Condom Use: How It Relates to HIV and STI Prevention

• Introduction
• The Effectiveness of Condoms in Preventing HIV and Sexually Transmitted Infections
• HIV
• Other STIs
• USAID’s Development Approach to Condom Promotion
• A Whole Market Approach for Improved Access
• Female Condoms
• Dual Protection
• Seeing Results

Introduction

	A shopkeeper displaying condoms in Guinea. Source: L. Lartigue

The U.S. Agency for International Development (USAID) has been a leader in HIV prevention and is fully committed to a combination of strategies targeting the sexual prevention of HIV transmission, some of which include abstinence, being faithful/partner reduction, and correct and consistent condom use (ABC approach). Condom use can significantly reduce the risk of HIV infection and, in conjunction with other behavior changes such as delayed sexual initiation and partner reduction, is a key component of effective HIV prevention programs.

HIV prevention efforts are complicated by the fact that the global pandemic is rooted in different causes in different settings. To prevent the sexual transmission of HIV, the U.S. Government, through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), supports the ABC approach because it can be used to target the sources of most of the new infections in a given population while still being tailored to meet the specific needs of the most-at-risk and vulnerable individuals.

The Effectiveness of Condoms in Preventing HIV and Sexually Transmitted Infections

HIV

While laboratory research has demonstrated that latex condoms provide an essentially impermeable barrier to particles comparable in size to or smaller than STIs, including HIV, studies have shown that correct and consistent use is essential to realize the full benefits provided by condoms in reducing the risk of HIV infection. The body of research demonstrating the effectiveness of latex condoms in reducing sexual transmission of HIV is both comprehensive and conclusive.

Scientific studies of sexually active discordant couples, where one partner is infected with HIV and the other partner is not, have demonstrated that the correct and consistent use of latex condoms reduces the likelihood of HIV infection by 80 to 90 percent. However, failure to use condoms correctly with every act of intercourse or, to some extent, slippage or breakage of the condom, has been shown to increase the risk of HIV transmission. In fact, some studies have shown that inconsistent condom users may face the same risks of HIV infection as non-users.

Other STIs

Condoms serve as a barrier that can protect both genders from exposure to genital secretions that transmit HIV and STIs. Gonorrhea, chlamydia, and trichomoniasis, like HIV, are transmitted by genital secretions. Scientific studies do provide evidence that latex condoms, when used consistently and correctly, can reduce the risk of gonorrhea and chlamydia infections in both women and men.

Genital ulcer diseases (such as genital herpes, syphilis, and chancroid) and human papillomavirus (HPV), which is the main cause of cervical cancer, are transmitted primarily through contact with sores/ulcers or with infected skin in areas that may or may not be covered by a condom. Recent studies have shown that correct and programs that promote condom use and provide support to con-consistent condom use reduces the risk of herpes.

Correct and consistent use of latex condoms reduces the risk of chancroid and the other genital ulcerative diseases only when the infected area or site of potential exposure is protected.

Additional research is needed to assess more accurately the degree of risk reduction latex condoms can provide to women and men for trichomoniasis and other STIs transmitted by genital secretions as well as whether and to what degree latex condoms may reduce the risk of acquiring HPV, including the few types that are associated with cervical cancer.

Providing Condoms Worldwide Through USAID’s Commodity Fund
	USAID has provided commodities for family planning and reproductive health activities since the mid-1970s and for HIV prevention since the 1980s. Since then, contraceptive and condom use rates around the world have increased, thanks to USAID and other international donors. However, the need for foreign assistance continues to grow, and in fiscal year 2008, USAID continued to respond to this need by providing family planning, reproductive health, and HIV commodities to countries in the Agency’s five regions: Africa (AFR),Asia, Europe & Eurasia (E&E), Latin America/Caribbean (LAC), and Middle East (ME). USAID has developed an operational plan for its HIV/AIDS strategy. One aspect of this plan includes a Commodity Fund to centrally finance male and female condoms for non-focus PEPFAR countries’ HIV/AIDS programs and ensure their expedited delivery to countries. Through this fund, USAID has made condoms available to dozens of countries at little or no cost. USAID provides male condoms at 2–5¢ a condom and female condoms at 57–86¢ a condom.
In fiscal year (FY) 2008, the value of USAID contraceptive and condom shipments worldwide reached $70.2 million. Shipments reached 57 countries in USAID’s AFR,Asia, E&E, LAC, and ME regions. Male condoms represented 28 percent of the total shipments, and female condoms represented nine percent.

