- Email: [email protected]
Acceptability of the female condom in Zimbabwe: Positive but male-centred responses
Sunanda Ray, Mary Bassett, Caroline Maposhere, Portia Manangazira, Jo Dean Nicolette, Roderick Machekano and Josephine Moyo An acceptability study of the female condom was carried out in Zimbabwe among sex workers @IS), urban women attending a family planning clinic in Harare (84), and rural women (23). Their main reason for trying this new method was as protection from sexually transmitted infections, including HIV. Over 50per cent of the women in all three groups said that they and theirpartners liked the condom very much and preferred it to the male condom. Less than loper cent did not like it. The main problems were with the inner ring and too much lubrication, but questions remain on sustainability, and cost is a major obstacle. Further, even though it did not interfere with the women’s sexual pleasure, most of the reasons for liking the method were male-centred.
IMBABWE has experienced a rapid rise in HIV seroprevalence in the past ten years. In 1985 the National Blood Transfusion Service began testing volunteer blood donors and in 1986 found over two per cent to be HIV positive.’ Current estimates of infection rates among adults are between 15-25 per cent.2-4 There are two main directions that national HIV/STD prevention strategies have taken: first, to promote fidelity within marriage, and second, to encourage condom use, especially in extra-marital sex. Condoms were not previously widely promoted for contraception in Zimbabwe.5 In a study among factory workers in Harare, 24 per cent of married men reported using condoms with their wives, compared with 44 per cent who used them with sex workers and 36 per cent who used them in other extra-marital affairs.4 Even though there have been encouraging signs of better acceptance of male condoms in many areas,6s7 many women still feel unable to negotiate for protection from sexually transmitted infections. There has therefore been increasing demand from women for safer sex methods that they can initiate, as an alternative to a method that requires male consent and initiative.
As the special vulnerabilities of women to infection with HIV were identified, women’s health activists began to hold HIV prevention discussions with groups of women to encourage them to protect themselves. Members of the Women and AIDS Support Network kept coming up against the same barrier - that women found it impossible to bring up the issue of safer sex in their marriages and relationships, in particular to ask their partners to use condoms. Even though the contradictions and double standards were recognised, it was considered to be going against tradition for wives to openly address their husbands’ infidelity. It was too confrontational or accusatory and implied lack of trust. Women often asked why doctors could not design a female condom, one that women could use. During these discussions it was apparent that the women were asking for something comparable to injectable contraception, something invisible that they could use without their partners knowing, which would protect them from infection. Then a female condom was developed in Europe, but it was far from invisible and needed the cooperation of both players. The female condom is a 17cm long poly-
Reproductive
urethane tube with an outer and inner ring. The inner ring anchors the condom at the top of the vaginal canal around the cervix, while the outer ring covers the vulva and prevents the condom from slipping up the vagina. The condoms are supplied with their own lubrication, which plays an essential role in the mechanical functioning of the device during intercourse. Laboratory tests show that female condoms are an effective barrier against HIV and other STDS,*,~and are less likely to leak than latex condoms for men.” There is no evidence of trauma to the lower genital tract in women having frequent sexual intercourse who use them.l’ Their contraceptive efficacy and continuation of use is similar to that of other barrier methods for women.12 There have been mixed reactions to the method in European studies,13,14 but this is among women who, in the main, have wider choices with more power and expectations in their relationships. Studies from Thailand35,16 and Cameroon” describe more promising reactions, but these have mainly been carried out among sex workers. Low income AfricanAmerican women in the USA endorsed the female condom because it allowed them control over a safer sex practice without challenging the power of their male partners.l* We believed the female condom might offer an alternative that women in Zimbabwe could use. An appropriate first step seemed to be an acceptability study among different groups of women, to see whether it was liked or not and whether women could negotiate its use. This was done through the Zimbabwe AIDS Prevention Project and the Department of Community Medicine at the University of Zimbabwe Medical School.
BACKGROUND AND SETTING Zimbabwe is a small landlocked country in Southern Africa with a population of 10.4 million. The main route of transmission of HIV in Zimbabwe is heterosexual. There have been 38,552 cases of AIDS reported through the Ministry of Health, I9 but the real figure is estimated to be 90,000, with a million people infected with HIV. The ratio of male to female cases is 1.3 to 1 but there is considerable underreporting of AIDS in women, especially in the
Health Matters,
NO 5, May 1995
rural areas. In many other countries in the region, there are more women infected than men.20~21 Sentinel surveys in urban and rural areas of Zimbabwe in 1993 showed HIV seropositive rates of 14-40 per cent in women attending antenatal clinics and 50-60 per cent of patients attending for STD treatment (both male and female).2
THE STUDY The study was conducted among volunteers from three different groups of women: sex workers, urban women and rural women. The sex workers were women involved in a peer education programme in Masvingo, a provincial town in southern Zimbabwe, which recruits sex workers to promote condom use and to give HIV/AIDS information in bars and beerhalls. The women meet together every week to share information and report on their activities. A second group of sex workers were recruited at a later date. Approximately 30 of the women in the second group were also in the first group. The fact that so many of them took part in both the first and second recruitment was an indication of their desire to continue having access to the method. The urban women were attending the family planning unit attached to Harare Central Hospital. The third group of women were mainly peasants in a rural area of western Zimbabwe (Gokwe) who were participating in an HIV/ AIDS needs assessment research project. These women were all either married or in stable, longterm relationships.** The condom was shown and explained to each group by a research nurse. It was explained that the device was not being tested as a contraceptive device and women wanting to avoid pregnancy needed to use some other method which would not interfere with the study (eg. oral contraception, sterilisation, or an IUD). The women were then invited to volunteer for the study. Women were eligible if@they were sexually active, over 18 years of age and able to give informed consent. They were excluded if they had any anatomical abnormality or pelvic problem which might have interfered with proper use of the female condom (eg. uterine prolapse or severe genital warts).
Ray, Bassett, Maposhere,
Manangazira,
Nicolettc,
Machekano
Those who volunteered were not paid for participation. Incentives to participate in the study included free clinical examinations and treatment of symptomatic sexually transmitted diseases, reimbursement of travel costs, and refreshments at the follow-up sessions. Volunteers were counselled, given a pelvic examination and shown how to fit the condom, on an individual basis. If they wanted to proceed with the trial, they gave written consent and were interviewed using an enrolment baseline questionaire. The questionnaire had closed responses and asked for socio-demographic data, and about knowledge of HIV transmission and perceived personal risk (see Table 2). They were then given a supply of male and female condoms. Participants from all three groups were followed up on two subsequent occasions. Both times, we used the same questionaire and gave the women a further supply of condoms. The first group of sex workers were followed up after one week and then after a further week. The questionaires used elicited specific informa-
Table 1. Baseline
data on women
enrolled
Characteristic
and Moyo
tion on commercial sex work, including cliem behaviour and attitudes to the female condoms The second group of sex workers were followec up similarly after one month. A longer period 01 follow up was allowed with the second recruit: ment to get a better idea of sustainability. The urban women were followed up for two consecutive weeks at the family planning unit and then involved in focus group discussions. Those who did not attend the unit for follow up were visited at their home addresses. They were considered lost to follow up if they could not be found after the third attempt. With the rural group there was a longer interval for follow up because many of them did not have much opportunity to use the condoms, as their husbands were away working in urban centres. Hence, we saw them twice but only used the questionnaire once. There were far fewer women in both the sex workers group and the urban group (48 per cent and 25 per cent respectively of those originally recruited) at second follow up because many had travelled to the rural areas or were away for
in the female
condom
Sexworkers-two
groups
N&g Mean age (years)
acceptability Urban women N&l
study Ruralwomen N=23
29.7
29.3
28.0
Range (years)
19-59
i a-45
15-44
Numbermarried
10%
82%
Number divorced
83 %
67 %
5%
0
72%
89 %
96 %
88 %
76%
57 %
Refusal by partners to use male condom
62 %
45%
22 %
Self-reported
46%
13%
4%
Number with dependent
children
Mean years in commercial
sex
3-9
Number
O-4 5-9
57 % 27 %
Ever-use
clients perweek of male condom
history of STD in past year
_
Knows person with AIDS
37 %
58 96
61 %
feels she could get HIV/AIDS
72%
69 %
70%
Considers
19%
8%
her risk high
Has had HP/test Reason for joining trial-wants First impression
protection
of female condom-OK
First impression-too
big
from STD/HIV
4%
15 %
23 %
4%
84 %
70%
78 %
42%
34%
56 %
28%
23 %
17%
Reproductive
i~mily reasons. A few of the sex workers were &k at the time of follow up. At the end of the follow up for each group, wus group discussions were held with 8-10 par@pants at a time, to get more in-depth information on topics covered by the questionnaire. muse the focus group discussions were done e the end of the second follow up, there may have been a bias towards a more favourable mpnse. In the main, however, the focus group @cussions reinforced the impressions from the westionnaire interviews at the first follow up.
