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HIV Prevention Knowledge Base
Behavioral Interventions: Comprehensive Condom Use Programs
I. Definition of the Prevention Area
Unprotected sex is the leading cause of HIV transmission, accounting for more than 80 percent of the total number of infections. Male and female condoms, when worn correctly, serve as an impermeable barrier to the sexual exchange of secretions that carry HIV and a number of other sexually transmitted infections (STIs), providing protection against transmission.
In recent guidance on HIV prevention, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) recommends programming that combines multiple, evidence-based approaches to increase availability, accessibility, acceptability, and use of condoms in targeted groups and in the general population. Comprehensive condom programming remains an essential component of combination prevention programs.
II. Epidemiological Justification for the Prevention Area
Condoms, both male and female versions, are the most effective barrier method currently available to sexually active individuals who require protection from HIV and other STIs and from unwanted pregnancies. Male condoms reduce the risk of HIV by 80 percent or more when used correctly and consistently. Modeling studies indicate female condoms can provide the same level of protection against HIV infection, although evidence is limited.
Consistent and correct use of male latex condoms is associated with lower rates of transmission among higher-risk groups, notably sex workers, men who have sex with men, and serodiscordant couples. In countries with concentrated epidemics (e.g., Thailand), programs promoting 100 percent condom use in the commercial sex industry have lowered overall prevalence levels. While the impact of condom use is unknown at the population level in mixed and generalized epidemics, condom programming remains an important aspect of the overall prevention portfolio.
III. Core Programmatic Components
Components of comprehensive condom programs are identified by the United Nations Population Fund as well as by PEPFAR in its recent guidance on prevention:
- Create demand: Understanding the local environment and characteristics of specific client groups is necessary to target individuals at higher risk and the venues they frequent. Demand can be accelerated by promoting condoms along with treatment and prevention, particularly for serodiscordant couples and for dual protection.
- Increase supply and availability: This is important for both male and female condoms in low and middle income countries. Managing the pipeline is critical to maintaining a constant supply of condoms. Advocacy for female condoms at both the international and national levels will increase demand, reduce production costs, and increase supply.
- Ensure high quality and low cost: Making both male latex condoms and nitrile female condoms available for free or at very low cost at key distribution points frequented by men and women (e.g., marketplaces, hair salons, workplaces) can increase use.
- Address acceptability: Confront prevailing cultural myths and inaccuracies using media campaigns and behavior change strategies—education and individual training—to target specific groups and communities, as well as larger audiences. Female condoms have unique advantages for women (greater control and dual protection) and men (increased sexual pleasure). Programs can capitalize on these features.
- Conduct monitoring and evaluation.
IV. Current Status of Implementation Experience
Meta-analyses and well-designed evaluations have shown that when coupled with education and counseling, condom promotion programs can be effective in increasing male condom use among youth and among such marginalized groups as sex workers, men who have sex with men, and serodiscordant couples. Successful condom programs employ multiple strategies, such as ensuring high coverage in accessible venues, training people on how to use condoms, building negotiation skills and self-efficacy, and working within social networks.
Condom programs have been implemented using mass media campaigns, community-level initiatives, and interpersonal outreach. They have also targeted people in the general population who engage in higher-risk sex (e.g., multiple partners, concurrent partners, commercial sex) in high-prevalence settings. Although these initiatives have shown success, male condom use between longstanding sexual partners, such as married couples, does not persist over time.
Demand for condoms exceeds availability; only a quarter of the total number of male condoms needed is available. Female condoms are even less available, due primarily to high cost and policymaker bias. Greater international funding and support for both male and female condoms must be increased to reduce the current gap and meet future needs.
Condom Effectiveness in Reducing Heterosexual HIV Transmission
Weller, S. C., & Davis-Beaty, K. The Cochrane Library (2009).
This study reviewed data from 14 longitudinal studies of sexually active serodiscordant heterosexual couples. In 13 of the studies, all the participants were 100 percent condom users, while the cohort in one study comprised those who never used condoms. Overall, the studies showed that consistent condom use for all acts of penetrative vaginal intercourse was associated with an 80 percent reduction in HIV seroconversion. The authors note a lack of detail in the studies (e.g., on correct use), and there were inconsistencies in terminology about condom use across the different studies. There was also a lack of information on disease-free exposure time, the review found. The results imply that condom use is less effective for HIV prevention than it is for pregnancy prevention. Recommendations for future studies include improving the way that condom use is coded to give more detailed information.
