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Universal Access to Female Condoms helps normalize an HIV/STI prevention and family planning method
by Chael Needle

Advocates for female condoms walk with paper dolls in D.C. during the International AIDS Conference. Photo courtesy UAFC
Advocates for female condoms walk with paper dolls in D.C. during the International AIDS Conference. Photo courtesy UAFC

As part of an ongoing international campaign, the Universal Access to Female Condoms (UAFC) Joint Programme displayed strings of paper dolls at the International AIDS Conference in Washington, D.C., last July. Participants could fashion a pre-printed doll of their choice by coloring in an outfit and using other adornments to individualize the doll. And they could write a personalized message: “I have the right to protect myself,” “Wrap it up,” “Female condoms for free,” “Girl Power.”

The grass-roots effort proved that the demand for female condoms is overwhelming—and global. UAFC linked together over four miles of these paper dolls with eight-inch armspans, assembling over 20,000 messages of support from sixty-plus partner organizations in over thirty countries. And that demand, UAFC has found, increases the more people know about female condoms and how they can be incorporated into one’s everyday sexual life.

Latex-based or nitrile-based female condoms, inserted into one’s vagina before sex, offer dual protection as a contraceptive and an HIV/STI prevention method. Not dependent on an erection to function, some female condoms may even be inserted up to eight hours before intercourse. Different types have slightly different features, but all have an outer ring or device that stays outside of the body and may increase a woman’s pleasure by rubbing against the labia and clitoris. For men, sex may feel more natural than with a restrictive male condom. Female condoms may also be used for anal sex.

Those are the basics, but UAFC works with local partners in various countries to help women, as well as male partners, with destigmatizing the discussion around sexual health and sexual options, and to help every woman feel confident about putting into action her right to protect herself and her right to make choices in sexual situations.

The Paper Doll campaign is a good example of that—both women and men voicing their public support of the female condom, and the dolls in turn used as conversation starters by advocates about this woman-initiated prevention and family planning option. And the campaign goes hand in hand with UAFC’s underlying mission: to bring together diverse individuals on a project to make female condoms available, accessible, and affordable to all.

“By the end of the conference I felt more people were easily talking about female condoms—young girls, young men, gay, heterosexual—so hopefully there we made a big step toward normalization,” says Universal Access to Female Condoms Joint Programme coordinator Marie Christine Siemerink about the U.S., but also, importantly, the international participants and advocates that the conference attracted. That is, UAFC’s primary focus is to normalize and increase access to the female condom in countries most in need of HIV/STI prevention and family planning options, particularly in the resource-limited Global South.

Partners in acceptance
UAFC is a diverse consortium composed of four Dutch entities—Oxfam Novib; Rutgers WPF (World Population Foundation), a center for sexual and reproductive health and rights; i+solutions, an international nonprofit specializing in pharmaceutical supply chain management for low and middle-income countries; and the Dutch Ministry of Foreign Affairs—came together in 2008 as partners. Explains Siemerink: “The initiative came simultaneously from two program officers, one within Oxfam Novib, Mrs. Anny Peters, and one in Rutgers WPF, Yvonne Bogaarts, who separately realized that despite the existence of the female condom, it was not accessible for a huge group of women, especially women who were still facing the lack of prevention and protection methods [particularly in developing countries].”

Each entity brings to the table assets needed for these advocacy, awareness, and programming efforts, notes Siemerink. Oxfam Novib brings its experience with programming, especially in the Global South; Rutgers WPF is an expert in sexual-health advocacy and education; i+solutions knows the ins and outs of technical and supply chain management; and the Ministry contributes international NGO and political contacts, as well as funding networking support.

“Additionally, cooperation with the African partners is essential to ensure the target groups’ accessibility to the UAFC programs and products. Currently, two country programs have been implemented, in Nigeria and Cameroon,” says Siemerink. These large-scale but locally owned programs in the two sub-Saharan countries have met with success. The lead organization in Nigeria, the Society for Family Health, has used its vast experience in the male condom market to the same effect for female condoms, conducting massive outreach in both the public and private sectors. With its lead partner in Cameroon, Association Camerounaise de Marketing Social (ACMS), UAFC is finding that different target groups see the value in female condoms.

A 2009 UNFPA (United Nations Population Fund) statistic—that seventy-one male condoms were purchased for every one female condom—does not reflect a scarcity of demand, but a scarcity of knowledge and access. UAFC-supported program reports show that knowledge of how to use a female condom and female-condom accessibility generally translates into users finding them both acceptable and enjoyable as a family planning and HIV/STI prevention method.

As with the Paper Doll campaign, these outreach and research efforts disprove the longstanding myth that nobody wants the female condom or that the stigma surrounding them cannot be overcome. Normalization, reduction of price, and sustainable programming are possible.
When one realizes that women who have sex with men, and male-female couples, face limited choices when it comes to sexual health, the underutilization of a product that has been around for two decades seems like the mother of missed opportunities—for empowerment, for family planning, for health, for pleasure, for life.