CURRENTCONTRACEPTIVEUSE &&icipants were advised to use other contraception and not to rely on the female condom as a family planning method during the study. However, 53 per cent of the sex workers, 14 per cent of the urban group and 22 per cent of the rural group were not using any other form of contraception. A few of the women in the urban group actively wanted to get pregnant and the family planning unit at the hospital was helping them with fertility problems. At the same time, they wanted to protect themselves against infection. We taught them to identify the fertile period oftheir cycle and, by using the condoms outside the fertile period, to maximise their chances of achieving both objectives.
HISTORY OF MALE CONDOM USE 'fhe majority of sex workers (95 per cent) reported having used male condoms before (ever-use), probably as part of the peer education programme, in which they actively promote condom use and provide free supplies. Of the urban women, 76 per cent had used condoms before. This may also reflect their contact with the family planning service, which often provides condoms along with other contraceptive methods. Those who did not use male condoms gave as reasons that their partners refused (45 per cent) or that they themselves did not like condoms (10 per cent). Of the rural group, 57 per cent had used condoms before. Of those who did not use them, 22 per cent said that their partners refused to use them, while 13 per cent did not like condoms themselves. Male condoms were not available to 8 per cent of the rural and urban women.
Health Matters,
No 5, May 7995
When asked about condom use in the past year, 39 per cent of sex workers, 7 per cent of urban women and 17 per cent of rural women said they always used condoms; 36 per cent of sex workers, 14 per cent of urban women and 4 per cent of rural women had used them for more than half the time; 20 per cent of sex workers, 54 per cent of the urban group and 35 per cent of the rural group had used them for less than half the time.
RESPONSESTOTHEFEMALE
CONDOM
Most of the women in all three groups liked the female condom fairly well or very much, and most preferred it to the male condom. ‘They finished quicker‘ or ‘They took longer to finish’ were both mentioned as benefits! They commented that use became easier with practice. Their responses to the questionnaire at first follow up are shown in Table 2. Trust and power in relationships All three groups of women were able to initiate use of female condoms with their partners by explaining that they were taking part in research or trying out a new family planning method. This was not perceived as threatening or confrontational. With a few exceptions, after discussing it their partners were usually also interested in trying out the method. The majority of women were very appreciative of the condom and at follow up they reported that the vast majority of their partners liked the method and were encouraging them to get more. Only a few partners of urban women objected to the women using the method because they thought it would encourage them to become casual about sex, or because the women would be more in control and no longer have to worry about becoming pregnant or getting an infection. The women’s main reason for wanting to use this method was as protection against infection, because their partners often refused to use male condoms and they could not force them to do so. An overriding problem expressed during discussions with all three groups of women was a deep distrust of their partners. ‘Men sometimes take their condoms intercourse. You can’t rely on them.’ A curious
anxiety
they expressed
off during
was that
rcay, uassett, Maposnere,
Table 2. Response
Initialnumber
Manangazra,
Nxolette,
to female condom
enrolled
Number followed up (%) Time interval to follow
up
Mean number of female condoms
used
Machekano
and Moyo
at first follow up Sex workers
Sex workers
Group 1
Group 2
59
54
59 (100%) 1 week 7
Urban
Rural
84
24
54 1100%)
62 (74%)
18 (75%)
1 month
1-2 weeks
20
3 months
5
10 F_
General
reaction
- Liked very much
88 %
93 %
56 %
- Likedfairlywell
12 %
4%
39 %
0
74 96
100 46
- Steady partners
liked it
100 %
92 % IN=261
91 %(N=33)
- Clients liked it
82 % (N=39)
68 % (N=22)
Liked it better than male condom
81 %
91 %
66 %
100 %
- Liked it very much
76 96
98 %
53 %
100 %
- Liked it fairly well
24 %
35 %
_
Fits (right size)
78 %
93 %
74 %
100 %
92 %
93 %
97 46
100 %
8 %
6%
2%
0
- Very easy
66 %
94%
61 %
100 %
- Fairly easy
24 %
0
26 %
0
- Difficult
10 %
4 %
11 %
0
Material
Method
of insertion
- Using inner ring - Condom on penis
Easeof
_
insertion
Lubrication - Not enough
7 96
0
5%
0
- Just right
76 %
82 96
61 %
94 %
- Too much
17 %
17 %
31 %
6%
Condom stayed in place
76 %
76 %
74 %
89 %
Use became
89 %
98 %
92 %
easier with practice
100 % _
Easy to remove
85 %
98 %
79 %
_
- Inner ring problematic
2%
1%
3 %
0
- Outer ring problematic
2%
0
2%
0
0
0
0
0
1 %
9%
1%
0
Specific
problems
Breakage - Penis went between
vaginal wall and condom
- Outer ring was pushed up
3%
6%
10 %
0
- Interfered
0
0
11 %
0
with sex
l-4
Reproductive
their partners sometimes made pinholes or tears in male condoms, even through the packets. They said this was because their partners wanted to cheat them, that they did not consider the women really to belong to them unless they ‘left something behind. This gave the women the feeling that their partners were protecting themselves, but not worrying about protecting the women. The female condom was more appealing in this context because the women kept them, opened the packets and inserted the condom themselves. Very few of the women felt they could rely on their men to protect them, or to act in their best interests, or to be as careful as they themselves would be. With the female condom, they felt more confident because they inserted the condom themselves and they did not have to rely on their partners to do it. ‘We never see our men putting the condoms on, they turn away and hide themselves from us, and usually it is in the dark anyway. All we know is that these male condoms break very often and we are suspicious they have been tampered with.’ The women felt more protected with female condoms because they looked stronger and were unlikely to break. Many of the women were used to inserting water, cloths, and herbs into their vaginas in preparation for sexual intercourse and were familiar with how their vagina and cervix felt. Using female condoms became easier with practice and the majority felt that the method did not interfere with their sexual pleasure. Some of the women complained that the male condom was sometimes too small, leading to it breaking or being too tight for the man. None of them had these complaints about the female condom, which was perceived to ‘fit all sizes’. An added advantage mentioned by many women was that they liked to use the condoms when they were menstruating.
Main problems experienced Because practically all the women came for the first follow up, the range and incidence of the problems they described and the solutions they tried were more representative than at the second follow up,23 The urban group had more problems with the method overall, but they also
Health Matters, No 5, May 1995
used fewer condoms on average than the other groups. The main complaints from all three groups were initial difficulty of insertion (which became easier with practice), that the inner ring was uncomfortable, that there was too much lubrication and that they were afraid during sex that the outer ring might get pushed up during intercourse (see Table 2).
Znner ring Among the most common complaints was that the inner ring felt uncomfortable during intercourse. This was more likely if the condom was not positioned so that the inner ring was anchored around the cervix (as with a diaphragm). We corrected this by again demonstrating how to insert the condom or by advising the woman to remove the inner ring after insertion. A few women solved this problem themselves by removing the inner ring and using their partners’ penis as an insertor.
Outer ring Many women expressed anxiety that the outer ring would get pushed up into the vagina during penetration, and some reported that they held on to the ring because of this. The information sheet that comes with the device addresses this issue. It recommends that more lubrication should be added inside the condom or directly onto the penis, in order to reduce friction between the condom material and the penis, and to assist the mechanics of penetration. We made the analogy to a car piston which needs plenty of oil to move smoothly in the cylinder! This was tried by some women with good results.
Lubrication
and dry sex
Most women felt that there was adequate lubrication, which made the condom easy to insert and made sex enjoyable. Others felt there was too much lubrication, which potentially creates a problem about comfort during use. The whole issue of ‘dry sex’ practices is a complex one. These are widespread in East and Southern Africa and have only recently been describea openly. Women usually say they use vaginal drying agents because their men want them to, but these practices may themselves contribute to transmission of STDs and HIV.26,27Nothing has been published to date on what men actually feel about dry sex and why it is important for them.
