Lessons from the evaluation of the South African National Female Condom Programme.

BACKGROUND: Understanding of the facilitators and challenges to female condom (FC) uptake has been limited due to lack of evaluation of national FC programmes. SETTING: The FC has been an integral component of South Africa's (SA) HIV prevention programme for 20 years and is the largest government-funded FC programme worldwide. METHODS: The national FC evaluation used a mixed-methods approach and consisted of key informant interviews and a telephone survey in a national sample of public and non-public sites. A sub-sample of sites participated in client and provider interviews, and a self-administered client survey. A review of distribution statistics from South Africa's District Health Information System was also conducted. RESULTS: All 256 public-sector and 28 non-public-sector facilities reported having ever distributed FCs. Less than 5% of these facilities reported stock-outs and less than 3% reported they had a supply of expired female condoms. Systems for male condom (MC) and FC distribution were complementary, with similar ordering, delivery and reporting processes. FC promotion by providers (n = 278) varied with regard to FC training, whether attitudes about FCs influenced providers offer of FCs, and how they counselled clients about FCs. Of the 4442 self-administered client surveys in 133 facilities, similar proportions of women (15.4%) and men (15.2%) had ever used FCs. Although FCs were available at almost all sites surveyed, only two-thirds of clients were aware of their availability. CONCLUSION: Data highlight the role of providers as gatekeepers to FC access in public and non-public sectors and provide support for further FC programme expansion in SA and globally.

Seeking the female (internal) condom in retail pharmacies: Experiences of adolescent mystery callers.

BACKGROUND: Female (internal) condoms could be viable alternatives to male (external) condoms. Our objective was to describe barriers that adolescent mystery callers encountered when trying to access female condoms in U.S. pharmacies. METHODS: In mid-2016, university students seeking "condoms for girls" called retail pharmacies in Arizona, California, New Mexico and Utah. We evaluated differences in product availability and callers' experiences by pharmacy type. RESULTS: Of our final sample (n=1475), only eight outlets (0.5%), all national chains, definitely stocked female condoms. Of those not (or probably not) stocking female condoms, 11% tried to be helpful (e.g., offered to special order), 59% made no substantive comment, and 30% were unhelpful (e.g., dismissive, rude, gave wrong information). National chain employees were significantly more unhelpful (34% vs 22%, p< .01). CONCLUSION: Almost no pharmacies in four southwestern states stocked female condoms in mid-2016. Pharmacy staff frequently were unhelpful, which could deter adolescent use of female condoms even if new types become available.

Assessing and Mapping the Availability of the Female Condom in the Philadelphia Metropolitan Area.

This study assessed and mapped the availability of the female condom in relation to the male condom and HIV prevalence in the Philadelphia metropolitan area, which has a high density of HIV. One percent of the 1228 service providers contacted sold/provided the female condom and 77 % sold/provided the male condom. The lack of availability of the female condom suggests this product will have no public health impact on reducing HIV and that interventions that promote use of the female condom are not sustainable in this high-risk area. Our findings may help policy makers increase female condom availability in this area.

Structural issues affecting creation of a community action and advocacy board.

The most effective woman-initiated method to prevent HIV/sexually transmitted infections is the female condom (FC). Yet, FCs are often difficult to find and denigrated or ignored by community health and service providers. Evidence increasingly supports the need to develop and test theoretically driven, multilevel interventions using a community-empowerment framework to promote FCs in a sustained way. We conducted a study in a midsized northeastern US city (2009-2013) designed to create, mobilize and build capacity of a community group to develop and implement multilevel interventions to increase availability, accessibility and support for FCs in their city. The Community Action and Advocacy Board (CAAB) designed and piloted interventions concurrently targeting community, organizational and individual levels. Ethnographic observation of the CAAB training and intervention planning and pilot implementation sessions documented the process, preliminary successes, challenges and limitations of this model. The CAAB demonstrated ability to conceptualize, plan and initiate multilevel community change. However, challenges in group decision-making and limitations in members' availability or personal capacity constrained CAAB processes and intervention implementation. Lessons from this experience could inform similar efforts to mobilize, engage and build capacity of community coalitions to increase access to and support for FCs and other novel effective prevention options for at-risk women.

The female condom: a promising but unavailable method for Dominican sex workers, their clients, and their partners.

