|The Female Condom and AIDS (UNAIDS, 1997, 8 p.)|
point of view
UNAIDS Best Practice Collection
· A woman's equivalent of the traditional condom seems a simple idea, yet the "female condom" (worn within the vagina rather than on the penis) has been around for less than a decade. Available in an increasing number of countries around the world, it offers great promise for reducing the spread of HIV and AIDS.
· Cheap and reliable, the traditional condom (or male condom) is used by millions all over the world to avoid pregnancies. Until recently, it has also been the only barrier method for preventing the passing of sexually transmitted diseases (STDs), including HIV, between two sex partners. Used correctly every time people have sex, it is over 95% effective against the transmission of HIV.
· The fact that the condom prevents transmission of other STDs such as syphilis or gonorrhoea is of additional importance to the fight against HIV and AIDS because people who have another STD are more vulnerable to being infected by HIV.
· The traditional condom is not the perfect method for everyone, however. For example, many couples dislike having to interrupt sex in order for a man to put one on. Up to 8% of people are allergic to latex, the main ingredient in most condoms. And many feel that it dulls sexual pleasure.
· In family planning programmes, it has been proven that a wider choice of contraceptive methods results in fewer pregnancies. The same has been found in testing of the female condom: adding this new option for protected sex results in fewer cases of unprotected sex.
· About 42% of the 22 million adults now living with HIV are women. Moreover, the proportion of women becoming infected with the virus is growing in every region of the world.
· Eight out of 10 infected women get the virus by having unprotected sex with an infected male partner.
Women's biological vulnerability to HIV through sexual intercourse is up to four times as high as men's. Yet women often have little control over whether a man uses a traditional condom or not. In many situations, women are reluctant or unable to say no to sex if the man refuses to wear one.
· Though usually requiring the agreement of both partners, in some cases the female condom can give a woman more control. Since it can be inserted hours before intercourse, it can improve protection in situations where consumption of alcohol or drugs may reduce the chances that a male condom will be used.
· A female condom is a soft yet strong polyurethane sheath, about the same length as a male condom but wider. A plastic ring at the closed end helps keep the condom fixed within the vagina during sex. A larger ring at the open end stays outside the vagina, spreading over the woman's external genital area.
· The female condom is safe and can be used without a prescription or medical supervision. Unlike an IUD or the pill, it causes no side effects such as bleeding or cramps.
· Polyurethane is less likely to break or leak than the latex which most male condoms are made of, and causes fewer allergic reactions.
· The female condom provides extra protection to men and women because it covers both the entrance to the vagina and the base of the penis. These are areas where STD sores make it easy for HIV to enter.
The human immunodeficiency virus (HIV) which causes AIDS continues to spread in many parts of the world, and women are an increasingly large proportion of those infected. From 25% in 1990, women's proportion of the total number of adults with HIV or AIDS rose to 42% in 1995.
By the end of 1996, over 9 million women were estimated to have the virus. About 80% of them got the disease through unprotected sex with an infected male partner. (The challenges posed by women's greater physical and social vulnerability to HIV transmission through sex are described below.) The others got HIV through other means such as infected blood transfusions and injecting drugs with unclean needles.
The male condom is an indispensable part of the campaign to prevent infection by HIV, and until recently was the only "barrier" available. Today, the invention of the "female condom" offers a new barrier method which gives women more control over their bodies and couples more options for protecting themselves and their sex partners.
The female condom does not replace the male condom or any other form of protection. Instead, it doubles the arsenal of weapons available in the fight against sexually transmitted diseases (STDs) including HIV. Testing in various parts of the world suggests that when it is made available to women, the female condom reduces further the number of unprotected sex acts and the transmission of STDs.
What is a female condom, exactly?
First proposed by a Danish doctor named Lasse Hessel in the mid-1980s, the female condom is now commercially available in many countries. It is manufactured by the Female Health Company through its subsidiary Chartex International of Chicago, Illinois. Brand names include Reality, Femidom and Femi.