Ray, Bassett,
Maposhere, Manangazira, Nicolette, Machekano and Mayo
Another study in Harare, which is following up a cohort of factory workers, has done a small pilot survey with a group of 15 men to find out their views on these practices.24 Most of the 15 men said they found women’s vaginal fluids distasteful and a sign of ‘uncleanliness’ rather than a sign of arousal: ‘I don’t like it because diseases, like STDs. ’
those
fluids give you
because their clients adamantly refused to wear male condoms. They agreed that the female condom gave them an alternative, which they could insert themselves, but at least most of the time they still needed their partners’ willingness. (Sometimes the men were too drunk and did not seem to notice it was there.) This was why some commented that they only had the confidence to use it with their regular partners initially. However, as they got used to the device, and because their clients seemed interested, they were able to use the female condoms more openly with clients. The sex workers sometimes saw other advantages of the female condom with clients. As one sex worker said:
Many of the men said they had asked their partners to sort themselves out, often sending them to female relatives to learn the techniques. Substances used vary from cold water and towels, to toothpaste, antiseptic and balm, as well as many traditional herbs. This was especially the case after childbirth. The men also felt it was easier to discuss this with their girlfriends than their wives, but they also expected their wives to perform these practices. Certain sex workers have developed good reputations as women who use a certain type of stone, which makes them ‘as tight as a virgin even though you know she isn’t!’ We found that it was not only tightness that was desirable, but also that the vaginal fluids would be removed. Several men mentioned that if they found a woman to be wet during sex, it made them suspicious of who had been there before them. This was the case not only with sex workers, but also with their wives.
A few were worried about the cosmetic effect of the outer ring hanging outside, that the sight would ‘put off’ their clients. A few others were concerned that having the outer part covering the vulva might interfere with foreplay. On the other hand, about half the sex workers appreciated the fact that the condom was conspicuous and protected the vulva from contact with possible open sores. Most clients were curious to try this new condom. Only one client remarked:
‘If you find a woman too easy to penetrate, shows she has been used a lot.. ’
‘I don’t want this plastic bag, give me a proper condom.’
it
‘Those fluids make a woman too big, like a river, then you think she is like a prostitute.. . ’ The men admitted that using a condom meant that they did not have to come into contact with these fluids, but at the same time, they said they missed that ‘skin to skin’ contact.
SPECIAL ISSUES FOR SEX WORKERS In the sex workers’ group, 55 per cent used the condom with their regular partners (boyfriends) only, 25 per cent used them with clients only, and 20 per cent used them with both. Almost all the sex workers had been forced at one time or another to have unprotected sex
‘With male condoms, men take longer to ejaculate and this is more tiring if we see many men in one day. ’
After using it, though, he too was interested in continuing to use female condoms. Enthusiasm did not decrease; in fact, many men continued to ask for the female condom in preference to the male condom. Some of the sex workers reported being forced to have unprotected sex because they were unable to get hold of any more female condoms when our supplies ran out, and their male partners were no longer willing to accept male condoms.
RELUCTANCE TO RE-USE The manufacturers of the female condom clearly state that female condoms are for use once only. However, there has been concern that the high
Reproductive
cost of the device would encourage women to wash and re-use them. In fact, in our groups there was a reluctance to re-use the condoms, even after washing, due to concerns about hygiene, and that partners would object and refuse to have sex if they suspected this had been done. Sex workers were uneasy about using the same condom with different men. The idea that the semen of different men might somehow get mixed together was very offensive to them (most sex workers said that they douched after every sexual act). One sex worker suggested that she could keep a separate condom for each of her regular clients. One woman said she had tried to wash hers a few times, but the material became hard and seemed more likely to crack.
MALEPARTNERSRESPONSESAS REPORTEDBYTHEWOMEN Of the urban group, 74 per cent said that their steady partners liked the female condom compared to 100 per cent of the rural group. Of the sex workers, 92 per cent said that their steady partners liked the female condom and 77 per cent that their clients also liked it (see Table 2). The main reasons that the majority of men were said to prefer the female condom over the male condom were as follows:
Putting it on Women often inserted the female condom at the beginning or before initiation of sex, so that there was no interruption. Men liked the fact that they were no longer responsible for protection, and that the women had something to use, especially if the men were drunk. Some women commented that men did not like using male condoms, because it became more obvious when they did not have a full erection, which was humiliating but common - especially with the effects of alcohol. Female condoms did not feel tight or constricting, especially at the base of the penis. ‘Because the material is soft, it does not interfere with his erection which is something every man worries about.’
Taking it off Some women commented that their partners liked not having to withdraw from the vagina
Health Matters, No 5, May 1995
immediately after ejaculation, as with the male condom, and that they could fall asleep still inside the woman. ‘After all, that is the place you most want to be when you fall asleep.’ The women liked this freedom also, reporting that they were often anxious when using the male condom, that if the man did not withdraw straightaway, there would be leakage of semen, which would still put them at risk of pregnancy or infection.
NEWSOURCEOFPROTECTIONBUTTOO LATEFORSOME We offered all the women treatment for STDs on a symptomatic basis or if we found they had abnormal discharges when we were showing them how to fit the condoms. We also offered HIV testing with pre- and post-test counselling to the second group of sex workers if they wanted it. Of the 45 women who requested testing and gave written consent, 41(91 per cent) were found to be HIV positive on two ELBA tests. There was a strong denial of risk among the women in this group. They had been feeling so pleased with themselves, especially since they had been trying to protect themselves for some time by using condoms and now they had successfully used this new type of condom and even liked it better. The fact that they had already been exposed and had HIV was highly distressing for them, as well as for the research team. In post-test counselling, they were advised to continue using condoms to protect themselves from STDs and to protect their partners.
DISCUSSION This study shows that women and their partners in different settings and kinds of sexual relationships are very interested in using female condoms to prevent sexually transmitted infections. Although most women reported that the device did not interfere with their sexual pleasure, most of the reasons they gave for liking this new * method were male-centred. Even though participation in research was used as the initial justification for introducing female condoms into relationships, most men were very willing to continue using them for protection against STDs. However, without this initial justification, it is unclear how much
Ray, Bassett,
Maposhere,
Manangazira,
Nlcolette,
Machckano
and Moyo
AIDS poster, Harat-e
Kcproductlvc
difficulty women will have convincing their partners to try using it. More research is needed in the whole area of negotiation between men and women. A major barrier to negotiating safer sex is the communication gap between partners and the distrust they feel for each other, as demonstrated in this and other studies.25 We conducted several feedback sessions for the communities who took part in the research, and for policymakers and other interested groups of men and women on what we learned in this study. The discussions which took place as a result did a lot to open up issues relating to sexuality and negotiation which in themselves have proven useful and progressive. Few problems were reported in use of the female condoms, but these may well affect sustainability in the long term for some women, possibly those with the least negotiating power. One was too much lubrication, in the context of the widespread use of vaginal drying agents in preparation for sex. Reasons why these practices are encouraged by both men and women need elucidation and challenge, for in many ways they reflect the power imbalance in relationships between men and women. Further, changing men’s and women’s attitudes towards drying agents may be necessary for female condoms to be accepted and used effectively by some groups. Such attitudes may also influence whether other promising anti-HIV agents - such as microbicides in gel, foam or other form - will prove to be acceptable. Since such agents would be less obtrusive than female condoms, they could provide a good opportunity for protection for women. It would be very unfortunate if, being a form of lubricant, these were less acceptable because of the demand for dry sex. It should also be remembered that similar problems apply to the use of male condoms and are not specific to female barrier methods. As one author has pointed out, instructions for male condom use carry many assumptions, including that the user has three hands!zR She found that two thirds of her volunteer group of male condom users sometimes or often lost their erection while putting on a condom, and nearly as many lost their erection during intercourse, a situation often not acknowledged or dealt with in health promotion. All barrier methods need practice for users to be comfortable with them
Health Matters,
No 5, May 7995
and educators have to provide encouragement for users to persist until they do feel comfortable with them. Prevention of sexually transmitted diseases, including HIV, depend on consistent use of condoms, whether male or female.2g Both the infected and the uninfected have to be highly motivated not to share the infection. Knowledge of one’s risk can provide some of that motivation.4 The high prevalence of HIV among sex workers in our study is comparable to other studies from the region. In the past year, 13 per cent of the urban women, one of the rural women and 46 per cent of the sex workers self-reported having an STD. It is worrying that only 19 per cent of the sex workers in this study identified themselves as being at high risk. Studies in Nairobi showed a rapid increase in HIV prevalence amongst sex workers from 4 per cent in 1981 to 85 per cent in 1987 who were already infected.30 The female condom is the only proven barrier method against HIV at present which is initiated by women, even though it still requires male willingness to use it. Other writers have commented that women can justify use of this method solely on the basis of personal responsibility for contraception, which facilitates the negotiation processz5 This study shows that it is acceptable as a device both for women and men in different settings. However, whether it is used in a sustained and consistent fashion, so that it is effective over a period of potentially long years as a barrier to STD/HIV, depends on availability and affordability, perception of personal risk and ongoing insistence on and belief in protection of self and others. Our reality in Zimbabwe is that when this research project was over, female condoms were no longer available to ordinary women (that is, women who cannot afford to pay the high prices presently charged in Europe) even though they are clearly vulnerable to infection and do not have the power or the resources to protect themselves. The main obstacle to wider use of the female condom is the cost. The women were prepared to pay a maximum of around 25 Zimbabwean cents (US$ 0.03) per condom. In comparison, at the time of the study male condoms were being sold for 10 Zimbabwean cents each, though they are currently being given out free from government
Ray, Bassett, Maposhere,
Manangazira, Nicolette, Machekano and Moyo
and municipality primary health care clinics. Some of the rural women asked for the condoms to be sold from the local hospital. Sufficient demand for use as protection against STD/HIV infection, on the same scale as for the male condom, should encourage manufacturers to bring the price down. The World
Health Organization and other international bodies also have to play their part in facilitating availability for all women, not only for sex workers. At present, when subsidies are discussed, it is mainly for use by sex workers, who are still seen by donor agencies as ‘reservoirs of infection’. Costs of treatment for STDs among sex workers, their partners, their clients and their clients’ partners have to be considered when the sums are done, as well as the short and long term costs of HIV/AIDS to the people and the economy of a country.