Efficacy of Structural-Level Condom Distribution Interventions: A Meta-Analysis of U.S. and International Studies, 1998-2007
Charania, M. R., Crepaz, N., Guenther-Gray, C., et al. AIDS and Behavior (2011), Vol. 15, pp. 1283-1297.
This meta-analysis concludes that structural-level condom distribution interventions are effective in preventing both HIV and sexually transmitted infections. Structural interventions improve the availability, acceptability, and accessibility of male condoms. The analysis shows that structural-level interventions are particularly effective for increased condom acquisition, carrying, and use; abstinence or delayed sexual debut in young people; and reduced incidence of sexually transmitted infections. Limitations of the meta-analysis include extreme heterogeneity in the studies, exclusion of some important studies for methodological reasons, and a cut-off point of September 2007, after which other relevant studies were published.
Quick Reference Guide to Family Planning Research
Family Health International. (2010).
This synthesis with links to abstracts places research on condoms, both male and female, in the wider context of integrating family planning and HIV prevention services. Links to research papers and other documents demonstrate that the correct and consistent use of latex male condoms reduces the risk of HIV transmission by an estimated 80 to 90 percent. Other studies show that interventions targeted at both long-standing and serodiscordant couples significantly improve self-reported condom use rates; concentrated counseling can increase acceptability of condoms; and condom use has increased in high-risk groups, especially if condoms are widely available where risky sex takes place.
Changes in HIV-Related Knowledge and Behaviors in Sub-Saharan Africa: DHS Comparative Reports 24
Mishra, V., Agrawal, P., Alva, S., et al. (2009).
Condom use is among a range of HIV-related indicators in this report on 23 countries in sub-Saharan Africa. The report illustrates great variation in use, but in all countries more men than women reported ever using a condom and using one in the previous 12 months. Similarly, condom use during high-risk sex varied widely across sub-Saharan Africa, while condom use at first intercourse among those aged 15 to 24 varied but was low overall. Detailed tables present country-level data with figures for two time points where available.
Saving Lives Now: Female Condoms and the Role of U.S. Foreign Aid.
Center for Health and Gender Equity. (2008).
This report is based on expert interviews and an extensive literature search. It highlights the unique nature of female condoms as a means of protection from HIV that women can initiate. Female condoms are not readily available and awareness of this method of HIV prevention is low, the authors write. The way to stimulate demand for female condoms is to ensure high-quality female condom programming, including creative solutions to distribution; training for both providers and consumers; and promotion through civil society organizations that work with vulnerable population. The report makes recommendations to U.S. agencies involved in female condom programming to promote their integration into HIV prevention and family planning efforts, expand technical assistance, and scale up programming efforts. The scope of female condom promotion should be widened to the general public to avoid stigmatization of female condoms and supports the removal of hallmarked funding for abstinence-based HIV prevention programs.
Epidemiology of Male Same-Sex Behavior and Associated Sexual Health Indicators in Low- and Middle-Income Countries: 2003–2007 Estimates
Cáceres, C. F., Konda, K., Segura, E. R., et al. Sexually Transmitted Infections (2008), Vol. 84 Suppl. 1, pp. i49-i56.
Over 100 studies were reviewed to compile this summary of data on male-to-male sex, including condom use, in low- and middle-income countries. Asia accounted for the highest proportion of recent research, and there were also new studies from sub-Saharan Africa revealing epidemics of HIV among men who have sex with men. However, the authors found there is still a paucity of information from other regions, and Latin American studies were less extensive than anticipated. This newly available data should be used in the development of future interventions, but more systematic data collection would improve the evidence base for HIV prevention planning, the authors conclude.
Comprehensive HIV Prevention: Condoms and Contraceptives Count
Haddock, S., Hardee, K., Gay, J., et al. (2008).
This report stresses the importance of male and female condoms and other forms of contraception in HIV prevention and advocates scaled up access as well as integration into wider prevention strategies. Expanding access to condoms continues to face cultural and policy barriers and wide regional variations in condom use persist, the report finds. One section is dedicated to how programs address barriers to use and to improve rates of condom use among young people, those in long-term partnerships, serodiscordant couples, sex workers, and other socially marginalized groups. The section highlights specific issues such as gender-based violence as an obstacle to condom use and the experience of 100 percent condom use programs.
