FHI - Making Prevention Work Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997 Making Prevention Work 3. Prevention Marketing: Condoms and Beyond

Table of Contents

3. Prevention Marketing: Condoms and Beyond (See Below)

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

5. Behavioral Research: Using Results to Design Behavior Change Interventions

6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

Partners and Acronyms

3. Prevention Marketing: Condoms and Beyond

The use of marketing techniques and systems to promote and deliver methods of protecting public health -- known as social marketing, is a key HIV/AIDS prevention strategy. The basic approach involves packaging, pricing and presenting a product or behavior to appeal to the target market and engaging the participation of wholesalers and retailers in distribution and conventional trade promotions. Mass media are often used to convey the benefits of the desired behavior for a particular target audience.

Social marketing has been applied in a wide range of public health programs, including family planning, child survival and malaria prevention. These projects commonly make use of the existing logistics systems that supply the commercial networks delivering most daily necessities. The most successful projects depend on subsidized products to ensure retail prices that are within the buying power of most people in developing countries.

The advantages of a social marketing approach to promoting condoms for HIV/AIDS prevention include the ability to make products available to people when and where they need them and to saturate geographic areas of special interest with a product. The privacy -- even anonymity -- of the commercial transaction between a vendor and customer is another benefit. And social marketing is a cost-effective strategy: even with a highly subsidized product, the cost of distribution, from intermediate warehousing to the actual delivery of product into the hands of the user, is borne by the purchaser, not by a donor or the public health system.

The success of condom social marketing (CSM) efforts has led to a new interest in expanding the use of marketing strategies in public health programs. Such prevention marketing can be used to encourage health-promoting behaviors, as well as other prevention "products."

Improving Access, Increasing Sales

FHI worked with its social marketing subcontractor, Population Services International (PSI), and other organizations to make condoms accessible, affordable and attractive to millions of people. By June 30, 1997, the total number of condoms sold by social marketing projects and distributed for free by NGOs had exceeded 254 million. AIDSCAP-supported CSM projects sold 87 percent of those condoms (almost 222 million) in eight countries.

AIDSCAP CSM SALES

Country Length of Program Total Sales
in Millions

Brazil (states of Sa� Paulo and Rio de Janeiro) July 1993 - March 1997 82.0

Ethiopia January 1993 - September 1996 44.0

Tanzania August 1993 - June 1997 39.0

Cameroon January 1993 - August 1996 24.0

Haiti September 1993 - April 1996 16.3

Nepal February 1994 - June 1997 12.0

Rwanda April 1993 - April 1994
March 1995 - August 1996
2.6

South Africa (Welkom mining communities) April 1996 - April 1997 2.0

Total 221.9

In those countries AIDSCAP strengthened existing CSM operations, providing the support needed to expand sales outlets to new areas and to target marketing efforts to reach critical audiences. In fact, each of these CSM projects enjoyed a marked increase in sales under AIDSCAP support. For example, in Ethiopia the PSI project's sales rose 141 percent, from 829,000 a month before the AIDSCAP program in that country began to 2 million a month in September 1996. AIDSCAP support also boosted monthly sales by more than 100 percent in Haiti and Nepal.

Perhaps even more important, AIDSCAP-supported CSM projects succeeded in providing reliable supplies to otherwise difficult-to-reach groups and individuals at high risk of HIV infection by adapting traditional commercial logistics systems. Innovations such as the use of nontraditional sales outlets (bars, restaurants, kiosks and other small retailers), NGO sales agents and dedicated sales forces increased sales while ensuring that condoms were available to those who needed them most.

Impressive sales figures were achieved despite formidable obstacles in almost every country. In Ethiopia, for example, the CSM project was forced to ration condoms due to limited supplies. The internecine war in Rwanda claimed the lives of four PSI staff and forced the project to suspend sales for almost a year, prompting PSI to distribute free condoms in Rwandan refugee camps (Box 3.1). Political violence and an economic embargo in Haiti also posed safety concerns and logistical challenges to the PSI project there (Box 3.2), and Brazil was plagued by both tariff and regulatory barriers that restricted sales and complicated the administration of CSM operations.