Acknowledgements The authors would like to thank staff at the Zimbabwe AIDS Prevention Project, in particular, research nurses Verna Mzezewa, Tana Mashingaidze and Magda Kurangwa, who conducted many of the interviews; Patricia Mbetu and Mary Sandasi from the Women and AIDS Support Network Zimbabwe, for assistance with counselling; and Zimbabwe National Family Planning Council and Masvingo City Health Department for use of their facilities.
Note This study was funded by the Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, who also supplied the female condoms from Chartrex. Additional support and resources came from the Zimbabwe AIDS Prevention Project, which is funded by a PAVE US Public Health Service Award.
References HIV & AIDS Surveillance Report. Annual Report Ministry of Health and Child Welfare, Zimbabwe, 1992. HIV & AIDS Surveillance Quarterly Report (Ott-Dee 1993). Ministry of Health and Child Welfare, Zimbabwe. A sentinel survey is a study among random samples of well-defined and accessible groups, e.g. antenatal clinic attenders or all hospital patients, to get an idea of the rate of infection in the wider population. Mahomed K, Kasule J, Makuyana D et al, 1991. Seroprevalence of HIV infection amongst antenatal women in greater Harare, Zimbabwe. Central African Journal of Medicine. 37:322-25.
Mbizvo MT, Ray S, Bassett M et al, 1994. Condom use and the risk of HIV infection: who is being protected? Central African Journal of Medicine. 40(11):294-99.
A situation analysis of the family planning programme.
Zimbabwe National Family Planning Council &The Population Council’s Africa OR/TA Project, March 1992. Perez IM, 1989. HIV/AIDS prevention in Africa: Support Programme, Zimbabwe. Consultant Report. John Hopkins University. Institute for International Programmes. 20 November. Williams G and Ray S, 1993. Work against AIDS: workplace based AIDS initiatives in Zimbabwe. Strategies for Hope
Series 8. AIDS Action UK and AMREF Kenya. Drew LW, Blair M, Miner RC et al, 1990. Evaluation of the virus permeability of a new condom for women. Sexually Transmitted Diseases. 17(ApriIJune):llO-12. Rosenberg, MJ, Davidson, AJ, Chen, J-H et al, 1992. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female dependent methods and condoms. American Journal of
Public Health. 2(5):669-74. 10. Leeper MA and Conrardy M, 1989. Preliminary evaluation of Reality, a condom for women to wear. Advances in Contraception. 5:229-35. 11. Soper DE, Brockwell, NJ, Dalton
HP, 1991. Evaluation of the effects of a female condom on the female lower genital tract. Contraception.
44(1):21-29.
lP.Trussell J, Sturgen K, Strickler, J et al, 1994. Comparative contraceptive efficacy of the female condom and other barrier methods. Family Planning Perspectives. 26(2). 13. Bounds W, 1988. A female
condom (Femidom): A study of its user acceptability. British Journal of Family Planning. 14:83-87. 14. Bounds W, 1992. Female
condom (Femidom). A clinical stu’dy of its use-effectiveness and patient acceptability. British Journal of Family Planning. 18:36-41. 15. Jivasak-Apimas
S, 1991. Acceptability of the vaginal
Reproductivu Health Matters, No 5, May 1995
sheath (Fernshield) in Thai couples. Contraception. 44:18390. 16. Sakondhavat
C, 1990. The female condom (letter).
American Journal of Public Health. 80:498. 17. Monny-Lobe,
Tchupo PJ, Turk T, et al, 1991. Acceptability of the female condom among a highrisk population in Cameroon.
Family Health International, November. 18. Shervington DO, 1993. The acceptability of the female condom among low-income African-American women. Journal of the National Medical Association. 85(5):341-47.
lS.HIV/AIDS Surveillance Quarterly Report, Ott-Dee 1994. Ministry of Health & Child Welfare, Zimbabwe. 20. Berkley S, Naamara W, et al, 1990. AIDS &HIV infection in Uganda: are more women infected than men? AIDS. 4(12):1237-42.
21 Borgdorff M. Epidemiology
of HIV-l infection in Mwanza region, Tanzania. Royal Tropical Institute, Amsterdam. 22 HIV/AIDS Information Needs: Assessment 1993-94. Women and AIDS Support Network. (Unpublished) 23. Both the sex workers and the urban women who came to the second follow up had similar, but overall more favourable responses (data not shown). It is difficult to say whether this is because they had more practice with the condoms or because of a selection bias among those who had made the effort to come for the second follow up. 24. Ray S and Gumbo N. Attitudes towards vaginal drying agents among male factory workers in Harare, Zimbabwe. Zimbabwe AIDS Prevention Project. [Unpublished) 25.Gollub E and Stein AZ, 1993. The new female condom-item 1 on a women’s AIDS prevention
R&SUMB Une Ctude sur I’acceptabilitC du prhservatif fkminin a &tC menke au Zimbabwe chez des prostitukes, des citadines frkquentant un dispensaire de planification familiale ti Harare, et des paysannes. La principale raison les incitant g essayer cette nouvelle mkthode a tS de se protkger des maladies sexuellement transmissibles, y compris l’infection ti VIH. Dans chaque groupe, plus de la moitik des femmes ont dit qu’elles-m&mes et leurs partenaires apprtciaient fort ce prkservatif, et le prkfiraient au prfkervatif masculin. Moins de 10% ne l’ont pas aim& Les principaux problkmes venaient de l’anneau intkrieur et d’un excks de lubrication, mais des questions demeurent sur la fidClitC ?I la mkthode, et le prix constitue un obstacle majeur. En outre, m&me si ce prkervatif n’interfkre pas avec le plaisir sexuel de la femme, la plupart des raisons citCes en faveur de la mkthode concernaient l’homme.
agenda. American Journal of Public Health. 83(4). 26. Runganga A, Pitts M, and McMaster J, 1992. The use of herbal and other agents to enhance sexual experience. Social Science & Medicine. 35(8):1037-42. 27. Brown, JE, Ayowa OB, and Brown RC, 1993. Dry and tight: sexual practices and potential AIDS risk in Zaire. Social Science & Medicine. 37(8):98994. 28. Richters J, 1994. Researching condoms: the laboratory and the bedroom. Reproductive Health Matters. 3(May):55-62. 29. Johnson AM, 1994. Condoms and HIV transmission. New EnglandJournal 331(6):391-92.
ofMedicine.
30. Padian N, 1988. Prostitute
women and AIDS: epidemiology. AIDS. 2(62):413-19.
RESUMEN En Zimbabue se llev6 a cabo un estudio de aceptabilidad de1 conddn femenino entre trabajadoras de1 sexo, mujeres de la ciudad que acudian a una clinica de planificacibn familiar en Harare, y mujeres de1 campo. La principal raz6n por la cual probaron este nuevo mktodo fue la necesidad de proteccidn contra infecciones de transmisibn sexual, entre ellas el VIH. MC& de1 50% de las mujeres en 10s tres grupos expresaron que, tanto a ellas corn0 a sus compafieros, les habia gustado mucho el cond6n femenino y que lo preferian al masculine. Menos del 10% manifestaron que no les habia gustado. Los principales problemas fueron vinculados al aro interior o al exceso de lubricacibn; sin embargo, afin hay dudas sobre su uso a largo piazo, y el costo sigue siendo un obstkulo importante. AOn mk, si bien su uso no interfiri6 con el placer sexual de las mujeres, la mayoria de las razones a favor de1 mktodo estaban centradas en cl hombre.
