Condom Sales Boom as Rwanda and Haiti Struggle to Rebuild

In Rwanda and Haiti, nations beset in recent years by bloody civil strife and high HIV infection rates, condom social marketing programs have been extremely successful despite political and economic chaos.

In the center of Kigali's most congested traffic circle stands a kiosk. Once a newspaper stand, the 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 there 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.

This tiny sales outlet is just one of hundreds throughout Rwanda created for condom social marketing (CSM). Using commercial marketing techniques, affordable pricing and existing retail networks to promote, distribute and sell condoms, the AIDS Control and Prevention (AIDSCAP) Project's nonprofit CSM programs -- designed and managed by Population Services International (PSI) -- have created enormous demand for these preventive devices even in places where resistance to them was once so strong they couldn't be given away.

Overcoming cultural barriers to condom use is one of the great challenges facing CSM programs around the world. Restrictive public policies, poor infrastructure and communications, disapproving religious leaders and governmental indifference also inhibit these programs in their mission to encourage behavior change and promote condom sales.

But almost nowhere has CSM been put to the test more dramatically than in Rwanda and Haiti. These tiny nations experienced violent civil conflicts that destroyed families and communities, shut down critical government functions and ruined already fragile economies, even as both struggled to control a virulent HIV/AIDS epidemic.

With as much as 10 percent of the urban population infected with HIV, Haiti suffers from the most advanced epidemic in the Western Hemisphere. In Rwanda, the numbers are even more dire: before the war, a staggering 30 percent or more of the urban population was estimated to be HIV-infected. The social breakdown that overcame both Rwanda and Haiti threatened to drive these figures even higher, as populations were uprooted and prevention education efforts and health care delivery disrupted.

But today, Haiti and Rwanda are considered two of the world's true CSM success stories. After the AIDSCAP/PSI CSM program was launched in Haiti, for example, national monthly condom sales increased more than a hundredfold -- from an average of 3,000 to more than 400,000 -- even during the worst of the country's turmoil. AIDSCAP/PSI's Rwanda program, forced to close for eight months when the bloodshed began, opened 1,500 new points of sale and achieved impressive average monthly sales of more than 229,000 soon after it resumed in 1996.

That CSM in both countries triumphed over such formidable political, social, logistical and even psychological obstacles may seem astonishing, but experienced CSM programmers are not surprised. They credit the innovation, flexibility and strong community ties that are integral to CSM, as well as a fundamental drive within human society to regenerate itself through commercial activity.

"This social and economic fact of life is an inherent advantage that social marketing programs have over other health programs that operate through the government," said Richard Frank, president of PSI.

Cooperation Amid Chaos

After a military coup ousted Haiti's first democratically elected president, Jean-Bertrand Aristide, in September 1991, bloody civil strife became a daily reality. Demonstrations were put down with brutal force. Assassins struck in the night, leaving corpses to be found each morning in rural cane fields and on city streets by the terrorized populace. When the Organization of American States imposed an economic embargo on the country that cut off fuel and raw materials for manufacture, factories were forced to lay off workers, and businesses both small and large closed because their former customers could no longer afford to buy. Haiti -- never a politically stable or economically secure country -- was soon pushed even deeper into violence and desperate poverty.

At the time of the takeover, PSI had been working with AIDSCAP for a year to expand the CSM program it began in 1989 to promote and sell the Pantè condom. The terms of the embargo forced most USAID-supported projects to close or reduce their activities, but after a six-month slowdown, AIDSCAP and PSI were allowed to resume full operations as a humanitarian mission. Most government agencies, including the national health system -- which had in the past provided some free condoms and information about HIV/AIDS at public health clinics -- stopped functioning, and AIDSCAP, PSI and AIDSCAP's nongovernmental organization (NGO) partners became Haiti's sole source of affordable condoms and of HIV/AIDS education and behavior change campaigns.

"We suddenly found that, for better or for worse, we were essentially operating without a government to either support us, ignore us or give us a hard time," said Michele Cato, former program manager for PSI/Haiti, who now works for PSI in Guatemala.

But the military junta's political crackdown did affect important CSM activities. New restrictions on the media made it more difficult to broadcast condom ads and HIV/AIDS prevention spots on television and radio. Condom delivery van drivers had to learn to negotiate checkpoints with armed soldiers searching for weapons and fugitives. Suspicious military patrols frequently interrogated both AIDSCAP and PSI staff about their activities.

