© 2011 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2011;19(37):217–219 0968-8080/11 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 1 1 ) 3 7 5 7 2 - 6
Condoms Walking 26 km for a condom, Kenya Correct and consistent condom use is one of the bedrocks of Kenya's HIV/AIDS prevention programme but people in rural areas have limited access to condoms. A 21-year-old Maasai moran (warrior) in Kenya's Rift Valley has to walk to Narok hospital, 26km away, to fetch condoms. The head of the National AIDS and Sexually Transmitted Infections Control Programme believes that knowledge and awareness about condoms both in rural and urban areas could be above 90%. However, erratic funding and supply chain problems have led to fluctuations in condom distribution over the years. According to the UNAIDS Modes of Transmission Analysis 2008, condom distribution is very low generally and very unequal. Ineffective condom placement – for example at a chief's camp where young men are reluctant to venture – can also hinder access. Despite shyness, condoms in health centres go fast.1 Local TV channels recently showed men in Isiolo, northern Kenya, washing condoms and hanging them out to dry; the men said they could not afford to use them just once. Other men in the village said when they had no access to condoms they used polythene bags or cloth rags when having sex. The recycling of condoms shows how desperate people are to have safer sex. The government needs to be innovative in getting condoms to remote villages. The Ministry of Health says the country faces an acute, nationwide shortage of condoms; it has appealed to the US President's Emergency Plan for AIDS Relief, PEPFAR, to supply 45 million condoms.2 1. Kenya: walking 26km for a condom. Irin PlusNews, 2 December 2010. 2. Kenya: condom recycling highlights gaps in HIV prevention programming. Irin PlusNews, 29 March 2011.
Exploring the condom gap in urban and rural Kenya In Kenya, the potential of condoms for the prevention of HIV and other STIs is far from being achieved. To explore the condom gap and investigate the relative roles of supply-side (distance, cost) and demand-side (social barriers) factors in determining condom access and use, a study was undertaken in Kilifi district, Kenya, which has a generalised HIV epidemic, ongoing awareness campaigns, and available HIV services. Potential condom outlets (n=281) were mapped with GPS and surveyed, and questionnaires on condom access and use (n=630) were administered to a random sample of men and women aged 15–49 in the urban (Kilifi town, n=322) and rural (Sokoke, n=308) settings. The median straight-line distance to free condoms was 18-fold higher in the rural vs. the urban site. Among sexually active respondents, 42% had ever used a condom, and 23% had used a condom in the past year, with lower levels among rural versus urban respondents (p<0.05). The mean number of condoms used was 2.2 per person per year among sexually active individuals, amounting to only 8.2% sex acts per person per year being protected. The adjusted odds of condom use (past year) were 8.1 times greater among individuals experiencing no supply-side or demand-side barriers, compared with individuals experiencing both types of barriers. Although supply-side barriers existed, especially in the rural site, the main factors accounting for low levels of condom use appeared to be prevalent demand-side barriers, and low levels of felt need. There is an urgent need for renewed condom promotion efforts aimed at building demand, in addition to improving physical access.1 1. Papo JK, Bauni EK, Sanders EJ, et al. Exploring the condom gap: is supply or demand the limiting factor – condom access and use in an urban and a rural setting in Kilifi district, Kenya. AIDS 2011;25(2):247–55.
