Male and Female Condom Use
The role of condom use in prevention of sexual transmission of HIV is clear. According to the WHO and the U.S. National Institutes of Health, male condoms that are intact are essentially impermeable to even the smallest sexually transmitted virus (UNAIDS, 2004). The effectiveness of male condoms has been shown to be between 8095 percent, depending on how correctly they are used (Weller and Davis-Beaty, 2007; Holmes et al., 2004; Hearst and Chen, 2004). Despite the fact that condoms are an old technology, "condom promotion remains a critical component of all prevention programmes" (Katsidzira and Hakim, 2011: 1122).
While the efficacy of neither the male nor the female condom in preventing HIV transmission has yet to be studied (IOM, 2001), mathematical modeling indicates that consistent use of female condoms, even at lower rates of efficacy, can play an important role in HIV prevention, especially for women whose partners will not use male condoms (Musaba et al., 1998). The efficacy of the female condom in preventing HIV transmission may never be fully determined. "While all evidence points to the effectiveness of female condoms to prevent HIV transmission and acquisition, it would be ethically impossible to test female condoms for HIV prevention: one cannot conduct a trial and give participants only female condoms and female and male condoms cannot be combined during the same sexual act. There is no possibility of doing a true gold standard randomized controlled clinical trials for female condoms" (Gabelnick, 2007 cited in CHANGE, 2008). Still, with laboratory and modeling studies indicating that the female condom is likely as effective as the male condom, the female condom is a critical component to HIV prevention for women.
Consistent Condom Use is Effective in Reducing HIV Transmission
"The condom is not pleasurable, but one uses it for the sake of ones life." Woman, South Africa (Susser, 2009:123)
Consistency is key. Women's lifetime risk of infection decreases with the consistent use of condoms. A microsimulation in Malawi found that if men always use male condoms with women who are not their wives, women's lifetime risk falls to 9 percent and that if both men and women always use condoms with partners other than their spouses, women's lifetime risk of infection falls to 8 percent (Bracher et al., 2004). Findings from Rakai, Uganda, showed that among 350 women who reported consistent male condom use, none became HIV-positive, but annual HIV incidence was 4.6 percent among women who reported inconsistent condom use (Kiddugavu et al., 2003). Conversely, many studies have shown that inconsistent condom users are at higher risk of HIV transmission than those who never use condoms. This may be because their behavior is riskier in other ways. Mathematical models suggest that a small number of people who use male condoms consistently can have a greater impact on reducing HIV transmission than a larger number who use them inconsistently (Hearst and Chen, 2004). An analysis of DHS data from 2005 to 2006 in Zimbabwe found that among 8709 women, knowledge that consistent condom use can prevent HIV infection was associated with HIV testing uptake (Sambisa et al., 2010). Interventions promoting consistent condom use are therefore paramount in reducing the incidence of HIV.
Variations in condom use across regions, countries and populations indicate that condom promotion should address barriers (socio-cultural, legal and policy, economic and financial and structural barriers) faced by different groups of women such as youth, married women, discordant couples, sex workers, and PWID, among others (Drezin et al., 2007).
Female Condoms Are The Only Female-Initiated HIV Prevention Method
"If you are not equipped, I have mine [female condom]." Ugandan woman (Green et al., 2001: 596)
While attention is drawn to work on AIDS vaccines and microbicides, the female condom is the first HIV prevention technology for sexual transmission developed since the beginning of the AIDS epidemic (Brown et al., 2007). In fact, "twenty years into the HIV epidemic, female condoms are the only currently available female initiated method of HIV... prevention" (Napierala et al., 2008: 121). The female condom is woefully under-programmed in prevention programs. By 2009, 50 million female condoms per year were distributed, an increase from 11.8 million in 2004. But in 2009, 71 male condoms were purchased for every female condom (UNFPA, 2011). "Nearly 25 years after its invention, the female condom is still not generally accessible" (Peters et al., 2010a: 120). "Despite comparable efficacy rates between male and female condoms, and high acceptability levels, limited access to female condoms and substantially higher costs have limited uptake and use of female condoms and thus an opportunity to reduce HIV infection in women through a women-initiated method" (Abdool Karim et al., 2010a: S125).
An analysis of five randomized controlled trials on effectiveness of the female condom found that the female condom increased the number of protected sex acts (Vijayakumar et al., 2006). While more costly than male condoms, "female condoms are safe to reuse repeatedly if proper care procedures are followed" (Marrazzo and Cates, 2011: S68).
Increasing Consistent Condom Use in Regular Partnerships is Important for Prevention
Promoting the use of condoms for high-risk sex is an effective approach to reducing HIV transmission, and studies indicate that interventions can achieve high rates of condom use in casual and commercial sex (Bollinger et al., 2004). However, promoting condom use for high-risk sex has contributed to the association of condom use with illicit sex (Feldman and Maposhere, 2003; Webber et al., 2010a; Kendall and Pelcastre, 2010), making it more difficult for women to negotiate condom use with regular sexual partners. Condom use among married couples is universally low, and normalizing condom use for all sex acts, including within marriage, is a challenge (Ali and Cleland, 2005; Hearst and Chen, 2004). In some countries, such as Malawi, remarriage following divorce is common and exposes adults to sequential multiple partners and risk of HIV acquisition (Kaponda et al., 2011).