IMBABWE has experienced a rapid rise in HIV seroprevalence in the past ten years. In 1985 the National Blood Transfusion Service began testing volunteer blood donors and in 1986 found over two per cent to be HIV positive.’ Current estimates of infection rates among adults are between 15-25 per cent.2-4 There are two main directions that national HIV/STD prevention strategies have taken: first, to promote fidelity within marriage, and second, to encourage condom use, especially in extra-marital sex. Condoms were not previously widely promoted for contraception in Zimbabwe.5 In a study among factory workers in Harare, 24 per cent of married men reported using condoms with their wives, compared with 44 per cent who used them with sex workers and 36 per cent who used them in other extra-marital affairs.4 Even though there have been encouraging signs of better acceptance of male condoms in many areas,6s7 many women still feel unable to negotiate for protection from sexually transmitted infections. There has therefore been increasing demand from women for safer sex methods that they can initiate, as an alternative to a method that requires male consent and initiative.
As the special vulnerabilities of women to infection with HIV were identified, women’s health activists began to hold HIV prevention discussions with groups of women to encourage them to protect themselves. Members of the Women and AIDS Support Network kept coming up against the same barrier - that women found it impossible to bring up the issue of safer sex in their marriages and relationships, in particular to ask their partners to use condoms. Even though the contradictions and double standards were recognised, it was considered to be going against tradition for wives to openly address their husbands’ infidelity. It was too confrontational or accusatory and implied lack of trust. Women often asked why doctors could not design a female condom, one that women could use. During these discussions it was apparent that the women were asking for something comparable to injectable contraception, something invisible that they could use without their partners knowing, which would protect them from infection. Then a female condom was developed in Europe, but it was far from invisible and needed the cooperation of both players. The female condom is a 17cm long poly-
Reproductive
urethane tube with an outer and inner ring. The inner ring anchors the condom at the top of the vaginal canal around the cervix, while the outer ring covers the vulva and prevents the condom from slipping up the vagina. The condoms are supplied with their own lubrication, which plays an essential role in the mechanical functioning of the device during intercourse. Laboratory tests show that female condoms are an effective barrier against HIV and other STDS,*,~and are less likely to leak than latex condoms for men.” There is no evidence of trauma to the lower genital tract in women having frequent sexual intercourse who use them.l’ Their contraceptive efficacy and continuation of use is similar to that of other barrier methods for women.12 There have been mixed reactions to the method in European studies,13,14 but this is among women who, in the main, have wider choices with more power and expectations in their relationships. Studies from Thailand35,16 and Cameroon” describe more promising reactions, but these have mainly been carried out among sex workers. Low income AfricanAmerican women in the USA endorsed the female condom because it allowed them control over a safer sex practice without challenging the power of their male partners.l* We believed the female condom might offer an alternative that women in Zimbabwe could use. An appropriate first step seemed to be an acceptability study among different groups of women, to see whether it was liked or not and whether women could negotiate its use. This was done through the Zimbabwe AIDS Prevention Project and the Department of Community Medicine at the University of Zimbabwe Medical School.
BACKGROUND AND SETTING Zimbabwe is a small landlocked country in Southern Africa with a population of 10.4 million. The main route of transmission of HIV in Zimbabwe is heterosexual. There have been 38,552 cases of AIDS reported through the Ministry of Health, I9 but the real figure is estimated to be 90,000, with a million people infected with HIV. The ratio of male to female cases is 1.3 to 1 but there is considerable underreporting of AIDS in women, especially in the
Health Matters,
NO 5, May 1995
rural areas. In many other countries in the region, there are more women infected than men.20~21 Sentinel surveys in urban and rural areas of Zimbabwe in 1993 showed HIV seropositive rates of 14-40 per cent in women attending antenatal clinics and 50-60 per cent of patients attending for STD treatment (both male and female).2
THE STUDY The study was conducted among volunteers from three different groups of women: sex workers, urban women and rural women. The sex workers were women involved in a peer education programme in Masvingo, a provincial town in southern Zimbabwe, which recruits sex workers to promote condom use and to give HIV/AIDS information in bars and beerhalls. The women meet together every week to share information and report on their activities. A second group of sex workers were recruited at a later date. Approximately 30 of the women in the second group were also in the first group. The fact that so many of them took part in both the first and second recruitment was an indication of their desire to continue having access to the method. The urban women were attending the family planning unit attached to Harare Central Hospital. The third group of women were mainly peasants in a rural area of western Zimbabwe (Gokwe) who were participating in an HIV/ AIDS needs assessment research project. These women were all either married or in stable, longterm relationships.** The condom was shown and explained to each group by a research nurse. It was explained that the device was not being tested as a contraceptive device and women wanting to avoid pregnancy needed to use some other method which would not interfere with the study (eg. oral contraception, sterilisation, or an IUD). The women were then invited to volunteer for the study. Women were eligible if@they were sexually active, over 18 years of age and able to give informed consent. They were excluded if they had any anatomical abnormality or pelvic problem which might have interfered with proper use of the female condom (eg. uterine prolapse or severe genital warts).
Ray, Bassett, Maposhere,
Manangazira,
Nicolettc,
Machekano
Those who volunteered were not paid for participation. Incentives to participate in the study included free clinical examinations and treatment of symptomatic sexually transmitted diseases, reimbursement of travel costs, and refreshments at the follow-up sessions. Volunteers were counselled, given a pelvic examination and shown how to fit the condom, on an individual basis. If they wanted to proceed with the trial, they gave written consent and were interviewed using an enrolment baseline questionaire. The questionnaire had closed responses and asked for socio-demographic data, and about knowledge of HIV transmission and perceived personal risk (see Table 2). They were then given a supply of male and female condoms. Participants from all three groups were followed up on two subsequent occasions. Both times, we used the same questionaire and gave the women a further supply of condoms. The first group of sex workers were followed up after one week and then after a further week. The questionaires used elicited specific informa-
Table 1. Baseline
data on women
enrolled
Characteristic
and Moyo
tion on commercial sex work, including cliem behaviour and attitudes to the female condoms The second group of sex workers were followec up similarly after one month. A longer period 01 follow up was allowed with the second recruit: ment to get a better idea of sustainability. The urban women were followed up for two consecutive weeks at the family planning unit and then involved in focus group discussions. Those who did not attend the unit for follow up were visited at their home addresses. They were considered lost to follow up if they could not be found after the third attempt. With the rural group there was a longer interval for follow up because many of them did not have much opportunity to use the condoms, as their husbands were away working in urban centres. Hence, we saw them twice but only used the questionnaire once. There were far fewer women in both the sex workers group and the urban group (48 per cent and 25 per cent respectively of those originally recruited) at second follow up because many had travelled to the rural areas or were away for
in the female
condom
Sexworkers-two
groups
N&g Mean age (years)
acceptability Urban women N&l
study Ruralwomen N=23
29.7
29.3
28.0
Range (years)
19-59
i a-45
15-44
Numbermarried
10%
82%
Number divorced
83 %
67 %
5%
0
72%
89 %
96 %
88 %
76%
57 %
Refusal by partners to use male condom
62 %
45%
22 %
Self-reported
46%
13%
4%
Number with dependent
children
Mean years in commercial
sex
3-9
Number
O-4 5-9
57 % 27 %
Ever-use
clients perweek of male condom
history of STD in past year
_
Knows person with AIDS
37 %
58 96
61 %
feels she could get HIV/AIDS
72%
69 %
70%
Considers
19%
8%
her risk high
Has had HP/test Reason for joining trial-wants First impression
protection
of female condom-OK
First impression-too
big
from STD/HIV
4%
15 %
23 %
4%
84 %
70%
78 %
42%
34%
56 %
28%
23 %
17%
Reproductive
i~mily reasons. A few of the sex workers were &k at the time of follow up. At the end of the follow up for each group, wus group discussions were held with 8-10 par@pants at a time, to get more in-depth information on topics covered by the questionnaire. muse the focus group discussions were done e the end of the second follow up, there may have been a bias towards a more favourable mpnse. In the main, however, the focus group @cussions reinforced the impressions from the westionnaire interviews at the first follow up.