That CSM projects were able to overcome these challenges to record such remarkable successes is testament to the resilience and pragmatism of the social marketing approach. It is also an indication of the great unmet need for condoms in many countries throughout the world. AIDSCAP's experience suggests that providing convenient access to affordable condoms is the most effective way to meet that demand.

3.1 Riding the Phoenix: CSM Sales Rise as Rwanda Rebuilds
In the center of Kigali's most congested traffic circle stands a kiosk. Once a newspaper stand, this modest structure was a mute witness to one of this century's bloodiest tragedies: the 1994 slaughter of more than a half million Rwandans by their fellow citizens.

Less than a year later, the kiosk -- freshly painted with a rainbow design -- became one of the first small businesses to reopen. In the midday heat, many stop to buy cold drinks, but also take the opportunity to ask the nurse behind the counter about AIDS and buy packets of Prudence condoms. In its new role, the kiosk has become a bright symbol of hope in a nation desperate to renew itself.

When genocidal civil war broke out in April 1994, most foreign assistance and NGO projects in Rwanda came to an immediate halt. Despite the desperate need for HIV/AIDS interventions -- before the war, 30 percent or more of the country's urban population was estimated to be HIV-positive -- the AIDSCAP program was also forced to close.

Instead, AIDSCAP used country program funds to establish an innovative HIV and STD prevention and care project for some 2 million Rwandan refugees in the Ngara District refugee camps in Tanzania. Managed by CARE International, the project included condom distribution by AIDSCAP's social marketing partner, PSI. Although the Prudence condoms that refugees remembered so well from home had to be distributed free of charge, PSI nonetheless promoted them creatively and aggressively to enhance their value and thus increase their use.

When AIDSCAP and PSI finally returned to Rwanda almost a year later, the staff who had survived the bloodshed faced the difficult and sometimes disheartening ordeal of rebuilding the program from the ground up. AIDSCAP/PSI's entire stock of condoms had disappeared from a nearby warehouse. The office was a shambles. All the computers and other office equipment and most of the files were gone, and only one vehicle from the original office fleet remained -- the one staff had used to escape to Burundi.

But the real challenge was not the nuts and bolts of restocking condoms or reconstructing records destroyed in the looting. Returning staff perceived a profound change in the society around them, a population deeply affected by the bloody nightmare it had experienced.

"We soon realized that the physical destruction in Kigali was almost insignificant compared to the trauma the Rwandans had lived through," said Kyle Peterson, former PSI country representative in Rwanda. "The experience of the genocide so overpowered everything else that we began to doubt that any other message might be heard at all."

Peterson and the rest of the PSI staff decided that the best way to both catch the public's attention and aid in Rwanda's long road to healing was to promote Prudence in the most positive way possible. They would use colorful, interesting advertisements and posters and create catchy, upbeat jingles for the radio that would lift spirits as they spread the Prudence brand name around the country. The new messages stressed the sweetness of life by emphasizing the benefits of taking responsibility for one's health.

The program built on the solid foundation it had established before the war to resume and expand sales throughout the country. Within months, it had succeeded in opening 1,500 new points of sale and had achieved impressive average monthly sales of more than 229,000.

Salesmen reported that Prudence's reputation had survived the war and the program's shutdown. "As survivors slowly returned to their homes, overcome with grief and loss, we were amazed to discover how many of them actually remembered Prudence and recalled their high opinion of its quality before the war broke out," said Peterson.

But the key to the astonishing success of condom social marketing in Rwanda may be more fundamental. Social marketing experts attribute the resilience of the program to society's basic instinct for survival. The marketplace has always been central to the Rwandan culture and economy, and the country's commercial infrastructure never disappeared entirely -- even during the worst of the violence, even in the refugee camps of Tanzania.