USAID’s Development Approach to Condom Promotion

Private sector advertising and commercial distribution are important approaches to make condoms more accessible. These programs distribute high-quality condoms at affordable prices through traditional outlets, such as health clinics and pharmacies, and through non-traditional outlets such as kiosks, bars, hotels, and brothels.

Such programs combine condom sales with social marketing that uses culturally appropriate educational messages to promote condom use and other forms of risk reduction. USAID projects assist governments and organizations in logistics management, including purchase, storage, and distribution, in order to ensure an adequate supply and efficient distribution of condoms.

It is not sufficient to provide condoms without support for how they will be distributed. Attention needs to be paid to the different target audiences, such as high-risk populations. USAID funds programs that promote condom use and provide support to condom programming.

Although it is imperative that USAID address the extraordinary health risks for society associated with prostitution and intravenous drug users by promoting the adoption of safer behaviors and encouraging condom use with casual and high-risk partners, this does not mean that USAID in any way endorses or supports prostitution or drug use.

A Whole Market Approach for Improved Access

A whole market approach for commodity security considers the entire market for commodities and services in a country or region to ensure the needs of all clients are best met. In order to achieve a whole market approach, USAID partners with NGOs and public and commercial sectors in order to properly maintain delivery and distribution services and continue meeting demand.

A coordinated approach helps provide condoms for the entire market, which includes everybody from those who receive free condoms to those who pay. A whole market approach can lead to sustainability, increased demand and supply of condoms, an increased number of individuals with access to condoms, and a better allocation of resources. A coordinated effort also helps avoid unnecessary duplication and an inefficient use of resources.

Female Condoms

The female condom, a woman-initiated contraceptive, was first launched by the Female Health Company (FHC) in 1993 as the FC1, or the Reality FC. Since then, it has undergone changes, and covers both internal and some parts of the external genitalia. Men may also find it more comfortable because there is less of a decrease in sensation than with the male latex condom.

FHC created the FC2 from synthetic nitrile, as opposed to polyurethane like the FC1, to reduce cost and maintain effectiveness. In many parts of the world, the original FC was found to be too costly, and the FC2 is 30 percent less expensive. A more affordable female condom allows for increased accessibility. However, it is still 15–20 times more expensive than the male latex condom.

In studies, the FC2 was found to be essentially the same as FC1 in preventing HIV, STIs, and unintended pregnancy. The FC2 has been reviewed by many agencies and, in 2006, the World Health Organization (WHO) recommended the FC2 be purchased by U.N. agencies. Since then, more than 22 million FC2s have been distributed in 77 countries. Three years after WHO approval, the FC2 was approved by the Food and Drug Administration for U.S. and international distribution, which is likely to increase to meet growing international demand.

Increasing Health Impact Through Targeting of Condom Sales in Malawi

Background The HIV epidemic has taken its toll on Malawi. UNAIDS estimated an 11.9 percent HIV prevalence rate among adults in 2007. Currently, there are roughly 930,000 adults and children living with HIV/AIDS in Malawi. The country’s most at-risk population is female sex workers; 69 percent are affected. The primary mode of HIV transmission is through heterosexual unprotected sex. The face of the HIV/AIDS epidemic in Malawi is a female one, with almost 60 percent of infected individuals being women. In 2007, the prevalence of HIV in youth (15–24 years) was much higher in females than in males, 8.4 percent and 2.4 percent, respectively. It is well known that the young women in Malawi are infected primarily by older men, whose HIV rate is higher, so the HIV rate in young men is comparatively lower than their female peers. Chishango Chishango, meaning “shield” in the local language, is the premiere brand of condoms in Malawi due to the social marketing campaign of a USAID-funded partner, Population Services International (PSI). Chishango sales increased from approximately 1 million in 1994 to around 9.5 million in 2007. This growth occurred simultaneously with an increased distribution of free condoms, which barely existed in the 1990s, to more than 22 million in 2007. Hot Zones Through research, 18 “hot zones” were identified in Malawi to focus the exclusive sale of Chishango. These hot zones were areas where the most at-risk populations could be found. Outlets included bars, hotels, lodges, and night clubs. The sales coverage of these popular spots operating in targeted zones nationwide increased from 72 percent in 2006 to 82 percent in 2007. Because of USAID-funded programming, the number of high-risk outlets reached and the number of condoms sold in high-risk outlets increased by more than 300 percent from FY 2006 to FY 2007. Chishango became the preferred brand of condoms. Changed Behavior Not only did condom sales increase, but the message of correct and consistent condom use began to resonate with the different populations in Malawi. With the help of USAID, the increase in reported condom use with non-cohabitating partners was significant between 2000 and 2006. In a survey for youth, only 34 percent of males used a condom with a non-cohabitating partner in 2000, and that number increased to 60 percent in 2006. Females had a lower condom use rate, with 32 percent using a condom in 2000 and 40 percent in 2006. An example is Carol, a 21-year-old mother who turned to commercial sex work in order to earn money to survive. Now, she protects herself. She refuses to sleep with any man who does not wear a condom. “I have a responsibility to look after my daughter. So, I need to make money, but I cannot sacrifice my life. Besides, Chishango condoms give me peace of mind,” she said.