CURRENTCONTRACEPTIVEUSE &&icipants were advised to use other contraception and not to rely on the female condom as a family planning method during the study. However, 53 per cent of the sex workers, 14 per cent of the urban group and 22 per cent of the rural group were not using any other form of contraception. A few of the women in the urban group actively wanted to get pregnant and the family planning unit at the hospital was helping them with fertility problems. At the same time, they wanted to protect themselves against infection. We taught them to identify the fertile period oftheir cycle and, by using the condoms outside the fertile period, to maximise their chances of achieving both objectives.
HISTORY OF MALE CONDOM USE 'fhe majority of sex workers (95 per cent) reported having used male condoms before (ever-use), probably as part of the peer education programme, in which they actively promote condom use and provide free supplies. Of the urban women, 76 per cent had used condoms before. This may also reflect their contact with the family planning service, which often provides condoms along with other contraceptive methods. Those who did not use male condoms gave as reasons that their partners refused (45 per cent) or that they themselves did not like condoms (10 per cent). Of the rural group, 57 per cent had used condoms before. Of those who did not use them, 22 per cent said that their partners refused to use them, while 13 per cent did not like condoms themselves. Male condoms were not available to 8 per cent of the rural and urban women.
Health Matters,
No 5, May 7995
When asked about condom use in the past year, 39 per cent of sex workers, 7 per cent of urban women and 17 per cent of rural women said they always used condoms; 36 per cent of sex workers, 14 per cent of urban women and 4 per cent of rural women had used them for more than half the time; 20 per cent of sex workers, 54 per cent of the urban group and 35 per cent of the rural group had used them for less than half the time.
RESPONSESTOTHEFEMALE
CONDOM
Most of the women in all three groups liked the female condom fairly well or very much, and most preferred it to the male condom. ‘They finished quicker‘ or ‘They took longer to finish’ were both mentioned as benefits! They commented that use became easier with practice. Their responses to the questionnaire at first follow up are shown in Table 2. Trust and power in relationships All three groups of women were able to initiate use of female condoms with their partners by explaining that they were taking part in research or trying out a new family planning method. This was not perceived as threatening or confrontational. With a few exceptions, after discussing it their partners were usually also interested in trying out the method. The majority of women were very appreciative of the condom and at follow up they reported that the vast majority of their partners liked the method and were encouraging them to get more. Only a few partners of urban women objected to the women using the method because they thought it would encourage them to become casual about sex, or because the women would be more in control and no longer have to worry about becoming pregnant or getting an infection. The women’s main reason for wanting to use this method was as protection against infection, because their partners often refused to use male condoms and they could not force them to do so. An overriding problem expressed during discussions with all three groups of women was a deep distrust of their partners. ‘Men sometimes take their condoms intercourse. You can’t rely on them.’ A curious
anxiety
they expressed
off during
was that
rcay, uassett, Maposnere,
Table 2. Response
Initialnumber
Manangazra,
Nxolette,
to female condom
enrolled
Number followed up (%) Time interval to follow
up
Mean number of female condoms
used
Machekano
and Moyo
at first follow up Sex workers
Sex workers
Group 1
Group 2
59
54
59 (100%) 1 week 7
Urban
Rural
84
24
54 1100%)
62 (74%)
18 (75%)
1 month
1-2 weeks
20
3 months
5
10 F_
General
reaction
- Liked very much
88 %
93 %
56 %
- Likedfairlywell
12 %
4%
39 %
0
74 96
100 46
- Steady partners
liked it
100 %
92 % IN=261
91 %(N=33)
- Clients liked it
82 % (N=39)
68 % (N=22)
Liked it better than male condom
81 %
91 %
66 %
100 %
- Liked it very much
76 96
98 %
53 %
100 %
- Liked it fairly well
24 %
35 %
_
Fits (right size)
78 %
93 %
74 %
100 %
92 %
93 %
97 46
100 %
8 %
6%
2%
0
- Very easy
66 %
94%
61 %
100 %
- Fairly easy
24 %
0
26 %
0
- Difficult
10 %
4 %
11 %
0
Material
Method
of insertion
- Using inner ring - Condom on penis
Easeof
_
insertion
Lubrication - Not enough
7 96
0
5%
0
- Just right
76 %
82 96
61 %
94 %
- Too much
17 %
17 %
31 %
6%
Condom stayed in place
76 %
76 %
74 %
89 %
Use became
89 %
98 %
92 %
easier with practice
100 % _
Easy to remove
85 %
98 %
79 %
_
- Inner ring problematic
2%
1%
3 %
0
- Outer ring problematic
2%
0
2%
0
0
0
0
0
1 %
9%
1%
0
Specific
problems
Breakage - Penis went between
vaginal wall and condom
- Outer ring was pushed up
3%
6%
10 %
0
- Interfered
0
0
11 %
0
with sex
l-4
Reproductive
their partners sometimes made pinholes or tears in male condoms, even through the packets. They said this was because their partners wanted to cheat them, that they did not consider the women really to belong to them unless they ‘left something behind. This gave the women the feeling that their partners were protecting themselves, but not worrying about protecting the women. The female condom was more appealing in this context because the women kept them, opened the packets and inserted the condom themselves. Very few of the women felt they could rely on their men to protect them, or to act in their best interests, or to be as careful as they themselves would be. With the female condom, they felt more confident because they inserted the condom themselves and they did not have to rely on their partners to do it. ‘We never see our men putting the condoms on, they turn away and hide themselves from us, and usually it is in the dark anyway. All we know is that these male condoms break very often and we are suspicious they have been tampered with.’ The women felt more protected with female condoms because they looked stronger and were unlikely to break. Many of the women were used to inserting water, cloths, and herbs into their vaginas in preparation for sexual intercourse and were familiar with how their vagina and cervix felt. Using female condoms became easier with practice and the majority felt that the method did not interfere with their sexual pleasure. Some of the women complained that the male condom was sometimes too small, leading to it breaking or being too tight for the man. None of them had these complaints about the female condom, which was perceived to ‘fit all sizes’. An added advantage mentioned by many women was that they liked to use the condoms when they were menstruating.
Main problems experienced Because practically all the women came for the first follow up, the range and incidence of the problems they described and the solutions they tried were more representative than at the second follow up,23 The urban group had more problems with the method overall, but they also
Health Matters, No 5, May 1995
used fewer condoms on average than the other groups. The main complaints from all three groups were initial difficulty of insertion (which became easier with practice), that the inner ring was uncomfortable, that there was too much lubrication and that they were afraid during sex that the outer ring might get pushed up during intercourse (see Table 2).
Znner ring Among the most common complaints was that the inner ring felt uncomfortable during intercourse. This was more likely if the condom was not positioned so that the inner ring was anchored around the cervix (as with a diaphragm). We corrected this by again demonstrating how to insert the condom or by advising the woman to remove the inner ring after insertion. A few women solved this problem themselves by removing the inner ring and using their partners’ penis as an insertor.
Outer ring Many women expressed anxiety that the outer ring would get pushed up into the vagina during penetration, and some reported that they held on to the ring because of this. The information sheet that comes with the device addresses this issue. It recommends that more lubrication should be added inside the condom or directly onto the penis, in order to reduce friction between the condom material and the penis, and to assist the mechanics of penetration. We made the analogy to a car piston which needs plenty of oil to move smoothly in the cylinder! This was tried by some women with good results.
Lubrication
and dry sex
Most women felt that there was adequate lubrication, which made the condom easy to insert and made sex enjoyable. Others felt there was too much lubrication, which potentially creates a problem about comfort during use. The whole issue of ‘dry sex’ practices is a complex one. These are widespread in East and Southern Africa and have only recently been describea openly. Women usually say they use vaginal drying agents because their men want them to, but these practices may themselves contribute to transmission of STDs and HIV.26,27Nothing has been published to date on what men actually feel about dry sex and why it is important for them.