Effectiveness of Interventions for the Prevention of HIV and Other Sexually Transmitted Infections in Female Sex Workers in Resource Poor Setting: A Systematic Review
Shahmanesh, M., Patel, V., Mabey, D., et al. Tropical Medicine & International Health (2008), Vol. 13 No. 5, pp. 659-679.
This is a systematic review of 28 interventions targeting female sex workers. The interventions are presented in four categories: structural interventions, behavioral interventions incorporating condom promotion, provision of vaginal microbicide, and treatment for sexually transmitted infection. The evidence supports condom promotion as a HIV risk reduction strategy when combined with other sexual risk reduction and better access to treatment for sexually transmitted infections.
A Systematic Review of Published Evidence on Intervention Impact on Condom Use in Sub-Saharan Africa and Asia
Foss, A. M., Hossain, M., Vickerman, P. T., et al. Sexually Transmitted Infections (2007), Vol. 83 No. 7, pp. 510-516.
Condom promotion interventions targeted at sex workers and their clients can result in significant increases in condom use, according to this systematic review of 62 studies in sub-Saharan Africa and Asia. The evidence in support of such interventions with long-term partners who are not serodiscordant, and also with young people, is far weaker, the review finds. The findings were consistent across different countries. Relying on self-reported condom use leaves the studies open to reporting bias, and biological outcomes would be optimal. Standardized measures of condom use would also help future synthesis of condom promotion intervention evaluations, the authors note.
A Review of Female-Condom Effectiveness: Patterns of Use and Impact on Protected Sex Acts and STI Incidence
Vijayakumar, G., Mabude, Z., Smit, J., et al. International Journal of STD and AIDS (2006) Vol. 17 No .10, pp. 652-659.
This systematic review of 137 articles on the female condom, including five randomized controlled trials, looked at the impact of female condoms on risk reduction and incidence of sexually transmitted infections. Among the five randomized controlled trials, two indicated notable decreases in STI incidence and all five indicated increases in the number of protected sex acts. Data from multiple studies showed that female condoms are used by women who are not as likely to use other dual protection methods. Of the studies reviewed, almost half looked at acceptability, while other studies focused on cost-effectiveness, facilitators and barriers to use, negotiation, and promotion. The authors suggest that future research should move away from the focus on acceptability to examining the effectiveness and impact on diverse settings and to more closely examine the view that female condoms empower women to negotiate safer sex.
Condom Promotion For AIDS Prevention in the Developing World: Is it Working?
Hearst, N., & Chen, S. Studies in Family Planning (2004), Vol. 35, No. 1, pp. 39-47.
Thailand’s 100% Condom Program, which mandates enforced condom use in brothels, stands out as a significant success story in two decades of HIV prevention via condom promotion. Condom promotion among men who have sex with men and among sex workers and their clients can be successful, but there is less evidence in support of promotion to the general public, the review finds. Condom promotion strategies should be examined in conjunction with other interventions, such as partner reduction because of the potential for interaction, and interventions should truthfully represent the less than total efficacy of condoms in prevention of HIV transmission, the authors conclude.
Condom Use Errors and Problems: A Global View
Sanders, S.A., Yarber, W.L., Kaufman, E.L, et al. Sexual Health (February 2012), Vol. 9 No. 1, pp. 81-95.
Condom use errors are widespread globally and continue to lessen the efficacy of condoms. These results are from a systematic literature review of 50 articles on condom use representing 14 countries and a diverse set of populations (e.g., sex workers, clients at clinics for sexually transmitted infections [STIs], monogamous married couples, etc.) from 1995 to 2011. According to the authors, common errors involve incomplete use (e.g., putting on a condom after intercourse has begun or early removal of a condom followed by unprotected intercourse), not leaving space at the tip, not squeezing air from the tip prior to use, putting the condom on inside out and having to remove and replace it, not using water-based lubricants, and incorrect withdrawal. Some common problems include breakage, slippage, leakage, erection problems during condom application, erection problems during condom use, and problems with the fit or feel of a condom. The authors found that the majority of articles discussed breakage and slippage, yet argue that other problems, such as early removal of condoms and incomplete use, may be just as serious, particularly when they expose a partner to STIs. Some under-researched areas include duration of condom use during intercourse and condom-associated erection difficulties. The authors offer some guidelines on correct condom use before, at the time of, and after intercourse, and offer a Condom Use Experience model to guide future research.