Despite substantial risk within many primary relationships, condom use is low (Morrison et al., 2009: 265). Or as a sex worker in Ghana put it: "Even a married woman would be taking a risk in Ghana if she asked her husband to wear a condom. In my line of work, I can ask a man to wear a condom" (Raingruber et al., 2010: 517). [See also Addressing Violence Against Women] But national norms can change with regard to condom use: in Cuba, the percent of those who used a condom in a relationship lasting less than a year increased from 61.8 in 2001 to 78.1% in 2009; those who used a condom in the last sexual relation with a stable partner increased from 30.6% in 2001 to 41.95 in 2009 (Gorry, 2011). "Being married virtually always means being sexually active" (Clark et al., 2009: 398).
Consistent condom use remains largely uncommon among married couples and regular partners. A review of published literature on patterns of incident infection, risk factors for HIV infections, and rates of condom use used in regular partnerships found that a large proportion of incident HIV infection in some settings is in regular partnerships (Dunkle et al., 2008). For example, several epidemiological studies find marriage to be the main risk factor for infections in women. An analysis of 23 Demographic and Health Surveys (DHS) from low- and middle-income countries conducted between 1994 and 2000 found that in eight of the 23 countries, fewer than five percent of women aged 15 to 49 used condoms to prevent STIs (Snelling et al., 2006; de Walque and Kline, 2011). Married women particularly find it difficult to discuss condom use with their husbands as doing so touches on sensitive issues including fidelity and trust (Smith, 2007; Maharaj and Cleland, 2004; Nyblade et al., 2003; Chimbiri, 2007). Even when women can insist on condom use they may not want to negotiate condom use "... because condoms seem antithetical to trust, love, closeness and fidelity" (Higgins et al., 2010: 436). Women, as well as men, may be reluctant to press for condom use if they perceive condoms as interfering with physical pleasure. Men may be reluctant to press for condom use lest they signify lack of trust, closeness and fidelity (Higgins et al., 2010). Perceptions must be challenged, however; a study found that youth in Swaziland, Namibia, Kenya, Nigeria, Burkina Faso and Senegal believed that women initiate condom negotiation and men resist their use (Winskell et al., 2011b).
Condom use can be increased among all groups, including youth, discordant couples and sex workers. Promoting condoms to prevent STIs that may result in infertility may be a promising way to make condom use more socially acceptable within long-term or married relationships (Delvaux and Nostlinger, 2007). In addition, promoting condoms for pregnancy prevention as well as for HIV prevention can increase condom use. "For women who do not currently desire pregnancy, the dual method approach combining condoms for HIV/sexually transmitted disease (STD) prevention with longer-acting, more effective contraceptives for added protection against pregnancy simultaneously prevents both heterosexual and perinatal HIV transmission" (Mark et al., 2007: 1201). However, increasing condom use among women ultimately requires the cooperation of men (Foss et al., 2007), who need to be persuaded to use male condoms or to support womens use of female condoms.
Condom Distribution and Programming is Critical to HIV Prevention
Limited access to condoms and inadequate supplies of condoms are also a challenge to prevention of sexual transmission of HIV (Haddock et al., 2008). In 2004, the Global HIV Prevention Working Group noted that only 42 percent of people who wanted to use a condom during sex could obtain one. Of the estimated 18 billion condoms needed in 2006, donors provided just 2.3 billion (UNFPA, 2008 cited in Haddock et al., 2008).
"Why is the government gender-biased in as far as it issues only male condoms? Why are women discriminated against by having no condoms to use, leaving women no choice if their man refuses to use male condoms?" -Fifteen year old Kenyan girl (Njoroge et al., 2010: 146)Evidence from South Africa demonstrates that condoms distributed to the public are in fact used in sex and not wasted (Myer et al., 2001). Public sector male condom distribution rose from six million in 1994 to 198 million in 1999 as part of the government's condom promotion efforts for HIV/AIDS prevention. The government is the largest distributor of condoms in South Africa, with social marketing programs and commercial retailers together distributing an additional 10 to 20 million male condoms in 1997. A prospective study was undertaken during 1998-1999 at 12 representative public health facilities where a total of 384 participants and the 5,528 condoms they received were followed successfully. After five weeks, 43.7% of the condoms had been used or broken in sex, 21.8% had been given away, 8.5% had been lost or discarded, and 26% were still available for use. Those who had actively procured condoms (rather than passively receiving them) had increased rates of use. After five weeks, less than 10% had been wasted (Myer et al., 2001). Continuous monitoring for condom availability and ensuring that condoms are displayed can dramatically increase condom sales (Piot et al., 2010). Condom access requires national and district level planning and coordination, with systems to track demand and supply.
Expanding access to female condoms allows women greater control over protecting themselves and could even be preferred by some men as well. "Men may prefer using the female condom if it gives them more pleasure than does use of the male condom and some men may prefer not being responsible for HIV protection" (Agha, 2001: 55). Qualitative studies with female sex workers in Kenya, India, Uganda, South Africa and Zimbabwe found that they covertly used female condoms to compensate for their inability to enforce male condom use (Okal et al., 2011; Ghose et al., 2011; Scorgie et al., 2011). Programs must pay more attention to increasing access to the female condom, along with education about proper use. "As a currently available device that women might use to protect themselves against HIV, the female condom stands alone" (Barbosa et al., 2007: 261).
Condom use is a critical component to HIV prevention (Cohen, 2002 cited in Feldblum et al., 2003) and remains the best method of protection for sexually active women. Interventions that increase condom availability and use are urgently needed to prevent HIV among women and girls. Additional condom promotion interventions are needed to address barriers (socio-cultural, legal and policy, economic and financial, and structural) faced by different groups of women such as youth, married women, discordant couples, sex workers, and women who use drugs, among others.