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Barrier contraception use during and after HIV prevention trial, Zimbabwe This study examined the use of condoms and the diaphragm following completion of a clinical trial of the effectiveness of the diaphragm for HIV prevention. The Methods for Improving Reproductive Health in Africa (MIRA) trial, conducted in 2003–2006 in South Africa and Zimbabwe, randomised over 5,000 women to receive either a diaphragm, lubricant and male condoms, or only male condoms. The trial found that the diaphragm and lubricant did not provide extra protection compared to condoms and STI treatment. A follow-up study involved 801 Zimbabwean MIRA participants who completed one post-trial visit 2–20 months after the MIRA trial ended, and assessed the use of condoms, diaphragm and any other barrier method at last sex, compared to at enrollment, final MIRA and post-trial visits. In the condoms-only group, condom use decreased from 86% at the final trial visit to 67% post-trial (AOR 0.20; 95% CI 0.12–0.33). 50% of the condom group chose to be fitted with diaphragms at the end of the MIRA trial, but only 14% of these were using them at the post-trial visit. In the diaphragm plus condoms group, condom use was 61% at the final trial visit, and did not decrease significantly post-trial (AOR 0.77; 95% CI 0.55–1.09), while diaphragm use decreased from 79% to 50% post-trial (AOR 0.18; 95% CI 0.12–0.28). Condom use significantly decreased between the enrollment and post-trial visits in both groups. Use of any barrier method was similar in both groups: it significantly decreased between the final trial visit and the post-trial visits. In sum, high condom use levels achieved during the trial were not sustained post-trial in the condom group. It could be that without the trial support, women did not feel the need or did not feel able to continue using the methods. Post-trial diaphragm use remained relatively high in the diaphragm group (in spite of its unknown effectiveness), but was very low in the condom group. Introducing “new” methods for HIV prevention may require time and user skills before they are adopted. These findings underscore the potential benefit of providing a mix of methods to women as it may encourage more protected acts.1 1. Van der Straten A, Cheng H, Minnis AM. Change in condom and other barrier method use during and
after an HIV prevention trial in Zimbabwe. Journal of International AIDS Society 2010;13:39.
Impact of an advertising campaign on condom use in urban Pakistan An evaluation of the effect on contraceptive use in Pakistan of the second phase of an intensive condom advertising campaign was carried out between April and June 2009. Advertisements for Touch condoms appeared on private television channels and radio stations. A nationally representative survey of married men in 17 cities collected information on behaviour related to condom use and recall of the advertisements. 806 men were interviewed at baseline in March 2009 and 617 (77%) were successfully re-interviewed for follow-up in August 2009. Respondents with confirmed awareness of the Touch campaign (about 15%) experienced significant improvements in indicators related to condom use, even after controlling for confounding factors. Those indicators included perceived availability of condoms (p<0.05); discussion of family planning (OR 2.75, p<0.001); approval of family planning (OR 1.83, p<0.05); procurement of condoms in the previous month (OR 2.54, p<0.01); and ever use (OR 2.70, p<0.001), current use (OR 2.06, p<0.05), and consistent use (OR 2.38, p<0.01) of condoms with the men's wives. Awareness of the campaign was not associated with other determinants of condom use such as increase in perception of condom effectiveness, decline in perceived reduction of sexual pleasure from condom use, or decline in men's embarrassment in negotiating condom use. The study indicates that condom advertising can be effective in increasing condom use in urban Pakistan.1 1. Agha S, Meekers D. Impact of an advertising campaign on condom use in urban Pakistan. Studies in Family Planning 2011;41(4):277–90.
Interpretations of condom use and a microbicide gel in a clinical trial, South Africa During a phase-three microbicide trial, women from Soweto and Orange Farm, South Africa, used a microbicide gel to test its efficacy for
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illness. The paper argues that women broadened the meaning of the gel beyond its primary intended effect of preventing HIV and “reinvented” it as a substance that transformed their bodies and sexual relations. This has implications for understanding how local knowledge of health and illness intersects with biomedical knowledge. Medical products may be conceptualised and employed in ways unimagined by product developers. Researchers should adopt a more nuanced understanding of responses to health campaigns, and if a microbicide is found to be successful, it may prove useful to draw on local knowledge and understanding to promote it.1 1. Stadler J, Saethre E. Blockage and flow: intimate experiences of condoms and microbicides in a South African clinical trial. Culture, Health and Sexuality 2011;13(1):31–44.
GIACOMO PIROZZI / PANOS PICTURES
preventing HIV. They were also counselled to use condoms as the gel's effectiveness was not proven. Qualitative research explored 179 women's experiences and perceptions of gel and condoms and the opinions of 18 of their male partners and community members. Participants were aware that condoms were effective in preventing HIV and that the microbicide gel's efficacy was unproven. Yet, participants ascribed improvements to their reproductive health and intimate relationships with men to gel use. Condoms were believed to prevent disease, yet also embodied mistrust; they were believed to contain dangerous substances and to block the womb. These apparently contradictory views about condoms and gels were explored in the light of people's conceptions of flow and blockage. Health was thought to be achieved by maintaining a steady balance of substances within the body, while anything that prevented the flow of fluids would result in
Condom billboard, Port Vila, Vanuatu, 2006