Behavioral Interventions to Reduce the Transmission of HIV Infection among Sex Workers and their Clients in Low- and Middle-income Countries
Warik,i W.M., Ota, E., Mori, R., et al. Cochrane Database of Systematic Reviews (February 2012), Vol. 15 No. 2.
This review describes the results of a meta-analysis on HIV prevention projects implemented among sex workers in low- and middle-income countries. The objectives of the review were to 1) evaluate and 2) assess the effectiveness of behavioral interventions in reducing the transmission of HIV and sexually transmitted infections (STIs) among sex workers and their clients. Only randomized and quasi-randomized controlled trials were included, a total of 13 studies. The outcomes of interest were STI and HIV incidence and prevalence. Secondary outcomes included changes in behavior such as condom use, sexual and drug use risk behavior, and STI treatment-seeking behavior. Two reviewers searched the gray and peer-reviewed literature from various sources, and included published data from 1980 to 2010. Primary outcomes were identified in seven studies (e.g., HIV incidence, STI incidence, and STI prevalence). It was found that a Social cognitive intervention did reduce HIV incidence among sex workers compared to standard counseling, and an intervention promoting both male and female condoms was more effective than promoting male condoms alone. Six interventions were effective in reducing STI incidence. Positive findings were also found among the secondary outcomes of successful interventions, such as an increase in condom use, reduction of drug use, and reduction of sexual partners. The authors concluded that a combination of behavioral interventions is the most effective, but not all interventions are successful in ameliorating health outcomes.
Social Network-Based Interventions to Promote Condom Use: A Systematic Review
Wang, K., Brown, K., Shen, S. Y., et al. AIDS and Behavior (2011), Vol. 15 No. 7, pp. 1298-1308.
This review compiles evidence from 11 studies on social network-based condom promotion interventions. All of the studies used social networks as defined by the study participants themselves, and 10 out of 11 studies measured significant improvements in condom use. Only three of the studies (among drug users in Thailand, Roma men in Bulgaria, and high-risk women in Baltimore, Maryland, in the United States) had biological outcomes, and the primary outcome of condom use varied greatly by timeframe. Eight of the nine studies with controls showed a substantial improvement in at least one condom measure among intervention groups versus controls. The authors conclude that social network-based HIV prevention interventions can increase condom use and reduce other HIV risk behaviors.
Effectiveness of HIV Prevention for Youth in Sub-Saharan Africa: Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials
Michielsen, K., Chersich, M. F., Luchters, S., et al. AIDS (2010), Vol. 24 No. 8, pp. 1193-1202.
This systematic review and meta-analysis assessed 28 interventions for reported condom use and condom use intentions. It revealed that sexual behavior, whether risky or not, did not increase after sex education and condom promotion. However, only condom use by males at last sex increased, and the interventions did not result in positive changes to sexual behavior. The design of many studies was suboptimal, and the heterogeneity of studies suggests a lack of consensus on interventions and research into their efficacy.
Reduction in Risk-Taking Behaviors Among MSM in Senegal Between 2004 and 2007 and Prevalence of HIV and Other STIs. ELIHoS Project, ANRS 12139
Wade, A. S., Larmarange, J., Diop, A. K., et al. AIDS Care (2010), Vol. 22 No. 4, pp. 409-414.
This study compares prevalence data for HIV and sexually transmitted infections before and after the implementation of prevention campaigns targeting men who have sex with men (MSM) in Senegal, a group with high HIV prevalence and a high rate of risky sexual behaviors. Frequency of sexual practices remained unchanged, but condom use in male-to-male sexual encounters increased markedly. HIV prevalence remained the same, but prevalence of gonorrhea halved. Using the same sampling method in both surveys meant that the data could be meaningfully compared, but the authors caution that the results cannot be considered representative of the MSM population in Senegal, because the snowball sampling method likely caused selection bias.
Effects of Structural Intervention on Increasing Condom Availability and Reducing Risky Sexual Behaviours in Gay Bathhouse Attendees
Ko, N. Y., Lee, H. C., Hung, C. C., et al. AIDS Care (2009), Vol. 21 No. 12, pp.1499-1507.
