The AIDS pandemic has focused attention on providing barrier contraceptive methods, which can reduce risk of sexually transmitted diseases (STDs). "Decisions about contraceptives should reflect both the need to prevent STDs and the need to prevent unplanned pregnancies," says Dr. Ward Cates, FHI's corporate director of medical affairs. "So far, most family planning programs have appropriately focused on pregnancy at the expense of STDs. However, the importance of preventing reproductive tract infections is being increasingly recognized as essential to good reproductive health care."
Consequently, a needs assessment for contraceptive expansion should address STD/HIV issues. This includes STD/HIV prevalence rates in program areas and the ability of programs to address STD prevention and management. Prevention includes information, counseling and condom distribution. STD management covers diagnosis of STDs, treatment with antibiotics, partner tracing and attempts to keep infected persons from spreading the disease.
"Until recently, condoms have not been favored by most family planning providers due to concerns about condom effectiveness, acceptability, consistent and correct use, breakage, logistics and cost," explains Dr. Nancy Williamson of FHI, who has studied the integration of STD services with family planning programs. "Promoting condoms aggressively requires a major reorientation for many family planning programs."
Most funding and interest in condom promotion has been through AIDS prevention programs that are usually quite distinct from family planning agencies. Combining these two networks of agencies, staff expertise and funding sources creates substantial administrative challenges.
The methods most effective at preventing STDs, barrier methods, are usually not the most effective contraceptives. Thus, providers have an added responsibility to give clients clear information, counseling and access to the methods most desired.
At the same time, many family planning programs should consider providing information and counseling on STD/HIV prevention, including condom distribution, says Dr. Williamson.
"The emphasis should not be on what the programs should promote, but how to provide information clearly enough so that a woman or man can make a really educated choice," says Laurie Fox, who directs FHI's family planning/STD integration research. "It is not up to the programs to choose a method. It is up to each individual."
Successful AIDS prevention programs suggest that people will use barrier methods for family planning when they are available. Population Services International (PSI) and the SOMARC project, both supported by USAID, have developed condom distribution campaigns throughout the world. From 1987 to 1991, annual condom sales increased from 300,000 to 18.3 million in Zaire, where PSI launched its first AIDS prevention campaign with the Zaire National AIDS Committee. Three of every four persons reported that they bought the condoms for family planning as well as for AIDS prevention.1
Female condom
The need for female-controlled methods to protect against STD/HIV has encouraged USAID to evaluate whether to provide the female condom to family planning programs. USAID recently made a one-time purchase of 250,000 female condoms for use in 22 countries. FHI has prepared information packets for family planning managers and a survey instrument to gather users' opinions (see related article on page 23). This approach is consistent with introduction strategies that suggest a new method could be made available on a limited basis and carefully evaluated before large-scale distribution.
Whether USAID will add the female condom to the methods it routinely supplies overseas involves many complex issues, especially overall budget constraints, says Mark Rilling of USAID's commodities office. "The degree of interest among programs and the price they are willing to pay will help us determine whether to purchase the female condom on a longer-term basis," he says.
For the female condom to be used widely in developing countries, service delivery systems must identify the most likely users, determine how to help women continue using the device even when men resist, and overcome the relatively high cost of the condom, says Carol Joanis of FHI, who has led several acceptability studies on the female condom. "Often a woman cannot persuade a man to use a male condom," she says. "In our previous studies, the women most interested in using the method were those at high risk of STD/HIV exposure. The female condom provides another option for pregnancy and disease control for women."
One possible way to lower the cost is to determine if the female condom can be used more than once without losing effectiveness or compromising safety. In a re-use study being conducted by FHI, preliminary results show that cleaning of the device after one use does not harm it structurally. If final results are encouraging, FHI will request permission from the U.S. Food and Drug Administration (FDA) to begin a study in which women would use a female condom multiple times. The female condoms would be tested against manufacturers' specifications after varying numbers of uses. If they continued to meet safety and efficacy specifications after multiple use, FDA may be asked to approve the device for more than one use. The FDA has approved the Reality and Femidom female condom brands for one-time use only.
Working with women's advocacy organizations in Kenya and Brazil, FHI is conducting a study of about 100 women from each country to determine what kind of support a woman needs to use a female condom, even when men initially resist. "Such efforts may help women's organizations get more involved in STD prevention and get the female condom to a larger population of women," says Dr. Maxine Ankrah, senior adviser on women's issues for FHI's AIDS Control and Prevention Project (AIDSCAP). "Then we might be able to introduce it more widely through a social marketing or a community-based distribution approach."
-- William R. Finger and Sarah Keller
Footnote
- Convisser J. The Zaire Mass Media Project. (Washington: Population Services International, 1992) 16.
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