"We had an evening training session scheduled for commercial sex workers in the town of Petit Bois," said Dr. Eddie Génécé, former resident advisor for AIDSCAP's program in Haiti. "The police broke in and insisted, despite all our protests, that the meeting was political and subversive and that we had to disperse."

But the most pressing problems confronting the Haiti program during these troubled years were logistical. For eight months during the embargo -- until supplemental fuel supplies for humanitarian organizations arrived from the United States -- gasoline for vans carrying condoms and educational materials to sales points around the country was extremely difficult to find. Spare auto parts were unobtainable. The telephone system often broke down, and electricity was sometimes cut off for hours or even days, paralyzing computers and typewriters. Much of Haiti's commercial distribution system slowed to a standstill for many months, yet CSM distribution continued, even into the remote countryside, even during the worst of the shortages.

What gave the Haiti CSM program its special advantage was the central role that Haitian NGOs played in CSM sales, promotion, education and training, and distribution throughout the country. All AIDSCAP programs create partnerships with indigenous organizations and health agencies to build their country's capacity to control the epidemic, but Haiti's CSM program benefited from an unusually rich collaboration with NGOs that have years of experience in community development and health programs.

"We were all part of a very motivated network that through sheer cooperative effort was able to overcome some of the burdens of the embargo and the unrest," said Dr. Génécé. "We shared information with each other: when one group found fuel for sale or someone discovered that a certain district or town was blockaded, we let each other know. We learned to make each gallon go a long way by shipping several months' worth of condoms at one time or splitting large shipments."

By offering NGOs training in sales and distribution and a percentage of condom revenues, AIDSCAP/PSI was able to recruit enthusiastic and often income-poor sales and delivery people with deep roots in their communities and an insider's knowledge of how to work around the dangers that seemed to come with each day. A study of Pantè sales figures from January 1992 to June 1996 found that NGOs had sold nearly 27 percent of the total; in 1994, NGO sales peaked at 43.5 percent of the total.

PSI's strong promotional campaign and the unusually high brand recognition for the PSI condom, Pantè, naturally helped support sales efforts. Points of sale throughout the country -- both established commercial retail outlets and new ones created by the NGOs -- increased to more than 3,000 and ultimately penetrated into all but one of Haiti's difficult-to-reach, poverty-stricken rural areas. For the first time, many of the 70 percent of Haitians who live in the countryside could find affordable condoms close to home.

"By expanding into rural areas, we were able to overcome the traditional shortcomings of commercial distribution systems, which do not extend efficiently to the poorest part of the population," said Cato.

Devastated by Violence

The social fabric of the tiny East African country of Rwanda was ripped to shreds in a matter of hours on April 6, 1994, after a plane carrying the presidents of Rwanda and Burundi was shot down. As the news reached the Rwandan population, political and genocidal violence targeting the Tutsi minority swept through the country. Within weeks, hundreds of thousands of men, women and children had been murdered. When Tutsi forces regained control of the country two months later, some 2 million Hutus -- fearing revenge -- fled into Zaire, Tanzania and Burundi to crowded refugee camps. Within one short spring, a nation had been destroyed by ethnic hatred.

Most foreign assistance and NGO projects in Rwanda came to an immediate halt. Despite the desperate need for ongoing HIV interventions, the AIDSCAP program was also forced to close. Tragically, four PSI staff were killed in the first few days. Another survived by hiding in an attic, and a second in the sewers of Kigali; two more escaped to Burundi in a PSI vehicle. AIDSCAP's accountant narrowly escaped death three times and lost an infant daughter to illness in a refugee camp. The stories of these staff members reflect the scale of loss that those who lived through the terror experienced.

"The survivors were still alive, but they had nothing left," said Kyle Peterson, former PSI country representative in Rwanda. "Many lost every relative, and all of their property and belongings as well."

Unable to operate within the chaos, AIDSCAP used country program funds to establish an innovative HIV and STD prevention and care program for some 2 million refugees in the Ngara District refugee camps in Tanzania. Managed by CARE International, the program was one of the first attempts anywhere to develop comprehensive prevention activities within a refugee setting.1 PSI's CSM project for the camp also broke new ground: 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 eight months later, staff faced the difficult and sometimes disheartening ordeal of rebuilding the program from the ground up.

"When we opened the office door again for the first time, we couldn't believe our eyes," said Peterson. "All the computers and other office equipment and most of the files were gone, the windows were blown out, and the wall was full of bullet holes."

AIDSCAP/PSI's entire stock of condoms had disappeared from a nearby warehouse. Only one vehicle from the original office fleet remained, the one that 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 Peterson. "It was the people, not the buildings, that had been destroyed."