An intervention in Taiwanese gay bathhouses to ensure availability and accessibility of condoms was successful in increasing use of condoms, according to this study. Bathhouse attendees were recruited before the intervention and were then surveyed six months later to assess whether or not greater access to condoms inside the bathhouses reduced unprotected sex and cut prevalence rates of HIV and sexually transmitted infections. Among attendees at bathhouses in the intervention group, self-reported consistent condom use during anal sex increased, but prevalence of HIV and sexually transmitted infections remained unchanged. It is important to ensure distribution of condoms in areas of the bathhouses where sexual encounters take place, the authors comment.
The UALE Project: Decline in the Incidence of HIV and Sexually Transmitted Infections and Increase in the Use of Condoms Among Sex Workers in Guatemala
Sabidó, M., Giardina, F., Hernández, G., et al. Journal of Acquired Immune Deficiency Syndrome (2009), Vol. 51 Suppl. 1, pp. S35-S41.
This intervention offered commercial sex workers in Guatemala biannual screening for HIV and sexually transmitted infections (STIs), condom education, and training in condom negotiation skills, and also comprised activities to reduce the criminalization of sex workers. It resulted in higher consistent usage of condoms with new and regular clients, as well as lower rates of HIV and STIs, according to this paper. The authors attribute the reduction in STIs and HIV to increased condom use. The study may be subject to bias due to the potential for greater loss to follow-up for subgroups at higher risk of HIV, as well as recall bias and misreporting.
The Efficacy of Female Condom Skills Training in HIV Risk Reduction Among Women: A Randomized Controlled Trial
Choi, K. H., Hoff, C., Gregorich, S. E., et al. American Journal of Public Health (2008), Vol. 98 No 10, pp. 1841-1848.
This randomized controlled trial of 400 Californian women examined the impact of a four-session female condom skills training intervention. Women received instructions in female condom use including self-efficacy training at baseline and supplies of male and female condoms during the study period. Information on condom use was gathered using computer-assisted self-interviews at baseline and at three and six months. At follow-up, female condom use among the intervention group participants increased and the absolute difference in at least one incidence of condom usage was over 20 percent higher in the intervention group versus the control group at both time points. However, there was no difference in male condom use. The study showed that women in the intervention group exhibited safer sexual practices without reducing baseline male condom use, suggesting the intervention can be an effective supplement to other prevention strategies.
Acceptability and Use of Sexual Barrier Products and Lubricants Among HIV-Seropositive Zambian Men
Jones, D. L., Weiss, S. M., Chitalu, N., et al. AIDS Patient Care and STDs (2008), Vol. 22 No. 12, pp. 1015-1020.
This study describes an intervention to provide Zambian HIV-positive and serodiscordant couples with male and female condoms and a variety of lubricants to assess their acceptability. It found that male condom use, already high at baseline, increased during the 6-month intervention and that the increase was sustained at 12 months. Female condom use also increased during the intervention, and men’s attitudes shifted away from a cultural preference for dry sex. Use of lubricants was influenced by the need for communication between partners about sex, and interventions that encourage communication could be useful, the authors note. Gender roles pitting men as the sexual decision makers must be taken into account in such HIV prevention interventions.
Smarter Programming of the Female Condom: Increasing Its Impact on HIV Prevention in the Developing World
Marseille, E., & Kahn, J. (2008).
This study looks at the relative effectiveness of female condoms as a HIV prevention strategy within the range of HIV prevention options. The study includes a comparative review of 14 female condom programs across 10 countries in the developing world as well as a wider literature review and interviews with stakeholders. There was also a cost-effectiveness analysis. This report found that female condoms are significantly less cost-effective than male condoms. Female condoms are not cost-effective for female sex workers due to the very high rate of substitution for male condoms; for women with regular sexual partners, they are not cost-effective because of the high cost relative to male condoms, the study found. However, the authors note that cost-effectiveness is not the sole criterion for funding decisions, that female condoms have utility in protecting women whose male sexual partners cannot or will not use a male condom, and that the benefits to women’s empowerment are implied by female condom programming, but difficult to quantify.
Temporal Trends in Sexually Transmitted Infection Prevalence and Condom Use Following Introduction of the Female Condom to Madagascar Sex Workers
Hoke, T. H., Feldblum, P. J., Van Damme, K., et al. International Journal of STD & AIDS (2007), Vol. 18 No. 7, pp. 461-466.