The female condom is a soft but strong sheath made of clear polyurethane plastic. The sheath has two plastic rings at either end. The one at the closed end is used to help with insertion and to keep the condom in place against the cervix. The ring at the open end is slightly larger and remains outside the vagina, covering both the woman's genitalia and the base of the man's penis.
The condoms are equipped with a water-based lubricant which makes insertion easier and allows comfortable movement during sex. Currently, they are labelled for single-use only.
Unlike a diaphragm or an oral contraceptive, no prescription or medical help is necessary for a woman to use the female condom. It does not need to be specially fitted. The woman puts it into her vagina using her fingers, and can do so anytime from hours ahead to immediately before sex. Another practical advantage is that the female condom does not have to be removed immediately after ejaculation.
The traditional condom is cheap, widely available and highly effective if used correctly. It is an essential part of the fight against HIV and AIDS. But it is not always the perfect solution.
Most commercial condoms are made of latex, a soft rubber. Up to 8% of people are allergic to latex, and therefore cannot use it. Because latex is soft, male condoms have to be used carefully in order not to break or tear them. A male condom can only be put on when the penis is erect. For many couples, this means an unpleasant interruption of sexual activity. As well, some men feel that a condom dulls their sexual pleasure, and for this reason prefer not to use one.
If alcohol or drugs have been consumed before sex, it is likely that a male condom will be forgotten or not used because of insufficient erection to put it on. There is also a greater risk that it will be used incorrectly, torn while being taken out of its package, or that leakage will occur from the open end.
Safe and reliable
Because of the polyurethane used to make it, the female condom is both strong and durable. No special storage arrangements have to be made because polyurethane is not affected by changes in temperature and dampness. In contrast, the latex in a male condom can be damaged by heat, light and humidity. The expiry date on the female condom is 60 months (5 years) from the date of manufacture.
Testing of female condoms indicates that semen leakage after sex is less than with a male condom, and that the risk of semen getting into the vagina due to dislodgement is about one-third lower. These tests were done with ultrasound equipment to check the stability of the condom, and various sexual positions were tried.
Other tests have investigated the female condom's risk of causing irritation, or encouraging bacteria or other health problems in the vagina. In some tests, female condoms were used in sex and then left in the vagina overnight, a much longer period than normal. The results showed no complications, indicating that even women with very sensitive skin can use the female condom.
"I don't feel right to refuse sex, because it's sinful. A woman is her husband's property. She is already bought."
A woman in Indonesia
There may be benefits to women who are no longer of child-bearing age. A recent study in Britain indicates that women who suffer pain during sex due to vaginal dryness (particularly women who have passed the menopause) can be helped by the female condom.
Women's lack of bargaining power
Until recently, the traditional male condom has been the only barrier method available to prevent the transmission of HIV during sexual intercourse. If the man refuses to use one, many women do not have the bargaining power to say no to sex. The reasons for this are many. Most frequently it is the result of the lower social status of women in many societies.
Many people think that a woman is only at risk of HIV if she has many sex partners or is a sex worker. Like the myth that HIV is a "homosexual disease," this is far from true. Many women are infected by the only man they have ever had sex with - their husband. It may be difficult for them to argue with his decision, particularly on when and how to have sex.
Women who have more than one partner are often in an even weaker position to insist on protection. Sex workers may be reluctant to argue with a client who does not want to wear a condom, fearing both the loss of income and - far too often - a violent reaction. In recent years, the demand for uninfected sex partners has resulted in growing numbers of adolescent girls being brought into the sex trade. These girls are even less able to insist that a man use a condom.
[See also Reducing women's vulnerability to HIV/AIDS: UNAIDS Point of View.]
Women's physical vulnerability
Women are about four times more vulnerable than men to sexually
transmitted diseases, including
HIV. This is largely because of anatomy: the area of the female genitals exposed to semen and other sexual fluids during sex is four times larger than that of men.
Women are also at more risk of getting infected because semen contains greater amounts of the virus than vaginal fluids. Like men, women run a much higher risk of infection with HIV if they have an untreated STD. But the problem is that STDs in women often cause no symptoms. And women with "silent" gonorrhoea, trichomoniasis or chlamydia may get late treatment or none at all.