These limited choices affect family planning options. According to “Adding It Up; Costs and Benefits of Contraceptive Services: Estimates for 2012,” a report published by Guttmacher Institute:

The number of women who have an unmet need for modern contraception in 2012 is 222 million. This number declined slightly between 2008 and 2012 in the developing world overall, but increased in some subregions, as well as in the 69 poorest countries.

Current contraceptive use will prevent 218 million unintended pregnancies in developing countries in 2012, and, in turn, will avert 55 million unplanned births, 138 million abortions (of which 40 million are unsafe), 25 million miscarriages and 118,000 maternal deaths.

Serving all women in developing countries who currently have an unmet need for modern methods would prevent an additional 54 million unintended pregnancies, including 21 million unplanned births, 26 million abortions (of which 16 million would be unsafe) and seven million miscarriages; this would also prevent 79,000 maternal deaths and 1.1 million infant deaths.

Along with the benefit of being a reversible form of contraception, the availability of female condoms increases choices for protecting

As part of a female condom outreach effort, hairdressers in Cameroon educate customers in the familiar setting of a salon. Photo courtesy ACMS
As part of a female condom outreach effort, hairdressers in Cameroon educate customers in the familiar setting of a salon. Photo courtesy ACMS
against the transmission of HIV/STIs. And choices are needed. According to UAFC, sixty-one percent of adults in sub-Saharan Africa who are HIV-infected are women. When one looks at young people living with HIV, seventy-five percent are women. Additionally, it’s easier for an individual to obtain access to antiretroviral treatment than it is to obtain a reliable supply of female condoms. A UNAIDS mathematical model has shown that female condoms are a cost-effective contraceptive and STI prevention method, yet, in 2007, female-condom funding accounted for only 0.3 per cent of $10 billion, the sum total of HIV-related funding for that year.

Fortunately, UAFC has shown how the “under” in “underutilized” can be erased—and is helping to do so, letter by letter.

Barriers to barriers
UAFC works on both supply and demand when it comes to female condoms, and this work involves dismantling barriers to acceptance, affordability, and access.

Notes Siemerink: “I think its getting better, but, for a long time, there was not enough knowledge of female condoms and they were generally not introduced or explained or offered when people would ask for family planning or HIV/STI prevention methods….And at the same time, and it’s a bit chicken and the egg, they were not readily available at the pharmacy or local shops. So if you don’t see it and you’re not told about it, then of course it’s not a normal method you will use. Little by little [as] more [brands of female condoms] are available, prices drop as they become more normal, it’s out of the corner of ‘this is only for sex workers,’ so more people will discuss it, talk about it and understand how to use it, and uptake will increase.”

According to Millennium Development Goals literature, obstacles to widespread female-condom availability and acceptance are numerous. Stereotype-steeped ideas and cultural bias about female condoms often outweigh evidence-based knowledge when it comes to policy decisions. Discussions end in clichés—they are too expensive; they require negotiation, just like male condoms—rather than start with problem-solving. Actual preferences about condoms are ignored, as are basic economics (prices will go down as demand increases). And conservative attitudes abound when it comes to what the female condom potentially offers to women—greater knowledge of and control of their bodies and sexuality—or offers to male-female couples—the chance to discuss sex and sexual health and a more even playing field when it comes to sex in general.

“The different barriers all have their different characteristics; the high price and lack of variety can be overcome with more market dynamics and once more manufacturers benefit from the large procurement by U.N. agencies,” notes Siemerink, who adds that UAFC addresses different issues in different ways.

More demand in the U.S. and other Western nations would also benefit the economics of female condoms around the world, as well as policy decisions on their procurement and programming.

The U.S. FDA has only so far approved one female condom (brand)—FC1, and then its replacement, FC2, both from the Female Health Company—even as the World Health Organization (WHO) recently prequalified the CUPID female condom for approval. Other female condoms, such as Dr. Reddy, are in the WHO review pipeline but available in the private sector, and the PATH’s Woman Condom is still in development. USAID and other U.S.-funded agencies that provide support to HIV/AIDS-related services, are limited to procuring the one FDA-approved condom.

A 2011 report by the Center for Health and Gender Equity, “Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health,” points to several challenges remaining for the U.S. policy role in terms of this country’s female-condom procurement and programming. “OGAC [Office of the Global AIDS Coordinator] officials recently drew attention to a burgeoning ‘condom gap’—an acute shortage of female and male condoms in many countries in Africa with high HIV prevalence. Evidence suggests that the female condom gap is due to inadequate funding from OGAC for female condom commodities and programming. In addition, lack of awareness and/or negative attitudes of headquarters officials and Mission field staff pose barriers to female condom support. OGAC and USAID still have no specific policy guidance for the field to promote female condoms or provide incentives to procure and program them, which would help combat these negative attitudes. Moreover, PEPFAR reauthorization contains provisions that favor abstinence and fidelity activities, sometimes to the exclusion of comprehensive approaches that contain female and male condoms. Finally, even though officials routinely ask to see more evidence of female condom uptake and utilization as a precursor to any scale up, OGAC has no mechanism to collect data on female condom distribution or use.”

