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Female Condom: Accelerating Access and Use


April 23 - May 2, 2008
http://my.ibpinitiative.org/femalecondom

The purpose of this forum was  to review the latest guidance and new technologies related to female condoms and exchange information and experiences with colleagues around the world who are working to provide good-quality service delivery.

Discussion Statistics


Number of participants: 519
Number of participants' countries: 75
Number of contributions: 119
% of contributions from developing countries: 59%
Number of countries contributing: 28 countries

Contributing countries: United States (44), Nigeria (20), India (5), Zimbabwe (2), Ethiopia (3), Kenya (4), South Africa (3), Uganda (3), Switzerland (2), Tanzania (3), Zambia (5), United Kingdom (2), Thailand (3), Cote D’Ivoire (3), Ghana (1), Netherlands (1), Bangladesh (1), Gambia (2), Madagascar (1), Malawi (3), Mozambique (1), Senegal (1), Sudan (1), Suriname (2), Argentina (1), El Salvador (1), Grenada (1)



Purpose and Objectives

To review  the latest guidance and new technologies related to female condoms and exchange information and experiences with colleagues around the world who are working to provide good-quality service delivery.                                                                          
                                                       
Day 1. 

Questions:

  1. Are female condoms being integrated into family planning programs in your country? 
  2. Are female condoms being integrated into HIV/AIDS prevention and treatment programs in your country? 
  3. What is your experience with large-scale or national-level female condom programs in your country?
  4. What is the rationale for integrating female condoms into one type of programming and not the other?
  5. If your clinic does not offer contraceptive implants, can you tell us why not? Has the clinic ever considered offering them?
  6. Is your clinic or facility undergoing a transition from
Norplant® to Implanon®, Jadelle® or Sino-Implant (II) ® (to be trademarked as Zarin® in African countries)? If so, how is the transition going? Have there been any challenges?
  7. Are Implanon®, Jadelle® or Sino-Implant (II) ® (to be trademarked as Zarin® in African countries) available in your facility? If so, how much must users pay for them? Are they provided at the same price for everyone, or are they given to low-income clients at a lower cost or free?

Emerging themes and Issues:

hank you to everyone who has contributed so far to this discussion. We have received 5 contributions (scroll down to read them) from Nigeria, South Africa and Ethiopia.

We are not surprised that more responses indicated that female condoms are being promoted through family planning programs than through HIV/AIDS programs. This supports findings from a survey that PATH conducted recently indicating little progress has been achieved in expanding access to female condoms through HIV/AIDS prevention and treatment programs. This could be influenced by the fact that family planning programs and service delivery mechanisms are more established in many countries than HIV/AIDS prevention, care and treatment services, which have only seen a significant influx in funding and development in recent years. We welcome further description of any efforts to promote female condoms in integrated HIV/AIDS and family planning programs.

One of the findings from CHANGE's recently released report, "Saving Lives Now," (attached to this document, and available in the forum community library and at www.preventionnow.net) is that because HIV is still so highly stigmatized, positioning female condoms as a method for family planning allows some women to better negotiate their use. We thank participants for drawing attention to the fact that female condoms should be part of a holistic package of HIV and AIDS and reproductive health/family planning methods and services, even though this goal is not being met through current efforts.

As Jeff Spieler, Senior Science Advisor, Office of Population and Reproductive Health Bureau for Global Health USAID, wrote in response to Day 1 questions, “While FCs are certainly a good option for Dual Protection, without the HIV prevention rationale, FCs would not be promoted for contraception, and we are not buying any for that specific indication. While the pregnancy prevention rational for FCs (and male condoms too) will help empower some women to negotiate its use, FCs are not cost-effective for contraception only. While we have very few options for HIV prevention, we have numerous options for contraception and I don't think a single donor would purchase FC1 or FC2 for family planning programs.”

Where is the most appropriate place to program female condoms in your community? We believe that female condoms should be programmed strategically to respond to the needs of women and men for protection from unintended pregnancy and/or STIs. One challenge is that some donors will only program female condoms for HIV/AIDS prevention when the felt need in the community may be broader. How can this be reconciled? We hope to explore this topic further during our discussions this week.
                                                         
                                                       
Day 2.  

Questions:

  1. Hypothetical models have shown that female condoms can be cost-effective in terms of both HIV infections and other STIs averted and sex acts protected. Still, cost is often cited as a major reason that female condoms are not promoted widely. 
  2. Do you believe that female condoms are a cost-effective method for family planning and/or HIV/AIDS prevention and treatment programs? 
  3. Do you think cost is the major barrier to integration of the method into family planning programs? Is cost the major barrier to integration of the method into HIV/AIDS prevention and treatment programs? Why?
  4. Given that female condoms are a cost effective HIV prevention method compared to the costs of ARV therapy, counseling and testing and, potentially, medical male circumcision, why are many program managers resistant to incorporating female condoms into their prevention packages? What do you think is needed to expand access to female condoms through HIV prevention and treatment programs?

Emerging themes and issues:

We are pleased to have received 11 contributions that we received from colleagues in Argentina, Uganda, South Africa, Mozambique, USA, Madagascar, India, Suriname, and Senegal.

