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close this bookNational AIDS Programmes: A Guide to Monitoring and Evaluation. UNAIDS/00.17E (UNAIDS, 2000, 133 p.)
close this folder3. INDICATORS
View the document(introduction...)
View the document3.1. Policy and political commitment
View the document3.2. Condom availability and quality
View the document3.3. Stigma and discrimination
View the document3.4. Knowledge about transmission of HIV
View the document3.5. Voluntary counselling and testing services
View the document3.6. Mother to child transmission
View the document3.7. Sexual negotiation and attitudes
View the document3.8. Sexual behaviour
View the document3.9. Sexual behaviour among young people
View the document3.10. Injecting drug use
View the document3.11. Blood safety
View the document3.12. STI care and prevention
View the document3.13. Care and support for the HIV-infected and their families
View the document3.14. Impact: HIV, STIs, mortality and orphanhood
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3.2. Condom availability and quality

Programme goals

Since it is not sex itself but unprotected sex that spreads HIV in most countries, increasing condom use has been a central intervention strategy for many AIDS programmes. Availability and easy access to good quality condoms are a prerequisite for their use.

There are a number of dimensions to the accessibility of condoms. First, they have to be available in the country, either manufactured or imported in sufficient quantities to meet the needs of the population. Secondly, they must be distributed throughout the country and be conveniently available to the people who need them. Thirdly, they must be affordable to the people that want them. Other dimensions of accessibility include real or perceived barriers to condom acquisition such as restrictions on the age of those who can obtain them or social barriers to women or young people buying condoms.

The quality of condoms is also of great importance, since if they are of poor quality (poorly manufactured or improperly stored) they will not provide effective protection. In some cases misconceptions that condoms do not protect one from HIV transmission have been fuelled by distribution of poor quality condoms. Because increasing condom use is one of the keys to stemming the epidemic, it is essential that stocks of condoms are readily available and of high quality.

In general, AIDS programmes should try to make high quality, affordable condoms accessible to anyone who is likely to have sex, preferably at or near the venues where riskier sex is most likely to occur. For example, making condoms available at drinking and dancing establishments will make it easier for people to access them - many national programmes have begun incorporating such interventions in response to the reality of human behaviour. Measuring the effectiveness of the intervention will require new methods to include non-traditional retail and social establishments in condom distribution assessments.

The fact that condoms are available does not mean they are used. Indicators of condom use are discussed in the section on sexual behaviour.

Key questions

· Is there a national policy on social marketing of condoms?

· Are condoms consistently available within a country?

· Are condoms available to consumers at the right time, place and price?

· Are all condoms of reliable quality by the time they reach the consumer?

Measurement challenges

Condom availability ought to be among the easiest areas of programming to track. A condom is either there or it is not - surely that can be measured? Unfortunately, poor information systems, a plethora of sources of condoms and accountability problems conspire against simplicity. And barriers to accessibility other than simple absence of condoms are often subjective and therefore difficult to measure. Condoms may be widely available in pharmacies, for example. But what help is that to a woman who finds herself unexpectedly choosing to have sex with a new partner after all the pharmacies have closed? If condoms are not readily available to her at that stage, has the programme met its goals or not?

Previous attempts to measure condom availability at the peripheral level (such as by WHO/GPA Prevention Indicator 3) have combined retail surveys with survey questions asking people whether they know where they can get condoms. Responses to individual questionnaires may however be poorly correlated with actual distribution patterns. Such measurement efforts are therefore of limited use in assessing the success of condom distribution nation-wide.

All of the indicators of condom availability and accessibility could equally be used for the female condom.

Condom Availability Indicator 1

Condoms available for distribution nation-wide

(WHO/GPA Prevention Indicator 2)

Core indicator for all epidemics

Definition

Total number of condoms available for distribution nation-wide during the preceding 12 months, divided by the total population aged 15-49. This indicator was formerly the WHO/GPA Prevention Indicator 2.

Measurement tools

WHO/GPA protocol for estimating condom availability for distribution at the central and peripheral level

What it measures

The best distribution system in the world is not much help if there is nothing to distribute. The first challenge for national programmes promoting condom use is to ensure that there are enough condoms in the country to satisfy demand. This indicator measures the number of condoms available for use by those in the most sexually active age group. Where active efforts are made to promote the availability of female condoms, it should include female as well as male condoms, although the indicator should be disaggregated by condom type.