Ray, Bassett,
Maposhere, Manangazira, Nicolette, Machekano and Mayo
Another study in Harare, which is following up a cohort of factory workers, has done a small pilot survey with a group of 15 men to find out their views on these practices.24 Most of the 15 men said they found women’s vaginal fluids distasteful and a sign of ‘uncleanliness’ rather than a sign of arousal: ‘I don’t like it because diseases, like STDs. ’
those
fluids give you
because their clients adamantly refused to wear male condoms. They agreed that the female condom gave them an alternative, which they could insert themselves, but at least most of the time they still needed their partners’ willingness. (Sometimes the men were too drunk and did not seem to notice it was there.) This was why some commented that they only had the confidence to use it with their regular partners initially. However, as they got used to the device, and because their clients seemed interested, they were able to use the female condoms more openly with clients. The sex workers sometimes saw other advantages of the female condom with clients. As one sex worker said:
Many of the men said they had asked their partners to sort themselves out, often sending them to female relatives to learn the techniques. Substances used vary from cold water and towels, to toothpaste, antiseptic and balm, as well as many traditional herbs. This was especially the case after childbirth. The men also felt it was easier to discuss this with their girlfriends than their wives, but they also expected their wives to perform these practices. Certain sex workers have developed good reputations as women who use a certain type of stone, which makes them ‘as tight as a virgin even though you know she isn’t!’ We found that it was not only tightness that was desirable, but also that the vaginal fluids would be removed. Several men mentioned that if they found a woman to be wet during sex, it made them suspicious of who had been there before them. This was the case not only with sex workers, but also with their wives.
A few were worried about the cosmetic effect of the outer ring hanging outside, that the sight would ‘put off’ their clients. A few others were concerned that having the outer part covering the vulva might interfere with foreplay. On the other hand, about half the sex workers appreciated the fact that the condom was conspicuous and protected the vulva from contact with possible open sores. Most clients were curious to try this new condom. Only one client remarked:
‘If you find a woman too easy to penetrate, shows she has been used a lot.. ’
‘I don’t want this plastic bag, give me a proper condom.’
it
‘Those fluids make a woman too big, like a river, then you think she is like a prostitute.. . ’ The men admitted that using a condom meant that they did not have to come into contact with these fluids, but at the same time, they said they missed that ‘skin to skin’ contact.
SPECIAL ISSUES FOR SEX WORKERS In the sex workers’ group, 55 per cent used the condom with their regular partners (boyfriends) only, 25 per cent used them with clients only, and 20 per cent used them with both. Almost all the sex workers had been forced at one time or another to have unprotected sex
‘With male condoms, men take longer to ejaculate and this is more tiring if we see many men in one day. ’
After using it, though, he too was interested in continuing to use female condoms. Enthusiasm did not decrease; in fact, many men continued to ask for the female condom in preference to the male condom. Some of the sex workers reported being forced to have unprotected sex because they were unable to get hold of any more female condoms when our supplies ran out, and their male partners were no longer willing to accept male condoms.
RELUCTANCE TO RE-USE The manufacturers of the female condom clearly state that female condoms are for use once only. However, there has been concern that the high
Reproductive
cost of the device would encourage women to wash and re-use them. In fact, in our groups there was a reluctance to re-use the condoms, even after washing, due to concerns about hygiene, and that partners would object and refuse to have sex if they suspected this had been done. Sex workers were uneasy about using the same condom with different men. The idea that the semen of different men might somehow get mixed together was very offensive to them (most sex workers said that they douched after every sexual act). One sex worker suggested that she could keep a separate condom for each of her regular clients. One woman said she had tried to wash hers a few times, but the material became hard and seemed more likely to crack.
MALEPARTNERSRESPONSESAS REPORTEDBYTHEWOMEN Of the urban group, 74 per cent said that their steady partners liked the female condom compared to 100 per cent of the rural group. Of the sex workers, 92 per cent said that their steady partners liked the female condom and 77 per cent that their clients also liked it (see Table 2). The main reasons that the majority of men were said to prefer the female condom over the male condom were as follows:
Putting it on Women often inserted the female condom at the beginning or before initiation of sex, so that there was no interruption. Men liked the fact that they were no longer responsible for protection, and that the women had something to use, especially if the men were drunk. Some women commented that men did not like using male condoms, because it became more obvious when they did not have a full erection, which was humiliating but common - especially with the effects of alcohol. Female condoms did not feel tight or constricting, especially at the base of the penis. ‘Because the material is soft, it does not interfere with his erection which is something every man worries about.’
Taking it off Some women commented that their partners liked not having to withdraw from the vagina
Health Matters, No 5, May 1995
immediately after ejaculation, as with the male condom, and that they could fall asleep still inside the woman. ‘After all, that is the place you most want to be when you fall asleep.’ The women liked this freedom also, reporting that they were often anxious when using the male condom, that if the man did not withdraw straightaway, there would be leakage of semen, which would still put them at risk of pregnancy or infection.
NEWSOURCEOFPROTECTIONBUTTOO LATEFORSOME We offered all the women treatment for STDs on a symptomatic basis or if we found they had abnormal discharges when we were showing them how to fit the condoms. We also offered HIV testing with pre- and post-test counselling to the second group of sex workers if they wanted it. Of the 45 women who requested testing and gave written consent, 41(91 per cent) were found to be HIV positive on two ELBA tests. There was a strong denial of risk among the women in this group. They had been feeling so pleased with themselves, especially since they had been trying to protect themselves for some time by using condoms and now they had successfully used this new type of condom and even liked it better. The fact that they had already been exposed and had HIV was highly distressing for them, as well as for the research team. In post-test counselling, they were advised to continue using condoms to protect themselves from STDs and to protect their partners.
DISCUSSION This study shows that women and their partners in different settings and kinds of sexual relationships are very interested in using female condoms to prevent sexually transmitted infections. Although most women reported that the device did not interfere with their sexual pleasure, most of the reasons they gave for liking this new * method were male-centred. Even though participation in research was used as the initial justification for introducing female condoms into relationships, most men were very willing to continue using them for protection against STDs. However, without this initial justification, it is unclear how much
Ray, Bassett,
Maposhere,
Manangazira,
Nlcolette,
Machckano
and Moyo
AIDS poster, Harat-e
Kcproductlvc
difficulty women will have convincing their partners to try using it. More research is needed in the whole area of negotiation between men and women. A major barrier to negotiating safer sex is the communication gap between partners and the distrust they feel for each other, as demonstrated in this and other studies.25 We conducted several feedback sessions for the communities who took part in the research, and for policymakers and other interested groups of men and women on what we learned in this study. The discussions which took place as a result did a lot to open up issues relating to sexuality and negotiation which in themselves have proven useful and progressive. Few problems were reported in use of the female condoms, but these may well affect sustainability in the long term for some women, possibly those with the least negotiating power. One was too much lubrication, in the context of the widespread use of vaginal drying agents in preparation for sex. Reasons why these practices are encouraged by both men and women need elucidation and challenge, for in many ways they reflect the power imbalance in relationships between men and women. Further, changing men’s and women’s attitudes towards drying agents may be necessary for female condoms to be accepted and used effectively by some groups. Such attitudes may also influence whether other promising anti-HIV agents - such as microbicides in gel, foam or other form - will prove to be acceptable. Since such agents would be less obtrusive than female condoms, they could provide a good opportunity for protection for women. It would be very unfortunate if, being a form of lubricant, these were less acceptable because of the demand for dry sex. It should also be remembered that similar problems apply to the use of male condoms and are not specific to female barrier methods. As one author has pointed out, instructions for male condom use carry many assumptions, including that the user has three hands!zR She found that two thirds of her volunteer group of male condom users sometimes or often lost their erection while putting on a condom, and nearly as many lost their erection during intercourse, a situation often not acknowledged or dealt with in health promotion. All barrier methods need practice for users to be comfortable with them
Health Matters,
No 5, May 7995
and educators have to provide encouragement for users to persist until they do feel comfortable with them. Prevention of sexually transmitted diseases, including HIV, depend on consistent use of condoms, whether male or female.2g Both the infected and the uninfected have to be highly motivated not to share the infection. Knowledge of one’s risk can provide some of that motivation.4 The high prevalence of HIV among sex workers in our study is comparable to other studies from the region. In the past year, 13 per cent of the urban women, one of the rural women and 46 per cent of the sex workers self-reported having an STD. It is worrying that only 19 per cent of the sex workers in this study identified themselves as being at high risk. Studies in Nairobi showed a rapid increase in HIV prevalence amongst sex workers from 4 per cent in 1981 to 85 per cent in 1987 who were already infected.30 The female condom is the only proven barrier method against HIV at present which is initiated by women, even though it still requires male willingness to use it. Other writers have commented that women can justify use of this method solely on the basis of personal responsibility for contraception, which facilitates the negotiation processz5 This study shows that it is acceptable as a device both for women and men in different settings. However, whether it is used in a sustained and consistent fashion, so that it is effective over a period of potentially long years as a barrier to STD/HIV, depends on availability and affordability, perception of personal risk and ongoing insistence on and belief in protection of self and others. Our reality in Zimbabwe is that when this research project was over, female condoms were no longer available to ordinary women (that is, women who cannot afford to pay the high prices presently charged in Europe) even though they are clearly vulnerable to infection and do not have the power or the resources to protect themselves. The main obstacle to wider use of the female condom is the cost. The women were prepared to pay a maximum of around 25 Zimbabwean cents (US$ 0.03) per condom. In comparison, at the time of the study male condoms were being sold for 10 Zimbabwean cents each, though they are currently being given out free from government
Ray, Bassett, Maposhere,
Manangazira, Nicolette, Machekano and Moyo
and municipality primary health care clinics. Some of the rural women asked for the condoms to be sold from the local hospital. Sufficient demand for use as protection against STD/HIV infection, on the same scale as for the male condom, should encourage manufacturers to bring the price down. The World
Health Organization and other international bodies also have to play their part in facilitating availability for all women, not only for sex workers. At present, when subsidies are discussed, it is mainly for use by sex workers, who are still seen by donor agencies as ‘reservoirs of infection’. Costs of treatment for STDs among sex workers, their partners, their clients and their clients’ partners have to be considered when the sums are done, as well as the short and long term costs of HIV/AIDS to the people and the economy of a country.
