Expanding Access and Ensuring Availability

Policies on condoms and contraceptives set the tone for prevention programs and should be evidence-based

Promotion of condoms has been hotly debated in recent years, particularly in the context of the U.S. government’s "ABC" approach to prevention, implemented under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The greater emphasis has been placed on abstinence until marriage—an emphasis legislated through the abstinence earmark—and on faithfulness in marriage. Many public health experts claim that the U.S. government approach to prevention ignores the reality of many vulnerable groups, as discussed in this report. Unfortunately, the controversy also obscures the fact that the U.S. government "has purchased more than one billion condoms in the past two years to help prevent HIV infections in the developing world, a significant increase from previous years."³⁰³

Further obscuring the important role of the US in condom provision and promotion, PEPFAR’s program-level tracking systems do not include indicators on condoms—instead condom promotion activities are subsumed under "other behavior change."³⁰⁵ In spite of record condom shipments, PEPFAR has greatly inhibited mass media communications around condoms and unnecessary and unfortunate misinformation about condom effectiveness, use, and more continues.

To fully and effectively address HIV and AIDS, policies must be based on sound evidence, which supports the efficacy of condoms in prevention HIV transmission. Policies should reinforce that no conditions should be attached to the promotion of condoms for HIV prevention, including provision of and use by vulnerable groups. Individuals should be able to decide themselves if condom use is the right prevention method for them and to switch prevention methods as needed.

The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), places no restrictions of promotion of condoms for HIV prevention and—recognizing the role of contraceptives in HIV prevention and care—in its most recent request for proposals (Round 8), has reiterated that grant funds can be used to procure contraceptives for relevant grant activities. Still, GFATM relies on countries to request funding for condoms and contraceptives in their country proposals.

Most countries have favorable supportive family planning policies, however in many instances, contraceptive choice is limited by legislation governing the use of certain methods and by government efforts to promote certain methods.³⁰⁶ Ross et al. (2002) found that full choice of contraceptive methods is possible only in a few countries.³⁰⁷ Many countries still underestimate the contribution of family planning to PMTCT—an analysis of the national strategic HIV/AIDS policies or plans of 14 African countries found that only half mentioned family planning.³⁰⁸ Choice is also limited by decreasing donor resources for contraceptives, and restrictions and confusion surrounding source of funding for contraceptives. For example, the reauthorization of the PEPFAR legislation in the U.S. is likely to prohibit procurement of contraceptives, even for PMTCT programs that have prevention of unintended pregnancy as a key pillar—and despite compelling evidence that contraceptives contribute significantly to preventing mother-to-child transmission of the virus.

Strong commodity management and logistics systems are a prerequisite for reliable availability of condoms and contraceptives.

Avoiding shortfalls and stock-outs of condoms and contraceptives is critical to the success of family planning and HIV prevention programs. An article in a Zambian newspaper reported month-long periods when Planned Parenthood clinics were stocked-out of both male and female condoms.³⁰⁹ Such stock-outs have important implications, as the most common reasons given by married women for not using contraception is lack of access to supplies and services.³¹⁰ As a response to funding declines, lack of donor coordination, and shortages of commodities, the international community has been working for the past decade to ensure availability of sufficient reproductive health supplies, including contraceptives and condoms [see Box 11: Advocacy for Reproductive Health Supplies].

Box 11: Advocacy for Reproductive Health Supplies

In 2001, an historic meeting in Istanbul on the issue marked a turning point for the global community by establishing a "Call to Action" to raise awareness, increase support and seek solutions to the crisis in supplies. The Call to Action included an extensive plan for tackling all of the major causes of the crisis as identified at Istanbul: advocacy, national capacity building, financing, and donor coordination.

A number of organizations, including PAI, have been working as advocates, facilitators and watchdogs at the international level for nearly a decade to identify and address the causes of, and solutions to, shortfalls in reproductive health supplies. These partners have capitalized on milestone events, high-level policy dialogues and contacts with decision-makers to bring the issue of supply shortfalls to the forefront of major bilateral and multilateral donor attention.

In recent years, evidence of the success of the resource mobilization and global awareness efforts includes:

• Establishment of a high-level coalition of supply donors and stakeholders, the Reproductive Health Supplies Coalition (www.rhsupplies.org), to focus on increasing resources, strengthening systems and effective partnerships;
• Launch of the RHInterchange (http://rhi.rhsupplies.org), a web-based portal for contraceptive procurement and shipping information that has improved the quality and timeliness of donor data; and
• Increased prominence of RH supplies on the global donor agenda, as illustrated by a steady increase in media coverage of the RH supplies issue; improved participation and investment by key stakeholders and partners; increased numbers of donor governments contributing to RH supplies; and increased volume of funding, such as a contribution of $75 million from the European Union to UNFPA in 2004.

Although the global level dialogue on reproductive health supplies has made great strides in recent years, the need for supplies continually outstrips available funding. Awareness remains low at the country level and recipient country governments have yet to prioritize and gain ownership of causes and solutions to supply shortfalls. PAI and its partners continue to work towards achieving universal access to RH supplies by building civil society knowledge and engaging and partnering with governments and multilateral institutions at the global, regional and country levels.

The process of financing, procuring, shipping, storage, and distribution of condoms is complex, with challenges facing each step. The time between placement of an order and delivery of commodities is approximately 12 months, even when the funds are readily available. Forecasting condom and contraceptive requirements must take place more than a year before the condoms and contraceptives will actually be used. Condoms logistics are complicated by the fact that exposure to heat and humidity contribute to more rapid deterioration of latex and reduce the shelf life of condoms. Donors, particularly the U.S. government, have worked with countries for years to strengthen commodity logistics systems, both through the USAID-funded DELIVER Project and the Supply Chain Management System (SCMS) Project. This attention to national commodity management systems is critical to bring together "vertical" logistics systems that have been established for individual programs (e.g. separate logistics systems for family planning, HIV/AIDS, child immunization, etc.).

Please see the Appendix for this section's end notes.