This indicator can be used together with indicators of sexual behaviour to give a powerful picture of the adequacy of condom provision. For example, if a third of all men aged 15-49 say they have had non-regular sex in the past year and 20 percent of married couples say they have used condoms to avoid pregnancy, and yet there are only three condoms available per sexually active adult per year, it can be deduced that the supply of condoms nationally is not sufficient to meet the potential demand.

How to measure it

The indicator is measured by estimating the number of condoms (male and female) available for in-country use during the last 12 months. Key informants are identified and interviewed to uncover all possible sources of condom manufacture, import, distribution and storage. Next, data are collected from all manufacturers and major commercial distributors as well as major donors, condom storage facilities, and government, parastatal and NGO bodies involved in acquiring and distributing condoms.

This indicator sums the condoms in stock nationally at the start of the 12-month period, plus condoms imported during the 12-month period, plus condoms manufactured in country during the same period, minus any exports of condoms over that period. The sum of all condoms available for use in the country during the past 12 months is then divided by the total population aged 15-49.

Strengths and limitations

The number of condoms available at the central level helps assess the adequacy of overall condom availability. It is important to note, however, that “availability” is not the same as “accessibility”, which includes dimensions of price, location and access by sub-populations at risk for unprotected sex and HIV. It is often the case that not all available condoms are distributed, or reach the individuals that most need them to protect against the spread of HIV. This indicator by itself cannot give a picture of how many “in-stock” condoms actually get distributed or used.

Ironically, efforts at the national level to encourage condom use sometimes complicate the measurement of this indicator. Many countries have deregulated condom imports in the face of AIDS, in order to maximise the number of condoms available. This means that condoms may be imported by a wide variety of companies, NGOs, donors and government departments (the health ministry, the defence ministry, etc.) without necessarily reporting numbers imported to a central body. Traditionally, there is also a distinction between condoms distributed through family planning programmes and those distributed to reduce sexually transmitted infections. It is important to take both sources into account. If possible data need to be presented by programme, as family planning programme condoms are primarily intended for relatively low-risk acts within stable monogamous unions, while AIDS programme condoms aim at higher risk sexual contacts.

Where condom promotion activities are centred around marketing condoms at subsidised prices to people likely to be engaging in risky sex (social marketing), sales of particular brands of condoms can also provide a useful indicator of programme success. Organisations responsible for the social marketing of condoms typically keep very good records of condoms distributed down to the retail level. While these data tell only part of the story of condom availability, they provide a very low-cost source of information for the National AIDS Programme, and can be very useful for advocacy purposes. A rise in the number of condoms manufactured or imported into a country, or of condoms sold, can be useful in supporting other indicators measuring rises in self-reported condom use, or falls in self-reported STIs and eventually HIV prevalence.

Condom Availability Indicator 2

Retail outlets and services with condoms in stock

(Modified WHO/GPA Prevention Indicator 3)

Core indicator for generalised epidemics Additional for concentrated epidemics

Definition

The proportion of randomly selected retail outlets and service delivery points that have condoms in stock at the time of a survey, of all retail outlets and service delivery points selected for survey

Measurement tools

MEASURE Evaluation/WHO/PSI Compiled Condom Availability and Quality Protocol

What it measures

This indicator measures actual distribution of condoms at designated points at any one point in time. It reflects the success of attempts to broaden the distribution of condoms so that they are more widely available to people likely to need them, and at locations and times when people are likely to need them.

How to measure it

A number of sites of different types are randomly selected for a retail survey. The sampling frame should be stratified to reflect sites in both urban and rural areas. Sites will be selected from a standard checklist of venues where condoms should be accessible, including bars and night clubs, different classes of retail shops (for example pharmacies, supermarkets, convenience stores, market stalls, petrol stations), STI clinics and other service provision points. Outlets that provide services to people who may find it difficult to access condoms at conventional sites - for example teenagers - should be included. The indicator is the number of sites with condoms currently in stock, divided by the total number of sites surveyed.

While the indicator gives a single summary figure, the data can also be disaggregated by outlet type. This will provide invaluable information for programme managers, and for those seeking to improve the marketing of condoms. Outlet types may be analysed by the populations they seek to serve. This provides an idea of the adequacy of efforts to meet the needs of people with potentially high-risk behaviour, such as young people or those in mobile occupations.