This study looked at the impact among 1,000 sex workers in Madagascar of adding female condoms to male condom distribution. The study ran for 18 months, comprising 6 months when only male condoms were available to participants followed by 12 months when both types were available. Every two months, the women provided information on condom use and they were tested for sexually transmitted infections (STIs) every six months. Adding female condoms increased condom use from 78 percent of sex acts at the 6-month mark to 83 and 88 percent at 12 and 18 months, respectively. Over the same timeframe, prevalence of STIs also declined a fifth from 50 percent at month 6 to 40 percent at the 18-month mark. The authors conclude that female condom promotion has its place in the context of programs that first achieve maximum outcome from male condom programming, but that condom promotion is not sufficient on its own to control HIV and STIs.
Evaluation of the 100% Condom Program in Thailand
Joint United Nations Programme on HIV/AIDS. (2000).
This report describes in detail Thailand’s 100% Condom Program and evaluates its success in significantly increasing consistent condom use in commercial sex settings, in turn dramatically reducing rates of sexually transmitted infections. Factors affecting the success of the program include the wide extent of implementation of all components of the program, the degree of collaboration between stakeholders, and taking account of different types of commercial sex establishments and their varying needs. This success story can be built upon by improving condom access in indirect sites of commercial sex, given that surveillance had found the number of such sites increasing in 2000 when Thailand’s program was evaluated.
Condoms "Contain Worms" and "Cause HIV" in Tanzania: Negative Condom Beliefs Scale Development and Implications for HIV Prevention
Siegler, A.J., Mbwambo, J.K., McCarty, F.A., et al. Social Science & Medicine (July 2012), e-publication ahead of print.
Condoms are a cornerstone of HIV prevention, yet the demand for and use of condoms remains low despite the high HIV and AIDS prevalence rates in certain countries. Negative rumors about condoms abound, and negative beliefs act as barriers to the intention to use condoms consistently and correctly. This study used the Negative Condom Belief Scale in Tanzania to quantitatively measure how negative beliefs affect willingness to use condoms. The cross-sectional study was conducted in the Maasai regions of Tanzania. About 360 individuals were randomly selected based on geographical and household clusters. Face-to-face interviews were conducted in the local language. The survey contained questions on socio-demographic variables, HIV risk perception, and HIV knowledge. Thirty semi-structured qualitative interviews were conducted to develop the scale. Six commonly held beliefs emerged, including that new condoms contain worms, that these worms infect individuals with HIV, and that condom use can cause cancer. The dependent variable measured was “willingness to use a condom.” It was found that between 35 and 53 percent of individuals in the survey agreed with the six negative condom rumors. Having a negative condom score on the Condom Beliefs Scale was a significant predictor of an individual’s willingness to use a condom; other predictors were the ability to acquire a condom privately and condom self-efficacy. The results indicate a high level of negative beliefs about condom use and illustrate how those beliefs translate into reduced likelihood of actual condom use.
Guidance for the Prevention of Sexually Transmitted HIV Infections
U.S. President’s Emergency Plan for AIDS Relief. (2011).
This August 2011 guidance from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) on prevention of sexually transmitted infections aims to support PEPFAR country teams to identify the best combination of HIV prevention strategies, based on country-specific epidemiology. It describes the overarching principles for prevention programs and then spells out the evidence base and implementation guidelines for specific interventions. The chapter on biomedical interventions includes a summary of evidence on the efficacy of male and female condoms for prevention of HIV transmission. It spells out three key factors in program implementation: condom availability must be increased; knowledge, acceptability, and demand must be stimulated; and access to antiretroviral therapy is driving increased demand and creating more opportunities for accelerated condom promotion. It also has chapters on behavioral interventions and on assembling a portfolio of interventions to optimize the PEPFAR contribution to a country’s continuum of response.
Comprehensive Condom Programming: A Guide for Resource Mobilizationand Country Programming
United Nations Population Fund. (2010).
This 16-page report states the rationale for condom promotion, arguing that condoms are central to HIV prevention because they are both effective in reducing HIV transmission and cost-effective. The study outlines a step-by-step strategic approach to developing a condom program, starting with establishing a national condom team, conducting situation analysis, and developing a comprehensive national condom strategy. This is followed by budget and operational plans linked to national commodity security plans, resources mobilization, capacity strengthening, and demand creation. The final steps are strengthening advocacy and media engagement as well as monitoring and evaluation.
Lot Quality Assurance Sampling for Monitoring Coverage and Quality of a Targeted Condom Social Marketing Programme in Traditional and Non-Traditional Outlets in India
Piot, B., Mukherjee, A., Navin, D., et al. Sexually Transmitted Infections (2010), Vol. 86 Suppl. 1, pp. i56-i61.
