Women and HIV/AIDS: Confronting the Crisis—A Joint Report (Geneva: UNAIDS, 2004).
2. Global Coalition on Women and AIDS, “Preventing HIV Infection in Girls and Young Women: Background Briefs,” accessed online at http://womenandaids.unaids.org, on Oct. 1, 2005.
3. World Health Organization (WHO), The Female Condom: A Review (Geneva: WHO, 1997); and WHO and UNAIDS, The Female Condom: A Guide for Planning and Programming (Geneva: UNAIDS, 2000).
4. WHO and UNAIDS, The Female Condom: A Guide for Planning and Programming; and Deanna Kerrigan et al., The Female Condom: Dynamics of Use in Urban Zimbabwe, Research Summary (Washington, DC: Horizons, 2002).
5. Elizabeth Musaba et al., “Long-term Use of the Female Condom Among Couples at High Risk of Human Immunodeficiency Virus Infection in Zambia,” Sexually Transmitted Diseases 25, no. 5 (1998): 260-64; and Arnaud Fontanet et al., “Protection Against Sexually Transmitted Diseases by Granting Sex Workers in Thailand the Choice of Using the Male or Female Condom: Results from a Randomized Controlled Trial,” AIDS 12, no. 14 (1998): 1851-59.
6. David Soper et al., “Prevention of Vaginal Trichomoniasis by Compliant Use of the Female Condom,” Sexually Transmitted Diseases 20, no. 3 (1993): 137-39; P.P. French et al., “Use Effectiveness of the Female Versus Male Condom in Preventing Sexually Transmitted Disease in Women,” Sexually Transmitted Diseases 30, no. 5 (2003): 433-39; Fontanet, “Protection Against Sexually Transmitted Diseases”; and Paul J. Feldblum et al., “Female Condom Introduction and Sexually Transmitted Infection Prevalence: Results of a Community Intervention Trial in Kenya,” AIDS 15, no. 8 (2001): 1037-44.
7. Patrick Friel, “Review of Past Action Plans and Their Implementation” (presentation to the Global Consultation on the Female Condom, Baltimore, MD, Sept. 27, 2005), accessed online at www.path.org, on Oct. 26, 2005.
8. Kyung-Hee Choi et al., “Patterns and Predictors of Female Condom Use Among Ethnically Diverse Women Attending Family Planning Clinics,” Sexually Transmitted Diseases 30, no. 1 (2003): 91-98.
9. Fontanet, “Protection Against Sexually Transmitted Diseases”; Lynn Artz et al., “Effectiveness of an Intervention Promoting the Female Condom to Patients at Sexually Transmitted Disease Clinics,” American Journal of Public Health 90, no. 2 (2000): 237-44; Mary Latka et al., “Male-condom and Female-condom Use Among Women After Counseling in a Risk-reduction Hierarchy for STD Prevention,” Sexually Transmitted Diseases 27, no. 8 (2001): 431-37; Musaba, “Long-term Use of the Female Condom”; and Susan Hoffman, “The Female Condom—Acceptability and Patterns of Use,” (presentation to the Global Consultation on the Female Condom, Baltimore, MD, Sept. 27, 2005), accessed online at www.path.org, on Jan. 19, 2006. For a review of this topic, see Susan Hoffman et al., “The Future of the Female Condom,” International Family Planning Perspectives 30, no. 3 (2004): 139-45.
10. Michael J. Welsh et al., “Condom Use During a Community Intervention Trial in Kenya,” International Journal of STDs and AIDS 12, no. 7 (2001): 469-74; Nicholas Ford and Elspeth Mathie, “The Acceptability and Experience of the Female Condom, Femidom, Among Family Planning Clinic Attenders,” British Journal of Family Planning 19, no. 4 (1993): 187-92; and Gill Green et al., “Female Control of Sexuality: Illusion or Reality? Use of Vaginal Products in South-west Uganda,” Social Science and Medicine 52, no. 4 (2001): 585-98.
11. Deanna Kerrigan et al.,The Female Condom: Dynamics of Use in Urban Zimbabwe (New York: Population Council, 2000).
12. Mitchell Warren and Anne Philpott, “Expanding Safer Sex Options: Introducing the Female Condom into National Programmes,” Reproductive Health Matters 11, no. 21 (2003): 130-39.
13. Hoffman, “Female Condom Use.”
14. Mags Beksinska et al., “Acceptability of the Female Condom in Different Groups of Women in South Africa: A Multicentred Study to Inform the National Female Condom Introductory Strategy,” South African Medical Journal 91, no. 8 (2001): 672-78.
15. Robert Pool et al., “Men’s Attitudes to Condoms and Female Controlled Means of Protection Against HIV and STDs in South-western Uganda,” Culture, Health and Sexuality 2, no. 2 (2000): 197-211.
16. WHO and UNAIDS, The Female Condom: A Guide for Planning and Programming.
17. Hoffman, “The Future of the Female Condom “; Warren and Philpott, “Expanding Safer Sex Options”; and Global Coalition on Women and AIDS, “Preventing HIV Infection in Girls and Young Women.”
18. Friel, “Review of Past Action Plans and Their Implementation.”
19. Mags Beksinska, “Structural Integrity of the Female Condom After Multiple Uses, Washing, Drying, and Re-lubrication,” Contraception 63, no. 1 (2001): 33-36. Although WHO mandates a one-use policy owing to a dearth of evidence on the feasibility of reuse, the organization did issue a draft protocol in 2002 on female condom reuse using a bleach and water solution after a study in South Africa showed that the female condom could be used up to seven times without degeneration of its structural integrity. The Global Coalition on Women and AIDS says that the wide practice of such reuse could reduce unit cost to between 10 cents and 15 cents.
20. PowerPoint presentations made by the consultation’s participants are available at www.path.org.