Strengths and limitations

The statistical departments or finance ministries of many countries conduct regular (usually quarterly) retail surveys that include price and availability data for a wide variety of commodities. These are usually conducted to help in the compilation of the consumer price index and other economic statistics, and are often contracted to private market research firms. They typically use a well-established sampling frame covering a wide variety of venues nation-wide. Where such surveys exist, condoms can simply be added to the basket of commodities for which data are collected. Certain venues (such as STI clinics, family planning clinics, etc.) may not be covered by the regular retail survey; in this case special surveys of these extra venues can be undertaken to provide the necessary extra data. Outlets such as bars, places where young people congregate and other high transmission sites may not be part of a current sampling frame for retail survey. It may be necessary to identify such sites through key informants. On the whole, however, the cost to the national AIDS programme of adding condoms to retail surveys (in both human and monetary terms) should be minimal.

It is recommended that this indicator use a standard list of venues in conducting the retail survey. However some countries may choose to modify the list to include non-standard venues where a special effort is being made to distribute condoms - secondary schools might be an example. It may be difficult to identify all distribution sites if they are non-formal venues. In others, not all of the venues will be relevant. This is especially true in low-level or concentrated epidemics, where the focus may be distribution of condoms within a well-defined sub-population with particularly high risk. The fact that condoms are not widely distributed in convenience stores across the country will not be an indication of programme failure in this situation.

Countries may also wish to weight the different outlet types in constructing the aggregate indicator. It is not possible to recommend a standard weighting procedure. Any variation in venues or weighting will affect the comparability of the indicator across countries. These limitations will not affect the presentation of data disaggregated by outlet type, and should not affect trends over time in a single country unless the venue mix is changed.

A limitation of the measure is that it provides a “snapshot” of availability at a single point in time. Where distribution is relatively regular, this poses no major problems. However when there are serious disruptions to condom supply at the central level, the repercussions may be felt simultaneously at a large majority of venues. If a survey is carried out at this time, it will appear as though the peripheral distribution system is inadequate whereas in fact the fault lies at the central level. In countries where quarterly retail surveys are undertaken, it may be possible to report an annual average to better reflect consistency of supply.

Condom Availability Indicator 3

Condoms that meet quality control measures

Core indicator in all epidemics

Definition

The percent of condoms in central stock and in retail outlets that meet WHO quality specifications

Measurement tools

MEASURE Evaluation/WHO/PSI Compiled Condom Availability and Quality Protocol

What it measures

The quality of condoms at their time of use determines their effectiveness in preventing HIV, STIs and pregnancy. Quality (and more particularly poor quality) also affects popular perception of the value of condoms, which can in turn have a major impact on the success of prevention programmes.

There are many stages at which the quality of a condom may have deteriorated to the point of being unacceptable. Condoms may be poorly manufactured in the first place, and manufacturers’ quality control may be inadequate. Condoms may be improperly stored at the central level. Or they may be in perfect condition at the time of distribution but sit in the sunshine for two months on a market stall before being sold. Since it is not practical to sample condoms once they have been acquired by end users, the indicator is based on condoms sampled both from central storage and from retail outlets.

The quality indicator will be aggregated into a single figure. However it is vital that the data be reported separately by source of sampled condom for programme purposes. If poor quality is detected at the central level, national tender specifications or quality control procedures will have to be remedied. Poor quality at the retail level may require changes in the distribution system or better advice to retailers on stock handling and storage.

How to measure it

The sampling frame for retail outlets used in Condom Availability Indicator 2 can be used for the retail portion of this indicator; indeed, condoms may be sampled from retail outlets during the retail survey. Care should be taken in the handling and storage of condoms between sampling and testing, to ensure that no deterioration in quality is attributable to the sampling and testing procedure itself. At the central level, a sampling frame can be constructed from the central level storage facilities identified in the calculation of Condom Availability Indicator 1, and condoms sampled at random from those facilities.

A variety of testing procedures are available for condom quality control. Although all measure should give similar results, it is advisable to adopt one methodology and stick with it, to avoid any disruption of trends over time.

Strengths and limitations

This indicator provides an objective measure of condom quality within a country. It is simple to measure, but does require equipment and trained staff. Since behavioural studies suggest that perceptions of poor condom quality contribute significantly to people’s failure to use condoms, information about adequate quality can be used to good effect in promoting their wider use. It should be noted, however, that this indicator is a double-edged sword. If results are poor and immediate rectifying action is not taken, people’s reservations about condom use are likely to be reinforced, and condom use might suffer further.

This indicator will miss deterioration which takes place after the acquisition of a condom by a client, but before its use. Poor storage practices at this point may contribute significantly to condom failure rates.