"Social marketing, even during catastrophes, always make sense because the commercial sector always reappears, like a phoenix," said Peterson. "The question is, how can public health people learn to ride that phoenix?"

3.2 NGO Participation Boosts Condom Sales in Haiti
In the Haitian countryside, shopping for condoms once meant a two-hour hike to a distant town or rural clinic. Even in the cities, commercial sales outlets were scarce. But today, Pant� condoms, sold at bars, hotels, beauty shops, kiosks, markets and nightclubs, are accessible at all hours of the day, even in remote regions of Haiti.

Pant� (Creole for panther) is the brand name of the condom that PSI introduced in Haiti in 1990. Two years later, funding from AIDSCAP enabled PSI to create a dynamic condom social marketing (CSM) project to package, promote and sell the top-quality Pant� at a fraction of the cost of commercial condoms.

Accessibility and affordability meant extraordinary success for the project, despite the political instability and economic crisis that followed the overthrow of Haiti's elected government in 1991. Much of the nation's commercial distribution system came to a standstill, but the CSM project flourished. In less than four years, monthly sales of increased from an average of 3,000 to more than 540,000. In fact, in per capita sales, the project in Haiti ranked as one of the world's leading CSM projects.

Condom sales rose as PSI and AIDSCAP established more than 3,000 points of sale throughout the country, ultimately penetrating into all but one of Haiti's difficult-to-reach rural d�partements. For the first time, many of the 70 percent of Haitians who live in the countryside could find affordable condoms close to home.

This level of national coverage -- unusual even for a CSM project -- was the result of the unique approach that PSI and AIDSCAP took to improving distribution. In addition to working with some 100 independent and commercial vendors, the project recruited and trained 175 outreach workers from four of its partner NGOs to act as wholesale distributors and retail sales agents. Each NGO-initiated sale returned a percentage of the profit to the organization, an incentive that simultaneously built the CSM project and the financial strength of the NGOs,

These NGO partners helped the CSM project expand into rural areas where distribution simply was not profitable for commercial sales agents. And their enthusiasm and commitment carried the project through when distribution was threatened by gasoline shortages that caused the breakdown of commercial transportation.

"Many condom outlets remained stocked throughout difficult periods only because NGO sales agents collected stock themselves," said Bertrovna Grimard, a PSI consultant who worked with the Haiti project.

NGO sales agents sold almost 40 percent of all the condoms sold by the CSM project from 1991 to 1996. Their role in achieving remarkably high sales in a poverty-stricken country and in expanding condom access to remote regions can serve as a model for CSM projects throughout the world.

Lessons Learned

Reaching Those At Risk

Extending condom sales beyond pharmacies, supermarkets and other large stores to nontraditional outlets such as bars, brothels, liquor stores and roadside stands makes condoms available to individuals who are likely to use them in high-risk situations.

AIDSCAP's most significant and successful adaptation of the contraceptive social marketing model was to emphasize sales through nontraditional outlets to reach those at greatest risk of HIV infection. Sales through wholesalers and large commercial outlets are more efficient, but much less likely to provide access to condoms at the times and in the locations where people usually engage in high-risk sex. For example, pharmacies are rarely located in red-light districts, and most are not open for business late at night. By giving sales agents incentives to market condoms through nontraditional outlets, AIDSCAP provided convenient access to low-cost condoms at thousands of strategic locations.

NGOs can become important partners for social marketing.

The association between NGOs and social marketing is not a natural one. Social marketing specialists operate in the commercial sector, appealing to profit motives rather than altruistic goals. NGO staff who provide assistance to the poor may object philosophically to selling anything to their clients or members. But both groups recognize the urgent need to ensure a reliable condom supply to NGO clients and members, and that common ground enabled AIDSCAP to foster productive relationships between social marketing operations and NGOs.