A large-scale social marketing campaign under the Bill & Melinda Gates Foundation, the Avahan initiative resulted in condoms being more widely available in areas with a concentration of female sex workers. Improved coverage was achieved largely because of the increase in the network of non-traditional sales outlets such as bars, fuel stations, grocery stores, and restaurants. Areas were monitored to ascertain the availability and quality of condoms using lot quality sampling. The authors recommend lot quality sampling to do routine monitoring of geographic coverage because it is easy to collect data, sample sizes are small, and the data can be analyzed using simple methods.
Barriers to Condoms: Implementing and Documenting Advocacy Strategies
Torres, M. A., Kort, R., Daly, K., et al. (2009).
This report presents findings from three case studies of condom promotion activities in Cambodia, Jamaica, and India. All three case studies are described in detail, and there is a summary of the sociocultural, legal, economic, and financial barriers to condom access and use. Despite the diverse nature of the three settings, they had four elements in common. They all used a peer-based model; addressed stigma and discrimination as a precursor to condom promotion; had a practical, evidence-based approach; and integrated condom advocacy with other health services related to HIV as well as wider sexual and reproductive health services.
Public Health Procurement Guide and Product Catalog 2010
USAID | DELIVER PROJECT. (2009).
This document is published annually by the USAID | DELIVER PROJECT and spells out the ordering procedures for use by missions to procure male and female condoms as well as other contraceptive supplies. It includes logistics forecasts to individual countries to aid calculation of delivery lead times, guidelines on the disposal of expired contraceptive products, and a product catalog and price list.
Priority Interventions: HIV/AIDS Prevention, Treatment and Care in the Health Sector
World Health Organization. (2009).
This report is aimed at a broad readership including donors, public health officials, national HIV program managers, health care workers, and other stakeholders. It describes priority interventions for HIV prevention, treatment, and care. There are also policy and technical recommendations and guidance on setting HIV program priorities. Recommendations on prevention of sexual transmission of HIV include condom promotion for the general population as well as at-risk groups such as serodiscordant couples and sex workers. There is also a list of over 230 useful resources.
Logistics for Health Commodities
Felling, B. (2009).
This 75-minute course explains the purpose and components of a logistics system and its role in supporting contraceptive and commodity security. There are modules introducing the basics of logistics in theory and in practice, covering topics such as forecasting, finance, procurement, and delivery. There are examples from the field to show how logistics can make limited resources stretch further and make programs more successful. The course also covers the importance of a logistics management information system and guidance on forecasting, inventory control, and storage. Users can monitor their learning with frequent multiple-choice quizzes, culminating in an online exam. There is a click-through glossary for technical terms throughout the course. Go to link below and then register (free), then click “Course Catalog” and select “Logistics for Health Commodities.”
Condom Programming for HIV Prevention: An Operations Manual for Programme Managers
United Nations Population Fund, World Health Organization, & PATH. (2005).
Launching a new condom program or improving an existing one can be done with the seven-step process laid out in this manual. There are detailed chapters on understanding condom users and the program environment; creating an action plan; ensuring a pipeline of high-quality condoms; expanding distribution, condom promotion at distribution points, promoting condoms in the community and at district and national levels; and program monitoring and evaluation. The manual provides a checklist of key actions, examples from the field, and useful worksheets and contacts. There are also fact sheets on male and female condoms, their dual role as protection against HIV and pregnancy, and gender and condom programming.
Making Condoms Work for HIV Prevention: Cutting Edge Perspectives
Joint United Nations Programme on HIV/AIDS. (2004).
This report provides guidance on how to ensure optimal use of condoms as part of a comprehensive HIV prevention strategy. Steps include ensuring sufficient condom supplies, promoting their use within at-risk groups and the general population, clearly communicating their effectiveness, and addressing misconceptions. The report spells out the common features of condom promotion success stories and explains how to make condoms campaigns more effective. It gives useful but succinct information on the evidence base supporting condom promotion. Attention is given to recognizing and capitalizing on the interactions between different elements of condom promotion, such as social marketing and condom education.
Condoms for HIV Prevention
World Health Organization. (2011).