Acknowledgements The authors would like to thank staff at the Zimbabwe AIDS Prevention Project, in particular, research nurses Verna Mzezewa, Tana Mashingaidze and Magda Kurangwa, who conducted many of the interviews; Patricia Mbetu and Mary Sandasi from the Women and AIDS Support Network Zimbabwe, for assistance with counselling; and Zimbabwe National Family Planning Council and Masvingo City Health Department for use of their facilities.
Note This study was funded by the Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, who also supplied the female condoms from Chartrex. Additional support and resources came from the Zimbabwe AIDS Prevention Project, which is funded by a PAVE US Public Health Service Award.
References HIV & AIDS Surveillance Report. Annual Report Ministry of Health and Child Welfare, Zimbabwe, 1992. HIV & AIDS Surveillance Quarterly Report (Ott-Dee 1993). Ministry of Health and Child Welfare, Zimbabwe. A sentinel survey is a study among random samples of well-defined and accessible groups, e.g. antenatal clinic attenders or all hospital patients, to get an idea of the rate of infection in the wider population. Mahomed K, Kasule J, Makuyana D et al, 1991. Seroprevalence of HIV infection amongst antenatal women in greater Harare, Zimbabwe. Central African Journal of Medicine. 37:322-25.
Mbizvo MT, Ray S, Bassett M et al, 1994. Condom use and the risk of HIV infection: who is being protected? Central African Journal of Medicine. 40(11):294-99.
A situation analysis of the family planning programme.
Zimbabwe National Family Planning Council &The Population Council’s Africa OR/TA Project, March 1992. Perez IM, 1989. HIV/AIDS prevention in Africa: Support Programme, Zimbabwe. Consultant Report. John Hopkins University. Institute for International Programmes. 20 November. Williams G and Ray S, 1993. Work against AIDS: workplace based AIDS initiatives in Zimbabwe. Strategies for Hope
Series 8. AIDS Action UK and AMREF Kenya. Drew LW, Blair M, Miner RC et al, 1990. Evaluation of the virus permeability of a new condom for women. Sexually Transmitted Diseases. 17(ApriIJune):llO-12. Rosenberg, MJ, Davidson, AJ, Chen, J-H et al, 1992. Barrier contraceptives and sexually transmitted diseases in women: a comparison of female dependent methods and condoms. American Journal of
Public Health. 2(5):669-74. 10. Leeper MA and Conrardy M, 1989. Preliminary evaluation of Reality, a condom for women to wear. Advances in Contraception. 5:229-35. 11. Soper DE, Brockwell, NJ, Dalton
HP, 1991. Evaluation of the effects of a female condom on the female lower genital tract. Contraception.
44(1):21-29.
lP.Trussell J, Sturgen K, Strickler, J et al, 1994. Comparative contraceptive efficacy of the female condom and other barrier methods. Family Planning Perspectives. 26(2). 13. Bounds W, 1988. A female
condom (Femidom): A study of its user acceptability. British Journal of Family Planning. 14:83-87. 14. Bounds W, 1992. Female
condom (Femidom). A clinical stu’dy of its use-effectiveness and patient acceptability. British Journal of Family Planning. 18:36-41. 15. Jivasak-Apimas
S, 1991. Acceptability of the vaginal
Reproductivu Health Matters, No 5, May 1995
sheath (Fernshield) in Thai couples. Contraception. 44:18390. 16. Sakondhavat
C, 1990. The female condom (letter).
American Journal of Public Health. 80:498. 17. Monny-Lobe,
Tchupo PJ, Turk T, et al, 1991. Acceptability of the female condom among a highrisk population in Cameroon.
Family Health International, November. 18. Shervington DO, 1993. The acceptability of the female condom among low-income African-American women. Journal of the National Medical Association. 85(5):341-47.
lS.HIV/AIDS Surveillance Quarterly Report, Ott-Dee 1994. Ministry of Health & Child Welfare, Zimbabwe. 20. Berkley S, Naamara W, et al, 1990. AIDS &HIV infection in Uganda: are more women infected than men? AIDS. 4(12):1237-42.
21 Borgdorff M. Epidemiology
of HIV-l infection in Mwanza region, Tanzania. Royal Tropical Institute, Amsterdam. 22 HIV/AIDS Information Needs: Assessment 1993-94. Women and AIDS Support Network. (Unpublished) 23. Both the sex workers and the urban women who came to the second follow up had similar, but overall more favourable responses (data not shown). It is difficult to say whether this is because they had more practice with the condoms or because of a selection bias among those who had made the effort to come for the second follow up. 24. Ray S and Gumbo N. Attitudes towards vaginal drying agents among male factory workers in Harare, Zimbabwe. Zimbabwe AIDS Prevention Project. [Unpublished) 25.Gollub E and Stein AZ, 1993. The new female condom-item 1 on a women’s AIDS prevention
R&SUMB Une Ctude sur I’acceptabilitC du prhservatif fkminin a &tC menke au Zimbabwe chez des prostitukes, des citadines frkquentant un dispensaire de planification familiale ti Harare, et des paysannes. La principale raison les incitant g essayer cette nouvelle mkthode a tS de se protkger des maladies sexuellement transmissibles, y compris l’infection ti VIH. Dans chaque groupe, plus de la moitik des femmes ont dit qu’elles-m&mes et leurs partenaires apprtciaient fort ce prkservatif, et le prkfiraient au prfkervatif masculin. Moins de 10% ne l’ont pas aim& Les principaux problkmes venaient de l’anneau intkrieur et d’un excks de lubrication, mais des questions demeurent sur la fidClitC ?I la mkthode, et le prix constitue un obstacle majeur. En outre, m&me si ce prkervatif n’interfkre pas avec le plaisir sexuel de la femme, la plupart des raisons citCes en faveur de la mkthode concernaient l’homme.
agenda. American Journal of Public Health. 83(4). 26. Runganga A, Pitts M, and McMaster J, 1992. The use of herbal and other agents to enhance sexual experience. Social Science & Medicine. 35(8):1037-42. 27. Brown, JE, Ayowa OB, and Brown RC, 1993. Dry and tight: sexual practices and potential AIDS risk in Zaire. Social Science & Medicine. 37(8):98994. 28. Richters J, 1994. Researching condoms: the laboratory and the bedroom. Reproductive Health Matters. 3(May):55-62. 29. Johnson AM, 1994. Condoms and HIV transmission. New EnglandJournal 331(6):391-92.
ofMedicine.
30. Padian N, 1988. Prostitute
women and AIDS: epidemiology. AIDS. 2(62):413-19.
RESUMEN En Zimbabue se llev6 a cabo un estudio de aceptabilidad de1 conddn femenino entre trabajadoras de1 sexo, mujeres de la ciudad que acudian a una clinica de planificacibn familiar en Harare, y mujeres de1 campo. La principal raz6n por la cual probaron este nuevo mktodo fue la necesidad de proteccidn contra infecciones de transmisibn sexual, entre ellas el VIH. MC& de1 50% de las mujeres en 10s tres grupos expresaron que, tanto a ellas corn0 a sus compafieros, les habia gustado mucho el cond6n femenino y que lo preferian al masculine. Menos del 10% manifestaron que no les habia gustado. Los principales problemas fueron vinculados al aro interior o al exceso de lubricacibn; sin embargo, afin hay dudas sobre su uso a largo piazo, y el costo sigue siendo un obstkulo importante. AOn mk, si bien su uso no interfiri6 con el placer sexual de las mujeres, la mayoria de las razones a favor de1 mktodo estaban centradas en cl hombre.