All social marketing operations were coordinated with the activities of other AIDSCAP partners -- primarily NGOs -- to ensure that target populations received comprehensive HIV/AIDS prevention services. Some NGO personnel even acted as condom sales agents. For example, Ethiopian youth and Nigerian sex workers trained by AIDSCAP as volunteer educators sold condoms to their peers.

In a number of countries, NGOs emerged as significant retailers of condoms. For example in Haiti, where government condom distribution ceased during years of political turmoil and traditional social marketing efforts were unable to reach those living in the most poverty-stricken or remote regions, the AIDSCAP-supported PSI social marketing project sold condoms at wholesale prices to NGOs, who in turn sold them to their clients at retail (Box 3.2). NGO staff learned that the (highly subsidized) retail price was bearable to their clients, experienced the superior performance of the private sector delivery system, and generated funds for their organizations through the small profits they received. Skeptical at first of the ability of NGOs to handle retail products, the social marketing managers saw NGO staff account for an increasing share of their sales, reaching 25 percent of the 540,000 condoms sold every month.

The success of this strategy led to replication in several other countries. PSI managers of AIDSCAP-sponsored programs in Tanzania, Rwanda and South Africa trained more than 2,300 NGO staff as condom sales agents.

A social marketing project can successfully target marketing efforts with a sales force dedicated to selling its product.

In Brazil, AIDSCAP's social marketing partner DKT do Brasil could not rely on NGO sales agents to increase access to condoms for NGO clients because Brazilian law barred nonprofit organizations from the retail trade. Instead, AIDSCAP provided separate funds to DKT to ensure that sales efforts were particularly intense in the geographic areas served by the NGOs. Ordinarily DKT would have concentrated its resources on the most efficient (low-cost) sales, which in Brazil means large sales to chain stores and to the biggest retail outlets. With the additional resources from AIDSCAP, the social marketing operation was able to hire promodoras who sold to smaller outlets, ensuring adequate supplies of low-priced condoms in the areas where the NGO clients lived and worked.

A dedicated sales force also proved an effective strategy for reaching groups targeted by the AIDSCAP program in Nepal. These sales agents concentrated their efforts on the highways into the country from India -- a known route for transmission of the virus -- in nontraditional outlets such as tea shops, liquor stores and roadside stands. As a result of these efforts, condom access along the highways increased dramatically (Box 3.3).

3.3 Dedicated Sales Force Expands Condom Access in Nepal
In 1994, the Nepal Contraceptive Retail Sales (CRS) Company dispatched a sales force of three men to the country's Terai region. Part of AIDSCAP's comprehensive program in Nepal, this social marketing effort was designed to help reduce transmission of HIV and other STDs among the men who traveled through the Terai on the transport routes between Kathmandu and India and the women who were their sex partners along the way.

By improving access to affordable condoms in the nine targeted districts of the region, the salesmen aimed to increase their use. But first they had to get the condoms into the stores.

Storeowners were reluctant to stock condoms, fearing that it would turn customers away. They also pointed out that their wives and daughters usually tended shop during the day. "How can I ask my daughter to sell condoms?" was a common question.

The salesmen persevered. One by one, they convinced the owners of tea shops, grocery stores and roadside stands to take a single box of condoms. When the merchants found that the condoms sold quickly, they asked for more.

Advertising, distribution of free Dhaal calendars, signs and T-shirts and promotional events also helped reduce store-owners' resistance to selling condoms. CRS organized a contest, offering cash prizes to the storeowners who created the most creative store displays promoting CRS' Dhaal brand condoms. They went from store to store along the highway, handing out free Dhaal materials and encouraging storekeepers to participate.

Given the original reluctance to stock condoms, let alone display them prominently, the response was astonishing. Dozens of shops and stands were adorned with red Dhaal stickers, poster and banners arrayed in every imaginable pattern. The winning entry was a small, three-dimensional house fashioned entirely of Dhaal stickers.

The contest was a turning point, according to CRS Sales Manager Depak Pyakuryal. "After the display, people really wanted to keep the condoms in their stores," he said.

