FHI Research Briefs on the Female Condom — No. 5:

How the Female Condom Affects Levels of Protected Sex

As the only currently available method of dual protection against pregnancy and sexually transmitted infections (STIs) that women can initiate, female condoms offer an important alternative to male condoms. But questions remain about the potential impact of increased access to and acceptance of the female condom. For program managers, an important question is whether making both the male and female condom more available results in higher levels of protected sex.

Research suggests that making female condoms available increases the proportion of sex acts that are protected by either male or female condoms^1-4. In a study among 99 HIV-serodiscordant couples in Zambia, for example, couples who used female condoms 28 percent to 47 percent of the time over 12 months reported fewer unprotected sex acts than did couples who used them less than 10 percent of the time. The results suggest that the availability of the female condom led to more protected coital acts, rather than female condom use replacing male condom use.⁵

Likewise, overall condom use increased among STI clinic patients in the U.S. receiving counseling on a hierarchy of prevention options, beginning with the safest behaviors and continuing through options that offer less protection but might be more feasibly adopted. In one study, a group of patients receiving hierarchy counseling reported higher condom use than groups counseled in only male condom or only female condom use.⁶ Another study of a four-level hierarchy (male condoms, female condoms, diaphragm and spermicides) found that initial levels of male condom use were sustained over time and supplemented with female condoms, resulting in more condom protection.⁷

An intervention study in Mombasa, Kenya, also reduced levels of unprotected sex and resulted in a small but statistically significant increase in the percentage of participants who reported protected sex with all partners. However, female condom use replaced male condom use in about 30 percent of sex acts. Given the substantially higher cost of female condoms, this degree of substitution is problematic.⁸

No randomized controlled trial has yet directly compared how female condoms and male condoms affect the proportion of sex acts that are protected. Studies comparing condom use among women who had access to both male and female condoms to that of women with access to male condoms alone have shown that female condom availability does increase protection.⁹ In many comparative studies, however, levels of protected sex were only slightly higher when both female and male methods were available.¹⁰

More research needed

Researchers are trying to capture more accurate data on self-reported condom use and determine how the combined use of male and female condoms affects STI rates. As users become more familiar with this new device, user errors may decline. Studies of the STI protection provided by differing levels of female condom use are needed, as are studies of ways — such as enhanced counseling or training — to minimize incorrect use of the device.¹¹

Endnotes

1. Barbosa RM, Berquo E, Kalckmann S. Acceptability of the Female Condom in Different Social Contexts: Final Research Report. Brasilia, Brazil: Ministry of Health, National STD/AIDS Co-ordinating Office, 2000.
2. Hatzell T. Family Health International, Female Condom Operations Research, Progress Update. Presentation to the National Barrier Methods Task Force. Johannesburg, South Africa, Feb. 27, 2001.
3. Macaluso M, Demand M, Artz L, et al. Female condom use among women at high risk for sexually transmitted disease. Fam Plann Perspect 2000;32(3):138-44.
4. Fontanet AL, Saba J, Chandelying V, et al. Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial. AIDS 1998;12(14):1851-59.
5. Musaba E, Morrison CS, Sunkutu MR, et al. Long-term use of the female condom among couples at high risk of human immunodeficiency virus infection in Zambia. Sex Trans Dis 1998;25(5):260-64.
6. Latka M, Gollub E, French P, et al. Male-condom and female-condom use among women after counseling in a risk-reduction hierarchy for STD prevention. Sex Trans Dis 2000;27(8):431-37.
7. Stein Z, Saez H, el-Sadr W, et al. Safer sex strategies for women: the hierarchical model in methadone treatment clinics. J Urban Health 1999;76(1):62-72.
8. Thomsen S, Ombidi W, Toroitich-Ruto C, et al. A prospective study assessing the effects of introducing the female condom in a sex worker population in Mombasa. Sex Transm Inf 2006.
9. Hatzell T, Feldblum P, Homan R, et al. The female condom: is "just as good" good enough? Sex Transm Dis 2003;30(5):440-41.
10. Fontanet; Latka; Musaba; Feldblum P, Kuyoh MA, Bwayo JJ, et al. Female condom introduction and sexually transmitted infection prevalence: results of a community intervention trial in Kenya. AIDS 2001;15(8):1037-44.
11. Gollub E. The female condom: tool for women's empowerment. Am J Public Health 2000;90(9):1377-81; Musaba.

FHI produced these research briefs as part of an information dissemination effort supported by the Bureau for Africa/Office of Sustainable Development, U.S. Agency for International Development.