Despite evidence of the potential of the female condom as a method that effectively protects against sexually transmitted infections (STIs), HIV, and pregnancy, it is still not widely available. We conducted in-depth interviews with 18 sex workers, 15 male clients, and seven partners in the Dominican Republic to assess the acceptability of the female condom. The majority of the sex workers found the female condom acceptable and welcomed the option of a female-controlled method. Clients and partners of the sex workers were also positive about the female condom and, particularly with regard to pleasure; almost all preferred it to the male condom. These findings suggest that the female condom offers an acceptable option for protection against HIV, STIs, and pregnancy. The positive attitudes of women and men could be developed into messages in marketing campaigns for the female condom, targeting not only vulnerable groups but also the general population.

'Female condoms give women greater control': a qualitative assessment of the experiences of commercial sex workers in Swaziland.

OBJECTIVES: To explore commercial sex workers' experiences with the female condom in Swaziland. METHODS: This is a qualitative study that draws on two focus group discussions and ten individual in-depth interviews with female commercial sex workers in Lavumisa, Swaziland. RESULTS: The findings suggest that the majority of female sex workers prefer to use the female condom with their clients because it offers them greater control over the sexual encounter. Other factors that facilitate its use include the absence of side effects, the enhancement of sexual pleasure and protection against the risk of STIs (including HIV). In addition, the women reported that the female condom is stronger and more resistant to breakage than the male condom. Moreover, the female condoms can be inserted well in advance of sexual intercourse. Difficulties of insertion, partner objection and limited product availability were some of the barriers to the use of the device. There was also a tendency to reuse the female condoms because of lack of product availability and privacy to insert it. CONCLUSION: Although female condom use involves negotiation with clients, the fact that it offers sex workers an independent method of protection gives them more power and also, increases their ability to control their sexual and reproductive health.

The female condom: the international denial of a strong potential.

The female condom has received surprisingly little serious attention since its introduction in 1984. Given the numbers of women with HIV globally, international support for women's reproductive and sexual health and rights and the empowerment of women, and, not least, due to the demand expressed by users, one would have expected the female condom to be widely accessible 16 years after it first appeared. This expectation has not materialised; instead, the female condom has been marginalised in the international response to HIV and AIDS. This paper asks why and analyses the views and actions of users, providers, national governments and international public policymakers, using an analytical framework specifically designed to evaluate access to new health technologies in poor countries. We argue that universal access to female condoms is not primarily hampered by obstacles on the users' side, as is often alleged, nor by unwilling governments in developing countries, but that acceptability of the female condom is problematic mainly at the international policy level. This view is based on an extensive review of the literature, interviews with representatives of UNAIDS, UNFPA and other organisations, and a series of observations made during the International AIDS Conference in Mexico in August 2008.

Avaliação da continuidade de uso do preservativo feminino em unidades do Sistema Único de Saúde, na Grande São Paulo

O perfil da epidemia da Aids vem exigindo que se promova e implemente alternativas que, além de prevenir a entrada do HIV, facilitem a negociação de uso com o parceiro e possibilitem dupla proteção - contra as infecções transmitidas sexualmente, inclusive a Aids e contra a gravidez não desejada com o preservativo feminino. Objetivando verificar se a alta aceitabilidade inicial, descrita em outros estudos, é mantida na rotina de atendimento às diferentes populações vulneráveis foram monitorados, por 12 meses, 16 serviços do Sistema Único de Saúde da Grande São Paulo (7 serviços especializados em atendimento às doenças sexualmente transmissíveis inclusive Aids, 6 unidades básicas e 3 projetos comunitários). Foram incluidas no estudo 2469 mulheres, das quais 713 em serviços de atenção especializada às DST/Aids, 1417 em unidades básicas de saúde e 339 em projetos comunitários. A análise da continuidade de uso foi realizada por tábua de sobrevida Kaplan-Meier, teste log-rank e modelo de regressão de Cox. Observou-se que, ao final do seguimento, estavam em uso contínuo do preservativo feminino 14,38%(355) das mulheres. O tempo médio de uso foi de 3,55 meses. Os resultados evidenciaram que o tipo de serviço de dispensação do insumo e a frequência mensal de relações sexuais interferiram na continuidade de uso, de forma estatísticamente significante. O número de mulheres que iniciaram o uso do preservativo feminino nos diferentes tipos de serviços evidenciou que há uma demanda para alternativas de prevenção, e que é fundamenteal que se criem espaços onde elas possam ter acesso adequado a orientações e aos insumos.