Before the contest, he added, village women tended to avoid shops that displayed condoms because they didn't want people to think that they were buying the devices. When most of the grocery stores in the highway area started displaying condoms, that stigma began to disappear.

"So now the situation is changed," said Pyakuryal. "Now condoms are everywhere."

In fact, the number of sales outlets carrying Dhaal condoms in the nine districts rose from just 150 in 1994 to more than 2,500 in 1997.

During those years, CRS salesmen saw attitudes toward condoms change. Storeowners who were once afraid to ask for the condoms by name, simply muttering "I'll take one of those," now ask for four or five boxes of Dhaal without a trace of embarrassment. Participants in the workshops on salesmanship and HIV/AIDS prevention that CRS organized to enlist storekeepers in educating customers about the importance of condom use expressed their concern about the spread of HIV and STDs and their desire to help stop it.

CRS sales figures suggest that condom advertising and other AIDSCAP communication efforts are also changing the attitudes of the ultimate target audiences, the men and women who can now buy condoms in almost any commercial establishment along the highway. Annual sales in the region rose from 689,328 in 1993, when CRS sold condoms as only one of several options for family planning, to 1.3 million in 1996.

Without subsidies, social marketing projects cannot make condoms available to those who need them most.

The efficiency of social marketing projects and their ability to recover costs tempts donors to make them entirely self-sustaining. But it is donor support that allows social marketing to sell condoms at an affordable price. For example, in Nepal, where social marketing is an important component of the AIDSCAP program, the retail price for a condom is less than U.S.$0.01. In Brazil, on the other hand, subsidies are not available and government taxes and regulations discourage condom imports. There the cost is $0.30 per condom, largely because management is forced to sell them at a price that finances new supplies. This price makes it highly unlikely that Brazil's poorest citizens will buy condoms.

Social marketing operations can be self-sustaining, but at a cost. HIV/AIDS is increasingly a disease of the poor, and social marketing efforts will have less of an impact on the epidemic if condoms are not available at affordable prices.

Providing low-cost subsidized condoms or even free condoms does not undercut commercial condom sales.

In fact, AIDSCAP's experience suggests that condom social marketing efforts can actually help boost for-profit sales. In Brazil, for example, the CSM project managed by PSI affiliate DKT do Brasil stimulated a stagnant commercial condom market by aggressively promoting its brand in public and by challenging barriers to imported condoms. As a result, the total number of condoms sold in a year tripled to 135 million in 1995, and the market gained at least five additional condom importers.

A similar effect was documented in Thailand, a country that distributes millions of free condoms. An audit by FHI partners John Snow, Inc., and PSI showed that as the number of condoms distributed in the public sector increased, the demand for commercial condoms also rose. This demand encouraged three companies to open local condom manufacturing plants. The government was able to cut back on free distribution as the private sector condom market grew, rising from about 1 million to 60 million a year from 1985 to 1995.

Mass Media Marketing

As people watch their friends and relatives die of HIV/AIDS and as CSM programs relentlessly educate people through every conceivable media channel, the old barriers and stigmas attached to condoms are beginning to evaporate.

The climate for mass media messages about HIV/AIDS and condoms has improved substantially over the past five years. The image of Bishop Desmond Tutu endorsing condom use on South African television may have shocked some viewers there, but was perhaps even more surprising to social marketers who for years had battled to gain access to mass media. As recently as 1990, the word "condom" was prohibited in advertising by the Government of Kenya, requiring a wide range of subtlety and creativity on the part of social markers. Today, more explicit advertising is permitted there and in many other parts of the world.

Encouraging use of condoms through mass media facilitates their adoption by marginalized groups.

Targeted marketing has sometimes been misunderstood to mean developing brands and advertising messages that appeal directly or even exclusively to sex workers and their clients or to men who have sex with men. Such an approach associates condom use with behavior that is condemned by society and requires condom buyers to identify themselves as people who practice that behavior. Portraying condom users in the media as happy, successful, "normal" people helps those whose lack of acceptance in society has been a barrier to their obtaining condoms. When mass media conveys the message that "everybody" uses condoms, members of marginalized minorities can enter a store and buy a condom without drawing attention to their social status.