Before the killing began, AIDSCAP/PSI had concentrated on increasing the number and geographical breadth of sales points to improve condom accessibility throughout this largely rural country. By offering the incentive of earning a percentage of the sales price, PSI added dozens of new community-based sales networks and salespeople, including peer educators from CARE International in western Rwanda and Dian Fossey's Gorilla Fund in the north. An equally important focus in the early years had been a comprehensive and widespread information, education and communication (IEC) campaign to teach Rwandans about HIV/AIDS. Combined with intensive promotion of Prudence condoms as an effective means of prevention, this strategy paid off as knowledge about HIV and public understanding of the value of condoms increased dramatically.

IEC and promotion remained central when the project resumed, but Kyle Peterson soon realized that the dark cloud hanging over Rwanda could overshadow beneficial messages about HIV/AIDS prevention and condom use. "The experience of the genocide so overpowered everything else that we began to doubt that any other message might be heard at all," he said.

After much discussion, 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.

"Who knows if this approach actually motivated more condom sales?" said Peterson. "But we do know that our messages stood out from the gloom."

New IEC projects also promoted prevention while quietly acknowledging the genocide, emphasizing the need to rebuild society and to protect oneself from HIV in order to live a long, happy, healthy life. A mobile video unit, first used in the Ngara District refugee camps, traveled to distant rural communities with IEC materials and videos on HIV/AIDS prevention and health. This "Ciné Mobile" has been used at military bases, in schools and at public events in almost every region of the country and as a training tool for new community salespeople. The audiences, which average 1,500 at each two-hour showing, are invited to join in a discussion afterward, which is videotaped and shown on the spot. Live, on-location interviews with government and health leaders are also fed to the site for participants to view.

Ciné Mobile's success prompted PSI/Rwanda to open its own studio in Kigali, which has since produced more than a half-dozen videos targeting at-risk Rwandan audiences -- sex workers, youth, male soldiers, adults with multiple partners -- as well as those whose lives have been transformed forever by the experience of war. Many Rwandan women who were maimed or lost their families also suffered the agony of rape and the social stigma attached to their victimization. The popular "Emma Says," a short video drama set in post-genocide Rwanda, shows two women discussing how to negotiate condom use with reluctant partners. It includes a scene where one of the women, a widow, talks about safe sex with her new boyfriend, who also lost his spouse during the violence. The video seeks to empower women who survived to take control of their health while they rebuild their emotional lives.

Riding the Phoenix

The extraordinary success of AIDSCAP/PSI's Haiti and Rwanda programs during periods of social disruption and violence reveals the value of the sturdy connections that CSM establishes with the public it serves.

In Haiti, AIDSCAP/PSI's partnerships with NGOs and other community-based organizations helped create a network for distribution, training, promotion and public education that transcended the day-to-day uncertainties of commercial distribution and fuel supply. These NGOs, whose stature in their communities is based on years of grassroots activity, provided a valuable measure of stability and helped win the public's attention and acceptance of condom use during a time when most Haitians were distracted by the turmoil around them. The Rwanda program also benefited from a community-based sales force and from its staff's knowledge of the culture and sensitivity to the blows suffered by Rwandan society.

Perhaps equally important to the success of both programs is the dedication that many CSM staff members bring to their work, as well as their ability to deal with extraordinary levels of stress and uncertainty. Creating markets in developing countries -- and maintaining these markets during periods of unrest -- can require nerves of steel.

"Around the world, we've learned that it takes a special kind of person to handle the stress, the frustration and the fear for one's physical safety," said Richard Frank of PSI.

Both programs built on the solid foundations they had established before disaster struck. The Pantè condom had become so well known in Haiti that recognition of the brand and the memory of its ads and jingles continued strong even when promotion activities slowed temporarily. In Rwanda, Prudence's reputation survived the war and the program's eight-month shutdown.

"As survivors slowly returned to their homes, overcome with grief and loss, we were amazed to discover how many of them remembered Prudence and recalled their high opinion of its quality before the war," said Peterson.

But most CSM programmers see a more fundamental reason for success -- one they attribute to society's basic instinct for survival. In both Haiti and Rwanda, the marketplace has always been central to the culture and economy, and the commercial infrastructure never disappeared entirely in either country -- even during the worst of the violence in Rwanda, 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?"

Reference

1. See Benjamin JA (1996), AIDS prevention for refugees: The case of Rwandans in Tanzania, AIDScaptions 3(4):1-9, for a description of prevention efforts in the Ngara camps.