More protection for both women and men
Anything that reduces the spread of HIV in women reduces its spread in men and vice versa. One of the main ways of combating STDs for both is to reduce the number of times they have unprotected sex.
A 1995 UNAIDS study in Thailand indicates that the availability of female condoms can indeed reduce unprotected sex. In the study, some groups of female sex workers were given male condoms only, while others were given both male and female condoms. Those given both had less unprotected sex and got one-third fewer STDs than those given only the male condom.
Both women and men's vulnerability to HIV is greatly increased by genital ulcers caused by STDs such as syphilis or herpes. The female condom's greater coverage of the female genitals (vagina, cervix and vulva) and the base of the man's penis adds extra protection for both partners.
Using the female condom will require the agreement of both partners in most cases, but it does give a woman more control. Since it can be inserted hours before intercourse, it can provide protection in situations where consumption of alcohol or drugs may reduce the chances that a male condom will be used.
No one wants to use a product that feels uncomfortable, so a variety of studies have been done on how users and their partners feel about female condoms. The results of this research have varied from place to place and from study to study, but the overall finding is that the female condom is acceptable to many women and men. This is especially true when they are already familiar with the male condom. While many men preferred the male condom, few reported finding the female condom uncomfortable.
In one large study of almost 600 urban and rural women in South Africa, 84% of the women said they would use the female condom in future. 47% of these same women said their partners either liked it or had no problems with it.
Practice makes it easier
One overall finding of testing is that a little practice makes a great difference in how women feel about female condoms. Package instructions suggest women try it three times before deciding whether they like it or not. The most frequent complaint about the condoms themselves was that they seem too long and a little difficult to insert the first time. Some women reported discomfort with the rings. These problems were reduced or solved by repeated use.
Not just physical
Acceptability does not only depend on physical feeling. In several studies, it was found that women who feared that they were at a high risk of STD infection seemed more inclined to accept the female condom. A group of female sex workers tested in France said they felt reassured with a female condom because they knew that polyurethane is stronger than latex and therefore felt confident there would be no breakage. At the same time, another group of sex workers in Zimbabwe worried that the look of the part of the female condom that stays outside their vagina might "turn off" their clients.
"The availability of more prevention choices will lead to more satisfied users and, consequently, more HIV prevention."
Christopher J. Elias, The Population Council
The right price
Even if more manufacturers enter the market, the female condom will probably always cost more to produce than the male condom. Polyurethane is more expensive than latex, and more of it is used. As well, the manufacturing process itself is more costly even when large numbers are being produced.
When left entirely to commercial markets, the price of female condoms in developing countries is between US $2 and $3. This is much too high for the populations who are most likely to benefit from it. A study in Zimbabwe found that women were prepared to pay a maximum of 25 Zimbabwe cents (US $0.03) for female condoms. In comparison, male condoms were sold at around 15 Zimbabwe cents.
Recently, UNAIDS surveyed organizations in developing countries in order to estimate demand at different prices. Data from 60 countries suggest that there is global demand for female condoms at a widely affordable price. Demand was estimated at 7 million for 1997 and 13 million for 1998.
Selling at a public sector price
To make female condoms more affordable, UNAIDS has negotiated a programme with the producer of the female condom, the Female Health Company, based on a guaranteed purchase price for public sector agencies in developing countries. This price for 1997 is below US $1 and may decrease further in coming years if sales continue to increase. Even with an affordable price, information campaigns will be needed to educate women about the female condom. Men must also be targeted with information since their cooperation is needed for widespread acceptance.
Training will also be needed for health workers and counsellors so that they can introduce the female condom to potential users in a positive and empowering way. And distribution channels will have to be established. These will include family planning clinics and distribution points, but should also include private sector clinics, pharmacies and school-based clinics.
The female condom
"The female condom does not replace the male condom. What it does is give women an additional option for protecting themselves and their partners."
Peter Piot, Executive Director of UNAIDS
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1. Acquired immunodeficiency syndrome - transmission
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