|The Female Condom in Zimbabwe (UNAIDS - Best Practice Digest, 2001, 3 p.)|
Summarised from the report The Female Condom: Dynamics of Use in Urban Zimbabwe, by Deanna Kerrigan, Steve Mobley, Naomi Rutenberg, Andrew Fisher and Ellen Weiss. Published by Horizons, The Population Council, October 2000
For further information, contact Horizons Project, Communications Unit, 4301 Connecticut Avenue, NW Suite 280, Washington, DC 20008 USA.
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The female condom is a relatively new product that prevents pregnancy and sexually transmitted infections (STIs). The WHO estimates a 5% annual accidental pregnancy rate associated with perfect use of the female condom, compared to 3% with the male condom. Extrapolations from a study on contraceptive efficacy suggest that perfect use of the female condom also reduces the annual risk of becoming infected with HIV by more than 90% among women who have intercourse twice weekly with an infected male. This is similar to the level of protection offered by the male condom.
The female condom may also prove to be an HIV protection option over which women have more control. Many women may be unable or unwilling to negotiate male condom use with their sexual partners because of prevailing gender-related inequalities, norms and roles that exist in many socio-cultural contexts.
In 1996, based on the positive findings of acceptability trials and as a result of advocacy efforts by the Women and AIDS Support Network, the Zimbabwe National AIDS Coordination Programme (NACP) of the Ministry of Health and Child Welfare invited Population Services International (PSI) to initiate a five-year female condom social marketing programme in Zimbabwe. The programme was launched in 1997.
To avoid the stigma associated with HIV/STI prevention, the female condom is marketed as a family planning product, a "contraceptive sheath" under the brand name care (TM). The product's original marketing slogans included "The care contraceptive sheath is for caring couples" and "For women and men who care". The female condom was initially sold through selected pharmacies and clinics at a heavily subsidized retail price of US$ 0.24 for a box of two; distribution has since expanded to other urban outlets, including large supermarkets and convenience stores.
As experience with the female condom in Zimbabwe and in other countries increases, a number of research questions has arisen about its use and its potential for HIV/STI reduction. Answers to these questions (for example, who uses the female condom, with whom and why?) have important implications for reproductive health programmes. Currently, the female condom is a relatively expensive product, approximately ten times the cost of a male condom. From a programme and policy standpoint, the decision to introduce this product in a given country on a wide scale implies significant financial costs. The introduction of heavily subsidized and relatively inexpensive female condoms in Zimbabwe through a social marketing programme has provided large numbers of urban women with easy access to this product. So the situation in Zimbabwe allowed the Horizons Project and PSI to address critical research questions with a fairly large number of respondents about female condom use under real life conditions.
The study used a combination of quantitative and qualitative methods. An intercept survey was conducted with women and men exiting urban sales outlets that carry both Protector Plus ä male condoms and careä female condoms. In total, 493 female condom users, 633 male condom users and 624 non-users are included in the analyses upon which this report is based. Male and female users of the female condom also participated in in-depth interviews and focus groups.
1. Who uses the female condom?
Users are generally in their mid- to late-twenties and, compared to male condom users and non-users of either method, have higher levels of education and access to household resources. Among women, more users of the female condom are unmarried and are primary breadwinners in their households compared to users of male condoms and non-users. The vast majority of men and women used the male condom at least once before trying the female condom. More than half of male users but only 17% of female users reported having more than one sexual partner within the last year. Use of the female condom is higher within the context of marriage or regular partnerships rather than casual or commercial partnerships.
2. Reasons for female condom use
Novelty or experimentation and pregnancy prevention are primary reasons for the initial use of the female condom. However, a third of men and 21% of women reported STI/HIV prevention as a motivator for trying it.
3. Perceptions of, and problems with, the female condom
Users perceive the female condom to be effective and reliable as both an STI/HIV prevention method and a contraceptive method. But 30% of men and 57% of women reported some difficulty with use, such as problems with insertion, discomfort during sex and excess lubrication.
4. Negotiation of the female condom
Both male and female users concur that women, more than men, initiate dialogue about using the female condom, decide on its use and procure the product. However, a considerable percentage of both male and female users reported that both partners jointly decide to use it. Focus group and in-depth interview data reveal that while some women, particularly married women, are interested in using the female condom for disease prevention, they are not comfortable discussing this openly with their partner. Some 13% of women reported using the female condom without their partners' knowledge. While this suggests that for some women the female condom can be totally under their control, in the vast majority of cases it requires communication with and cooperation from a woman's partner.
Nearly a fourth of women and 15% of men said that one of their partners has opposed female condom use. While most said they used a male condom instead, among married women about half whose partner opposed using the female condom had unprotected sex instead.
5. Consistency of female condom use
Overall, about 15% of women and men reported always using the female condom. Consistent use was reported much less frequently with spouses than with regular partners outside marriage. Among those who have used both the female and male condom, approximately 80% of men said they intend to use both methods in future. A greater proportion of women said they will use the female condom again (68%) rather than the male condom (54%). Married women were less likely than single women to report continued use of either barrier method.
6. Increased STI/HIV protection among some female condom users
Twenty-seven percent of married women had never used a male condom before they used the female condom, and 20% of consistent female condom users reported that they were not consistent male condom users before trying the female condom.
7. Continued male condom use among female condom users
Of inconsistent female condom users who have used the male condom, 93.8% reported continued use of the male condom. Female condom users often alternate the use of male and female condoms. Women reported using female condoms when their husbands came home late at night or when they suspect infidelity. Also, some men reported using female condoms with their wives and regular partners while continuing to use male condoms with casual partners and sex workers.
The female condom has been used within marriage or a regular partnership, and among consistent users, primarily as a family planning method which reflects the aims of the social marketing campaign. Single women and married men with outside partners seem to benefit most from its introduction. These are important groups to reach in a country such as Zimbabwe, which has a high prevalence of HIV in the general population.
An important issue for programme planners is ensuring access to the female condom for people from all economic and educational strata. If significantly greater percentages of people with higher socio-economic status or more formal education continue to use the product at higher rates, then the price of the condom may be too high and/or special support services may be needed to facilitate access, negotiation, or correct use of the female condom among people with lower levels of resources and education.
Married women have particular needs that have to be addressed in future campaigns and educational programmes. Many married women perceive themselves to be at risk of HIV infection but do not use any barrier method. Among female condom users, married women are more likely than single women to encounter partner resistance to the female condom and less likely to report future use.
Face-to-face contact - with partners, friends, relatives or health professionals - was found to be important for motivating female condom use. Training both peer educators as well as clinicians and pharmacists to provide women and men with information and support services about the product may be an effective means of increasing correct and continued use. Also, female condom programming must assist users, in particular women, to be prepared for negotiation and agreement of use with partners. They must be equipped with the necessary skills and tools.
Data from this study suggest that female condoms are providing
new and additional protection from HIV/STI to some study participants. More
research is needed to more accurately assess the female condom's contribution to
increasing the incidence of protected sex among women and men in