Avaliação da continuidade de uso do preservativo feminino em unidades do Sistema Único de Saúde, na Grande São Paulo / Evaluation of the continuity of use of female condoms in units of the Unified Health System in Greater São Paulo

O perfil da epidemia da AIDS vem exigindo que se promova e implemente alternativas que, além de prevenir a entrada do HIV, failitem a negociação de uso com o parceiron e posssibilitem dupla proteção - contra as infecções transmitidas sexualmente, inclusive a Aids e contra a gravidez não desejada - como o preservativo feminini...

Avaliação da continuidade de uso do preservativo feminino em unidades do Sistema Único de Saúde, na Grande São Paulo / Evaluation of continuous use of female condoms in unities integrating the Unique Health System in Greater São Paulo

O perfil da epidemia da Aids vem exigindo que se promova e implemente alternativas que, além de prevenir a entrada do HIV, facilitem a negociação de uso com o parceiro e possibilitem dupla proteção - contra as infecções transmitidas sexualmente, inclusive a Aids e contra a gravidez não desejada com o preservativo feminino. Objetivando verificar se a alta aceitabilidade inicial, descrita em outros estudos, é mantida na rotina de atendimento às diferentes populações vulneráveis foram monitorados, por 12 meses, 16 serviços do Sistema Único de Saúde da Grande São Paulo (7 serviços especializados em atendimento às doenças sexualmente transmissíveis inclusive Aids, 6 unidades básicas e 3 projetos comunitários). Foram incluidas no estudo 2469 mulheres, das quais 713 em serviços de atenção especializada às DST/Aids, 1417 em unidades básicas de saúde e 339 em projetos comunitários. A análise da continuidade de uso foi realizada por tábua de sobrevida Kaplan-Meier, teste log-rank e modelo de regressão de Cox. Observou-se que, ao final do seguimento, estavam em uso contínuo do preservativo feminino 14,38%(355) das mulheres. O tempo médio de uso foi de 3,55 meses. Os resultados evidenciaram que o tipo de serviço de dispensação do insumo e a frequência mensal de relações sexuais interferiram na continuidade de uso, de forma estatísticamente significante. O número de mulheres que iniciaram o uso do preservativo feminino nos diferentes tipos de serviços evidenciou que há uma demanda para alternativas de prevenção, e que é fundamenteal que se criem espaços onde elas possam ter acesso adequado a orientações e aos insumos.

Sex, life and the female condom: some views of HIV positive women.

This article offers some insights into the experiences of HIV positive women with the female condom, drawing on my own personal experience and responses of 18 members of the International Community of Women Living with HIV/AIDS to an e-mail survey conducted in 2005. Major barriers reported to female condom use were cost and sporadic or very limited access. All respondents talked about needing to negotiate the use of female condoms with their male sex partners. Most felt more in control and more confident during sex when using the female condom than with the male condom or unprotected sex. Concerns about female condoms appear to be common, especially among women who have never used one; those who had used the female condom for long periods of time said good things about it. Women reclaiming our bodies is a central part of the joy and the challenge of promoting the female condom. For HIV positive women and girls, using a condom is more than protection against pregnancy, but a matter of life and death greater than the risks pregnancy can bring. Female condoms could make a critically important contribution to protecting HIV positive women's sexuality and continued sexual activity, as a fundamental part of our sexual and reproductive rights, if only they were more widely available and affordable.

Country-wide distribution of the nitrile female condom (FC2) in Brazil and South Africa: a cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness and potential impact of expanded female condom distribution. DESIGN: Cost-effectiveness analysis assessing HIV infections averted annually and incremental cost per HIV infection averted for country-wide distribution of the nitrile female condom (FC2) among sexually active individuals, 15-49 years, with access to publicly distributed condoms in Brazil and South Africa. RESULTS: In Brazil, expansion of FC2 distribution to 10% of current male condom use would avert an estimated 604 (5-95th percentiles, 412-831) HIV infections at 20,683 US dollars (5-95th percentiles, 13,497-29,521) per infection averted. In South Africa, 9577 (5-95th percentiles, 6539-13,270) infections could be averted, at 985 US dollars (5-95th percentiles, 633-1412) per infection averted. The estimated cost of treating one HIV-infected individual is 21,970 US dollars (5-95th percentiles, 18,369-25,719) in Brazil and 1503 US dollars (5-95th percentiles, 1245-1769) in South Africa, indicating potential cost savings. The incremental cost of expanded distribution would be reduced to 8930 US dollars (5-95th percentiles, 5864-13,163) per infection averted in Brazil and 374 US dollars (5-95th percentiles, 237-553) in South Africa by acquiring FC2s through a global purchasing mechanism and increasing distribution threefold. Sensitivity analyses show model estimates to be most sensitive to the estimated prevalence of sexually transmitted infections, total sexual activity, and fraction of FC2s properly used. CONCLUSIONS: Expanded distribution of FC2 in Brazil and South Africa could avert substantial numbers of HIV infections at little or no net cost to donor or government agencies. FC2 may be a useful and cost-effective supplement to the male condom for preventing HIV.