UAFC also points out the U.N. and the majority of donor agencies have failed to provide sustained support of the development and promotion of female condoms. Instead of stocks of female condoms expiring unused in warehouses, which happened frequently in the absence of programming support in the past, UAFC would like to see increased and sustained funding for trials and higher quality pilot programs and studies.

A holistic approach
UAFC tackles these barriers by addressing the whole picture. Firstly, UAFC encourages policymakers, such as the U.N. and international donor agencies, to support female condoms. And the initiative has been successful in generating “enthusiasm and interest,” says Siemerink. A key part is enlisting Southern advocacy in the form of national level NGOs, so that they can in turn encourage their governments’ support.

UAFC also supports the manufacturing and procurement side in several ways. “The fact that we have supported different manufacturers in their prequalification process is new and has not been done before,” says Siemerink about a process that involves clarifying WHO approval requirements; and funding functionality studies, a component of WHO approval, among other R&D activities. “Because of the holistic approach, we can immediately exchange the latest development between the different program parts; for instance, news on a prequalified condom is immediately shared with the advocates who can use this information in high level advocacy or to inform local NGOs in the South so they can use this information in their advocacy. The data and information collected in our own country programs are used for linking and learning and can be used to educate new programmers on how best to implement a female condom program.”

Lastly, UAFC helps promote the female condom by educating and surveying sexually active, straight-identified individuals in countries with the highest risk. Education through programs involves imparting knowledge about female-condom use and its possible role in HIV/STI prevention and family planning, as well as teaching communication and negotiation skills when it comes to sex.

“If people don’t have a good experience from not knowing how it works or how to talk about it with their partners, next time they will bypass the method,” says Siemerink about the importance of sensitization.

She adds: “Conservative attitudes, lack of knowledge on the use of female condoms and the still-persisting [and stigmatizing] idea that female condoms are for sex workers [or HIV-positive individuals] only, will take longer to overcome, but as our country programs show, can be overcome by targeting the whole sexually active population.”

Amaka Nneji, coordinator of the female condom in Lagos, Nigeria, explains how to use female condoms. Photo by Robert Bodegraven
Amaka Nneji, coordinator of the female condom in Lagos, Nigeria, explains how to use female condoms. Photo by Robert Bodegraven
This means targeting each partner in the sexual relationship, both men and women, when it comes to social marketing, such as barbershop and beauty salon outreach, and mass media campaigns. “Research that we had done for us shows that men are positive toward female condoms as long as they are involved in the decision-making. So although we were already also targeting men, we are now going to include them even more because we realize that if you bypass them and go directly to the woman because we want her to be empowered you sort of miss your objective because then the man feels excluded and is no longer willing to try these new methods. So it’s very important that they’re part of the education and part of the sensitization, which is something we now explain to women in our programs, that…it’s normal to discuss [sexual health] with their husbands, that they should be able to.”

Outreach always needs to be tailored, however, to local beliefs and practices, UAFC has found. For example, “[i]n our research on male views on female condoms, it showed that for some men, female condoms as a prevention method is less accepted within a steady relationship/marriage than as a family planning method. The idea behind this perception is that when a female condom is used for prevention of HIV/STIs, it implies unfaithfulness of one of the partners. If the female condom is introduced as a family planning method, it remains more neutral,” explains Siemerink.

This relationship-centered approach addresses women’s actual needs, and sets the stage for empowerment not to be simply a theory but a practice. About female condoms, Siemerink says: “We think and we know that it can empower women in their sexual relationships and that it will trickle down to other power relationships because, for example, if she doesn’t have too many children she can continue to work and that will [make it easier] to control her own life. So, in the end, it’s a long cycle and it starts with us, with the decisions on sexuality and the use of prevention and protection methods….”

Second and last phase
The UAFC, notes Siemerink, has always been a “temporary” consortium, one that will disband as it achieves (or does all it can to achieve) its mission. “The UAFC is going into the second and last phase, during which we want to train and support local advocates in the [Global] South; we will continue to support new manufacturers; we will work together with the international procurers to get a good price for manufacturers and procurers and end-users. We will continue to link and teach existing and new female-condom programmers, based on the experiences of our partners in Cameroon and Nigeria.

In terms of “high level advocacy, we aim for full integration of female condoms in all prevention and family planning programs; the female condom has to become a normal choice in the method mix and in prevention programs, next to male condoms and other methods.”
By 2015, UAFC foresees that its mission will be taken up by other stakeholders—advocates, programs and organizations in the Global South, and international agencies and manufacturers—to the extent that “Nobody wants the female condom” will finally become a retired myth, and everybody has a wider breadth of choice.

Log on to www.condoms4all.org for more information on UAFC or follow UAFC on Twitter: @ZawadiSmartlove or Facebook: Zawadismartlove.

Chael Needle is Managing Editor of A&U.

Read the article in the March 2013 on our site by clicking here or off-site by clicking here.