Protection vs. Protectionism?

One important reason why condom social marketing (CSM) programs have been so successful in Rwanda and Haiti is that they make it possible to sell condoms at prices even low-income people can afford. In Haiti­the poorest nation in the Americas­a packet of three Pantè condoms costs only U.S.$.06, about the same as a packet of four Prudence condoms in Rwanda.

It's a simple equation: Less expensive condoms mean higher condom sales, more condom use and more HIV transmission averted. Fewer infections mean funding for AIDS prevention and care can be diverted to other health needs, fewer workers become sick and drop out of the economy, and fewer orphaned children become wards of the state. It's hard to exaggerate the social, economic and health benefits of making condoms affordable for all.

One critical factor that allows for such low prices in Haiti and Rwanda is the absence of taxes and tariffs on imported condoms, which make up the lion's share of socially marketed condoms. Rwanda imposes an insignificant 1 percent import tax on condoms, while Haiti does not tax imported condoms at all. Similarly, Botswana, Tanzania and Bangladesh­nations where HIV is also a major public health threat­collect no duties on foreign condoms.

Yet not all countries open their gates so readily to condom imports. Zimbabwe, for example, imposes a 10 percent import tax on condoms. Malaysia, a major condom manufacturer and exporter, protects its domestic industry by setting a stiff 25 percent duty on condoms from abroad.

Perhaps nowhere in the world are the barriers so high as in Brazil, ironically the nation with the second most advanced HIV epidemic in the Western Hemisphere. The Brazilian government hits condom importers with a 10 percent import duty, in addition to the steep 18 percent "circulation tax" that all condom marketers must pay up front.

"Together, these taxes represent 45 percent of the retail price of our condoms," says Carlos Ferreros, director of DKT do Brasil, which directs AIDSCAP's CSM program in Brazil. "I know of no other country that demands more from condom importers."

In fact, condom prices in Brazil are among the highest in the world. Commercial brands cost between U.S.$.70 and $1.00 apiece. DKT's socially marketed condoms­heavily subsidized by international donors­sell at between U.S.$.25 and $.35. Yet even the DKT condoms are too expensive for many to buy consistently in a country where the annual per capita income is only U.S.$3,400.

Prices on imported condoms are also affected by another regulation that requires lot-by-lot testing of all foreign condom shipments into Brazil, which Ferreros says slows distribution and adds at least a half cent to the cost of each DKT condom. In 1995, DKT became the first vendor of imported condoms in Brazil to win precertification for an offshore plant, allowing its supplier to bypass these time-consuming tests. But DKT must occasionally take government regulators to court when they refuse to honor this special status.

Ferreros believes the combination of two hefty tariffs, extensive testing and legal expenses has limited DKT's ability to market in Brazil as broadly as possible. "Without these unnecessary costs, I estimate we could have sold up to 30 percent more than we have," he says.

Lower retail prices for CSM condoms are not the only potential benefit of decreasing or eliminating tariff barriers. If prices are already set at levels most people can afford, the money saved can be used to improve distribution and to boost sales by increasing promotion, advertising, and prevention education. As higher demand encourages more private sector companies to enter the market, competition increases, resulting in lower commercial prices as well.

In 1993, the Brazilian government declared a 14-month "tax holiday" for imported condoms, enabling DKT to temporarily cut prices by 10 percent. Sales increased, although Ferreros says that, given how short the hiatus was, it's hard to determine whether lower prices, better distribution or growing markets were responsible.

Ferreros and AIDSCAP/Brazil's Resident Advisor Maria Eugênia Lemos Fernandes are now working to reinstate that tax holiday permanently. They recently collected some 700 signatures on a petition calling for the elimination of the circulation tax and the import duty on foreign condoms. Supporters include influential federal and state government leaders, especially from the São Paulo region, which has been struck hard by the epidemic. The petition is now in the hands of the president, the minister of health and federal lawmakers.

Ironically, the Brazilian government's reluctance to eliminate the tariffs is at odds with its own commitment to thwarting the epidemic. In fact, Brazil is one of the few countries anywhere in the world that has passed legislation promising to pay for expensive new protease inhibitor treatments for every HIV-positive citizen who cannot afford them.

"Imagine the enormous amount of money Brazil could save by focusing on prevention," says Ferreros. "Lowering condom prices by lowering these taxes isn't just good preventive medicine­it's also real fiscal responsibility."

-- Margaret J. Dadian