A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa, Kenya.

OBJECTIVE: To assess the impact and costs of adding female condoms to a male condom promotion and distribution peer education programme for sex workers in Mombasa, Kenya. DESIGN: A 12 month, prospective study of 210 female sex workers. METHODS: We interviewed participants about their sexual behaviour every 2 months for a total of seven times and introduced female condoms after the third interview. We also collected cost data and calculated the cost and cost effectiveness of adding the female condom component to the existing programme. RESULTS: Introduction of the female condom in an HIV/AIDS prevention project targeting sex workers led to small, but significant, increases in consistent condom use with all sexual partners. However, there was a high degree of substitution of the female condom for male condoms. The cost per additional consistent condom user at a programme level is estimated to be 2160 dollars (1169 pounds sterling, 1711 euros) (95% CI: 1338 to 11 179). CONCLUSIONS: The female condom has some potential for reducing unprotected sex among sex workers. However, given its high cost, and the marginal improvements seen here, governments should limit promotion of the female condom in populations that are already successfully using the male condom. More research is needed to identify effective methods of encouraging sex workers to practise safer sex with their boyfriends.

[The right to prevention and the challenges of reducing vulnerability to HIV in Brazil]. / O direito à prevenção e os desafios da redução da vulnerabilidade ao HIV no Brasil.

The study evaluates the Brazilian response to the targets established by UNGASS for the prevention of HIV/AIDS. The analysis was based on national research, documents and information from the National Program STD/AIDS and on state-level action plans and targets. Brazil relies on various prevention policies to attain the UNGASS targets proposed for 2005. These include: addressing discrimination issues, promotion of HIV testing, distribution of condoms, needle exchange programs, discussion of sexuality in schools, prevention initiatives for sex workers and homosexuals and prevention in the workplace. These have resulted in increases in testing and condom use. Various challenges are discussed, including: overcoming discontinuity in action plans (particularly with more vulnerable groups), training prevention teams, increasing monitoring of quantity and quality of preventative actions and overcoming regional, racial and gender inequalities. It is concluded that the right to prevention is not a public priority, nor is it on the social movement agendas. This contrasts with the right to better HIV treatment. In order to increase the efficacy of these programs, it is suggested that they be understood and incorporated based on the promotion and guarantee of human rights, thereby advancing the ethical/political debate at local and national levels.

Use of psychometric techniques in the analysis of epidemiologic data.

PURPOSE: This article demonstrates techniques for developing reliable multi-item scales for analysis of complex public health data. METHODS: Information from a questionnaire designed to evaluate the acceptability and efficacy of the female condom as a method for STD/HIV prevention was summarized using psychometric analysis. 1159 high-risk women attending STD clinics participated in this study. Questionnaire items were designed to measure nine domains of predictors of condom use. RESULTS: Principal components analysis was employed to reduce the number of potential predictors. Reliability of the multiple-item scales was assessed using Cronbach's alpha. Pearson's correlation coefficients were calculated to evaluate collinearity among multi-item scales. Approximately half (51%) of the questionnaire items that were analyzed were retained in the final scales. Data reduction procedures identified several multi-item scales with acceptable reliability (Cronbach's alpha >0.70). The correlation coefficients between scales was never >.5, suggesting that there was little collinearity among the scales. CONCLUSIONS: When focused on multiple partially interdependent determinants of an outcome, data reduction decreases the number of independent variables to be evaluated, ensures they have adequate reliability, maximizes strength of their association with outcomes, and reduces collinearity among predictors.