In Tanzania, for example, one television ad showed dozens of people -- well-dressed young men and women, athletes, families with young children -- singing the upbeat "Salama" condom theme song. In a Haitian ad, a beautiful young woman holds a Pant� brand condom package and says, "Pant� -- It's for me." Then a man puts his hand lovingly on hers and corrects her: "It's for us." Such advertising helped boost condom sales among groups targeted by HIV/AIDS programs and the general population.

Recommendations

CSM projects should allocate resources to ensure that condoms are available in the nontraditional outlets most likely to reach those at greatest risk of HIV infection.
CSM programs should enlist new partners to ensure that low-cost condoms are available to target audiences.

NGO personnel proved extremely successful sales agents, expanding condom access to areas seldom reached by traditional CSM projects. Another effective way to target marketing efforts is to hire a dedicated sales force that sells to smaller outlets in neighborhoods where target audiences live and work.

Subsidies to CSM projects must be continued to ensure that condoms are affordable to those who need them most.
HIV/AIDS prevention programs should take full advantage of the emerging greater freedom to promote condom use and other behavior changes through the public airwaves and other means of mass communication.
CSM programs should design advertising messages and campaigns aimed at the general population, not groups at the margins of society.

In countries with mature epidemics, much of the general population is the target audience; in others, a more inclusive approach reduces the stigma often associated with condoms and discourages the perception that HIV/AIDS affects only marginalized groups.

Future Challenges

Expanding Social Marketing

The ability of social marketing to move physical goods within the convenient reach of target audiences and to create an effective demand for them has yet to be fully exploited, at least in part because of donors' hesitations about becoming further involved in commodity supply. For example, using social marketing to make supplies of latex gloves available near medical facilities and promoting the idea that it is a client's responsibility to supply the gloves might well be less costly than making the investments in public sector logistics systems required to ensure adequate supplies to physicians. As other HIV/AIDS prevention products become available, such as female condoms, appropriate virucides, and STD and HIV/AIDS drugs, social marketing may provide a more efficient means of delivery than traditional public health systems.

Marketing Prevention

Throughout the world, advertisements for toothpaste, soap and cars show happy, attractive people seeking to enjoy the thrill of being alive, conspicuously helped by the product of the moment. The same approach has made condom use less problematic in areas with strong social marketing programs, and it could also be used to promote less tangible "products." HIV/AIDS prevention programs need to tap the power of the media to influence behavior by marketing healthy sexual behavior as an attractive lifestyle.

Changing Norms

Condom social marketing has a positive impact on social norms, but the degree to which it does and mechanisms through which it operates are not well understood. From Brazil to Ethiopia to Nepal, AIDSCAP evaluations have found evidence that individual sexual behavior is changing. It is likely that condom social marketing and other HIV/AIDS prevention efforts are contributing to more long-term changes in social norms as well, but it is too early to detect such change. The experience of family planning programs in reducing fertility rates in many countries during the past 30 years, however, shows the potential for normative change through social marketing.

Investing in Condom Supplies

Meeting the demand for condoms created by social marketing is a major challenge. For years USAID has been the only donor providing significant condom supplies for public health and family planning programs. Although additional donors (notably the European Community and the German development agency) have recently entered this area, most are reluctant to support commodity supply -- particularly when the commodity is considered controversial. Governments in the developing world also shrink at the cost projections for adequate condom supplies. For example, it would cost a social marketing project U.S.$25 million to supply the country of Ethiopia alone with an adequate number of condoms. But experience to data suggests that investments in adequate condom supplies would save millions of lives. A serious effort to contain the spread of the virus will require political will and resources to provide enough condoms to everyone who needs and wants them.

Making Prevention WorkGlobal Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

3. Prevention Marketing: Condoms and Beyond

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997