Dual Protection

Male and female condoms are the only products currently available that protect against both HIV/STIs and unintended pregnancy; however, even though more than four-fifths of HIV infections are due to sexual transmission, many people still do not use condoms and continue to put themselves at risk. Data from USAID Demographic and Health Surveys in 18 African countries (132,800 women) showed that condom use for pregnancy prevention increased significantly in 13 of 18 countries between about 1993 and 2001. Additionally, more than half (58.5 percent) of condom users used a condom to prevent unintended pregnancy.

A Senegalese man discusses HIV/AIDS information tools with a representative of a USAID implementing partner. Source: Richard Nyberg, USAID/Senegal

With more women turning to condoms for contraception, there is an opportunity to promote condoms as a form of dual protection against unintended pregnancy and HIV/STI prevention. Dual protection is beneficial because the collaboration of efforts between sexual and reproductive health programs can help to leverage scarce resources, addressing the complexity of peoples' needs.

Given sustained high rates of HIV infection in southern Africa, in conjunction with continuing challenges in microbicide and vaccine development, it is necessary to reassess current condom promotion strategies. The international community, led by UNAIDS and the United Nations Population Fund (UNFPA), has advocated for widespread scale-up of combination prevention, which includes structural, behavioral, and biomedical interventions. Therefore, condom promotion must be re-conceptualized as one component of a larger package of services that address partner reduction, monogamy, STI treatment, circumcision, and the promotion of correct and consistent use of condoms for dual protection against unintended pregnancy and HIV/STI infection.

Seeing Results

Thailand
The potential impact of condom promotion on the spread of HIV has been demonstrated in Southeast Asian countries where prostitution has contributed substantially to new HIV infections. In recent years, several countries have succeeded in increasing consistent condom use among prostitutes and their clients. For example,Thailand slowed its explosive HIV epidemic by promoting "100 percent condom" use in brothels. As a result of this policy and an accompanying public information campaign, as well as improved STI treatment services, condom use among prostitutes increased to more than 90 percent; reported visits to prostitutes by men declined by about half; HIV infection rates among military recruits decreased by about half; and the cases of five other STIs decreased by nearly 80 percent among brothel workers.

Madagascar
Population Services International (PSI) in Madagascar worked with the USAID-funded health clinic network,Top Réseau, to provide high-quality reproductive health services to youth and prevent HIV/STIs and unintended pregnancy. In 2003, a survey was taken of youth (15–24 years) to learn about their sexual activity, their level of HIV/STI knowledge, and their condom behavior. After three years of youth-targeted communication interventions, social support, and condom campaigns, a second survey was taken in 2006. The second survey showed an increase in the percentage of youth who had never engaged in sexual activity, from 65.8 percent in 2003 to 82.1 percent in 2006. The survey also showed a significant increase in condom use among youth. In the 2003 survey, 24.8 percent of youth said they used a condom the last time they had sex; that number rose to 29.1 percent in 2006. Finally, youth who had medium or high exposure to the campaign had an even higher percentage of condom use (31 percent and 32 percent, respectively). After youth were exposed to condom campaigns, they were more willing to use condoms with their sexual partners.

The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.

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