The World Health Organization’s webpage on HIV and condoms provides links to general information as well as technical documents, scientific evidence, and data. There are recommended readings on a range of topics such as condom effectiveness and common myths and misperceptions associated with condom use, as well as a report on a 100 percent condom use program in China. A podcast on condoms for HIV prevention and links to condom-related information on the websites of related UN organizations are also accessible via the site.
HIV Prevention Gains Momentum: Successes in Female Condom Programming
United Nations Population Fund. (2011).
This report profiles specific country examples of successful female condom promotion programs. There are seven country profiles covering awareness-raising and behavior change to increase demand for female condoms, such as social marketing in hair salons and barbershops in Zimbabwe, and assertiveness training for women on Malawi. Programs in the Caribbean and Nigeria are cited as examples of successfully integrating female condom promotion into existing programs, while supply logistics and quality assurance are explored with examples from the Caribbean, Malawi, and Nigeria. Strengthening government capacity is also covered with four case studies from sub-Saharan countries.
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Center for Health and Gender Equity. (2011).
The publications page of the Center for Health and Gender Equity’s Prevention Now website has links to a wide range of materials on female condoms and female condom programming. There are fact sheets on female condoms and the Prevention Now campaign to increase donor funding for female condoms. A report on U.S. support for female condom programming is complemented by a poster detailing five-year trends in U.S. funding. There are country profiles from Malawi, Uganda, and Zimbabwe, and many of the publications are also available in French, Portuguese, and Spanish.
Condoms and STDs: Fact Sheet for Public Health Personnel
U.S. Centers for Disease Control and Prevention. (2011).
This three-page fact sheet explains how male condoms must be used correctly and consistently to reduce transmission of sexually transmitted infections, making a distinction between the degree of protection against diseases transmitted by genital secretions and genital ulcer diseases. It explains that male condoms offer a very high degree of protection from HIV, gonorrhea, chlamydia, and trichomoniasis, and reduced risk for transmission of genital ulcer diseases such as genital herpes, syphilis, chancroid, and human papillomavirus-related infections, i.e., genital warts and cervical cancer. For both categories of sexually transmitted infections, there are plain-language summaries of the theoretical basis for protection and the findings of laboratory and epidemiologic studies.
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Compendium of Evidence-Based HIV Prevention Interventions
U.S. Centers for Disease Control and Prevention. (2011).
The risk-reduction chapter of this compendium includes 74 HIV risk-reduction evidence-based interventions, identified by a thorough literature review through December 2009. Among the 43 individual- and group-level best interventions are those promoting condom use. The database can be searched according to different characteristics such as risk category, race, and gender of participants. Condom use interventions that have the most successful outcomes are those that provide education/training in condom use and are delivered to individuals or small groups using a social-cognitive theoretical approach.
Reducing Sexual Transmission
Joint United Nations Programme on HIV/AIDS. (2011).
The Joint United Nations Programme on HIV/AIDS (UNAIDS) website has a range of documents on male condoms, including a joint UNAIDS/United Nations Population Fund/World Health Organization position statement on condoms and HIV prevention and review document on condom programming.
UNAIDS Report on the Global AIDS Epidemic 2010
Joint United Nations Programme on HIV/AIDS. (2010).
The 2010 Joint United Nations Programme on HIV/AIDS (UNAIDS) report on the global HIV epidemic draws on the latest available data from 182 countries, including incidence trend data from 60 countries, the first time such data has been included in a UNAIDS global report. Data is disaggregated by country and by demographic categories. There are chapters giving an update of the epidemic, HIV prevention, HIV treatment, human rights and gender, and HIV investments. The report can be downloaded in its entirety or chapter by chapter.
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U.S. Agency for International Development Documents
U.S. Agency for International Development (2006).
The Development Experience Clearinghouse of the U.S. Agency for International Development (USAID) is a searchable repository of documents from USAID-funded projects worldwide. There are currently more than 3,000 documents related to HIV, and the site is due to relaunch with more downloadable documents and more user-friendly search tools.
FC2 Female Condom
FC2 Female Condom. (2009).
This website provides detailed information on the FC2 second-generation female condom, which combines the same safety and efficacy of the first-generation female condom with lower cost. There is information on where to obtain female condoms from both the public sector and on the retail market in the United States. There are step-by-step instructions on how to use the female condom, also available in Spanish. Health professionals can find resources and training materials, and there are pages for quick facts, frequently asked questions, and FC2 in the news. There is also a link to a 55-page bibliography of research on the female condom.