Why Condoms Count in the Era of HIV/AIDS

June 1, 2004

In 2007, more than 6,800 people became infected with HIV every day, and new HIV infections outnumbered persons receiving treatment by nearly 3 to 1.¹ Comprehensive HIV prevention—including both condoms and contraceptives—must become a top priority in the continued fight against HIV and AIDS. Because most HIV epidemics are fueled by sexual transmission of the virus, behavior change—including condom use—is critical to stemming the number of new infections.

At the same time, more than 200 million women in the developing world say they would prefer to avoid a pregnancy but are not using any form of modern contraception.² High rates of unintended pregnancies, including among women living with HIV or AIDS, is an urgent health and rights crisis [see Table 1]. In 2007, an estimated 420,000 children (under 15 years) were newly infected with HIV, amounting to an estimated 2.5 million children living with HIV.³ Helping women—including those who know they are HIV-positive—plan and space their pregnancies is essential for preventing mother-to-child transmission of HIV.

 

HIV Prevention Must Be Comprehensive

There is no one magic bullet for HIV prevention: All prevention technologies and strategies are additive in the fight against HIV and AIDS. Condoms and contraceptives must be promoted as scientifically proven components of comprehensive HIV prevention, in tandem with other evidence-based interventions such as partner reduction and male circumcision—along with continued investigation of microbicides and a vaccine.

 

Condoms Count for Comprehensive HIV Prevention

Able to block the bodily fluids that carry the HIV virus, condoms are a highly effective method of preventing HIV, with effectiveness rates ranging between 80 to 95 percent, largely depending on how correctly they are used.^{4 5 6 7 8}

Condoms are also an important means of pregnancy prevention and are the mainstay of dual protection (preventing both pregnancy and STIs). As commonly used, male condoms are about 85 percent effective for pregnancy prevention. If used consistently and correctly with every sex act, effectiveness for pregnancy prevention is higher—about 98 percent.⁹ As commonly used, the female condom is 79 percent effective for pregnancy prevention, whereas it is 95 percent effective with perfect use.¹⁰ Because condoms are less effective for pregnancy prevention than other contraceptive methods, dual method use should be promoted among contraceptive users.

Persistent variations in condom use across regions, countries and populations indicate that condom promotion should be targeted to address socio-cultural, political, economic and structural barriers faced by different groups (e.g. youth, married women and men, discordant couples, sex workers, men who have sex with men, and injecting drug users, among other groups).¹¹ Programs should not only encourage condom use, but also help people to become effective users of the method.^{12 13} Successful interventions demonstrate that programs can increase correct and consistent condom use when they address the barriers and concerns experienced by different people.

For example, programs for youth can emphasize condom use for both pregnancy prevention and protection against STIs including HIV, since sexually active youth tend to be primarily concerned with avoiding pregnancy. Public health campaigns can romanticize condom use as a sign of love and trust among married or long-term partners¹⁴ and as a way of protecting children. Condoms can be promoted to sex workers as both safe and pleasurable. It is critical to promote condom use among various groups without stigma—promoting safe sex can be done in a sex-positive way, rather than through fear-based messages.¹⁵ Programs must also address the misinformation surrounding condoms—including misinformation about effectiveness rates—and design effective condom promotion interventions.¹⁶ Existing evidence, coupled with market research, can help determine the most appropriate condom promotion and distribution strategies for populations with varying needs.

 

Contraceptives Count for Comprehensive HIV Prevention

Unlike condoms, the role of contraceptives and voluntary family planning services in HIV prevention is not sufficiently recognized, even though preventing unintended pregnancies is one of the four pillars of preventing mother to child transmission (PMTCT), as recognized by United Nations in the 2004 Glion Call to Action.¹⁷ There is emerging evidence that women living with HIV and AIDS experience high rates of unintended pregnancies. A study in Côte d’Ivoire of 149 postpartum women living with HIV found that over half of their pregnancies were unintended and roughly one-third were aborted.¹⁸ Another study of 288 Tanzanian women living with HIV found that more than 55 percent of pregnancies were unintended.¹⁹

Voluntary family planning services provide clients with critical information about the varying degrees of effectiveness of contraceptive methods for pregnancy prevention, the safety of pregnancy with HIV and contraceptive choices for women living with HIV or AIDS. Family planning services also educate clients on STI prevention and correct and consistent condom use. Many women living with HIV or AIDS want to have more children and are in need of family planning services to provide counseling on reversible contraceptive methods and on how to prevent mother-to-child transmission of HIV, as well as possible transmission to their husband or sexual partner. At the same time, voluntary family planning services are needed for all women and couples who want to prevent or delay pregnancy.

A 2003 study found that by adding family planning to PMTCT services in 14 high prevalence countries, more than 150,000 unintended pregnancies were averted, the number of child infections averted nearly doubled and the number of child deaths averted nearly quadrupled.²⁰ For the same cost as treatment with antiretroviral drugs to prevent MTCT, contraceptive use can avert nearly 30 percent more unintended HIV-positive births,²¹ as well as much human suffering. It is estimated that current levels of contraceptive use in sub-Saharan Africa are already preventing 22 percent of unintended HIV-positive births.²² Integrating family planning with other HIV services can increase contraceptive use and further reduce unintended pregnancies. While not all services should be integrated in all instances,²³ integrated approaches can expand access to and coverage of family planning, STI, and HIV and AIDS services.

Creating a Conducive Environment for Scaling Up HIV Prevention

Successful scale-up of condoms and contraceptives for HIV prevention depends upon strong leadership and coordination—for advocacy and policy dialogue, capacity building and resource mobilization. Scale-up also requires a supportive policy environment—one where policies are based on sound evidence that supports the efficacy of condoms and contraceptives in preventing the transmission of HIV. Likewise, the integration of contraceptives into HIV prevention programs must be supported at all policy levels.

Successful interventions address barriers to the demand for condoms and promote marketing
strategies that are tailored to particular audiences can work. Programs must also be supported by strong management, links with other programs, monitoring and evaluation and high quality services. On the supply side, strong commodity management and logistics systems are a prerequisite for reliable availability of condoms and contraceptives. Distributing condoms and contraceptives across a range of networks can help to reduce costs of service delivery and promotion by maximizing the contribution of existing outlets and programs. By limiting subsidized or free condoms to low-income consumers, market segmentation maximizes government and donor investments, freeing up funds for other strategies. Some promising mechanisms to coordinate and track commodity procurement and distribution are underway and should continue to be supported and expanded. Comprehensive HIV Prevention: Condoms and Contraceptives Count details successful public health strategies and a Comprehensive Condom Programming Framework²⁴ that incorporates all of these elements and can be applied to address gaps in the provision and use of condoms and contraceptives.

 

Increased Funding for Condoms and Contraceptives is Key

 As the number of women in their reproductive years increases and desired family size decreases, the global demand for family planning will increase. At the same time, the continued threat of HIV and the increasing number of people living with HIV or AIDS—people who are living longer, healthier lives due to expanded access to treatment—is leading to an increased need for condoms and other contraceptives. And yet the growing need has been met with long-term stagnant funding on the part of donors and only small increases in numbers of commodities.

Total donor support for all commodities in 2006 is reported by UNFPA as US$196 million. Although the number of donors funding contraceptive commodities has more than doubled over the past two decades, the vast majority of funding continues to be provided by USAID and UNFPA. Like support for contraceptive commodities overall, there has been little increase in donor provision of condoms in response to the HIV/AIDS epidemic [see Figure 1]. Of the estimated 18 billion condoms needed in 2006 (13.5 billion for HIV prevention and 4.4 billion for family planning)²⁵ donors provided just 2.3 billion.²⁶ In the ten-year period between 1998 and 2007, donors have provided on average 2.9 billion male condoms per year, peaking at 3.3 billion in 2007.²⁷

Although USAID remains the largest donor of contraceptives and condoms, funding for family planning and reproductive health overall has fallen dramatically compared to HIV/AIDS funding [see Figure 2].

For female condoms in particular, greater support needs to be devoted to their strategic introduction, marketing and programming in countries. Although the female condom is available in 108 countries, in many instances it is not readily accessible at shops and clinics.²⁹ Costing US$0.60, female condoms are expensive compared to the US$0.03 cost of male condoms. However if the second generation female condom, FC2, were purchased in large volumes—equal to only about 3 percent of the estimated male condom market—the cost per unit could be as little as US$0.22.³⁰

Condoms and contraceptives are inexpensive and cost-effective technologies, yet cost continues to be a barrier to their availability. International donors and developing country governments need to recognize the indispensable role of condoms and contraceptives in HIV prevention, and commit to providing the necessary resources to implement programs and services and to promoting policies to ensure wide distribution and availability of these critical tools in the fight against HIV and AIDS.