Today's contributions build on yesterday's postings and also bring to light important and diverse experiences that point toward the importance of a coordinated strategy for introducing female condoms into a given country or market. While it might make sense to introduce female condoms into a setting as a pilot program, if the aim of introduction is eventual widespread access and acceptability, the pilot must be part of a larger commitment and strategy to scale-up access. Coordination among donors and governments as well as HIV/AIDS and family planning programmers and civil society is central to a successful strategy. As our colleague from Mozambique pointed out, while including female condoms in the national family planning or HIV/AIDS strategy is an important step toward making them accessible, it is not sufficient in the absence of political commitment or adequate funding.

We want to reiterate the importance of incorporating female condoms within and across both family planning/reproductive health and HIV/AIDS programs, and the value of a holistic approach that presents many options to a range of women throughout the life cycle and as life situations change. A human rights approach to HIV and family planning demands providing individuals with a range of tools, information and skills so that they may select the interventions that best allow them to obtain their fertility desires and preserve their sexual and reproductive health. When tackling issues of cost, this approach must be weighed against the public health reality of needing to prevent the greatest number of infections with limited financial and human resources.

While some participants agreed that cost is a key barrier to female condom programming, one participant suggested that programs might invest more in this important dual protection method if stronger evidence of high acceptability existed. This respondent suggested that new female condom designs could improve on issues that have limited access and acceptability. We are happy to report that several new designs are currently being developed. For example, while most programs supply FC1, a newer version of the female condom is available in some countries. The FC2 is made from synthetic rubber and should be less expensive than the FC1. Dr. Reddy from India has developed a female condom that is made from latex and offers different product features. In Colombia, Natural Sensations markets a female condom panty. PATH has developed a female condom design and is seeking funding for late-stage clinical trials which would lead to regulatory approval. We anticipate that the expansion of female condom products on the market will lead to greater levels of protected sex, since no one product will meet the needs of all couples who need or want to use barrier protection.

Female Condom eForum Team
                                                               
                                                       
Day 3.

Questions:

  1. Even though female condoms are designed to be female-initiated, the product still requires negotiation between partners, and men can still refuse to use them. The Men as Partners program lead by Engender Health has successfully used men to introduce discussion of contraceptives and distribute products. In a Ghanaian pilot program for female condoms, men engaged their communities in dialogue around the use of female condoms. 
  2. In some settings, it may not be feasible to counsel men about the method. What have you done in your programs to address this issue?
  3. How are women getting men interested in using female condoms in your country? 
  4. Are you incorporating the pleasurable aspects of sex practices into your female condom counseling? For example, the Pleasure Project (www.pleasureproject.org) suggests several ways of using female condoms to enhance sexual experience including The Rub, The Bump and Show and Tell. Do you think this approach is useful for the RH programs you know? 
  5. Are there existing programs where men--in their capacity as partners, community leaders and service providers--champion female condom use to help reduce resistance and overcome social barriers? 
  6. As partners, healthcare providers and community leaders, how can men’s influence be tapped to strengthen female condom acceptability and support programming?
  7. Do you think that it is possible to use the female condoms without a male partner’s knowledge (i.e., covert use)? Is it safe for women to attempt covert use? If not, then what strategies can help women broach female condom use with a partner?

Emerging themes and issues:

Thank you for the continued thoughtful contributions. On Day 3, we received several contributions from Nigeria and others from Kenya, Zambia, Grenada, and the USA.

We would like to address participant responses relating to issues and perceptions of product accessibility and cost. As noted yesterday, the respondent from The Female Health Company (manufacturer of the FC1 and FC2) stands ready to support in-country programming efforts and has resources to assist in this at their website [see reference library for this discussion]. Thus, the perception of limited product availability and/or accessibility of
female condoms relates more to lack of programming in-country than inadequate product pipeline. Sufficient political commitment must be garnered to not only establish budget line items to procure female condoms but also to program them effectively. It is through these channels that availability/accessibility will be addressed.

Some discussion has been raised related to cost and the perception that female condoms are too costly to include in programs with limited budgets. We very much agree with the comments from the respondent from Zambia who suggests that comparing cost of female condoms to male condoms is inappropriate. In fact, it may never be possible to accurately compare cost of male to female condoms. This is because the total cost of the infrastructure that has been established to support widespread male condom promotion and distribution in response to the HIV/AIDS crisis over the last two decades is too diffuse to capture accurately.

We have also heard that social and cultural attitudes about condoms, sex and women create barriers to accessibility and acceptability. In order for female condoms to gain increased acceptance by communities, gender roles and norms that undermine or oppose women's empowerment and agency (especially gender-based violence against women) must be overcome.

We agree that there appears to be an overall negative perception of female condoms on the part of reproductive health advocates, providers, program implementers and some donors that also impacts acceptance and access. In contrast, colleagues in Europe recently initiated a bold new venture focused on increasing access to female condoms for women in developing countries through large-scale programming in select countries, international advocacy and development of more cost-effective product designs. We applaud the aims of the Female Condom Consortium and are hopeful that the energy and vitality that they bring to the field will result in renewed optimism.
                                                          
                                                       
Day 4.

Questions:

  1. The female condom has been available for 14 years and at least one donor agency reports that requests for female condoms have increased every year for the past 10 years. UNFPA is leading an ambitious effort to scale up female condom programming in at least 23 countries through their Global Female Condom Initiative. Still, the female condom is not often included in family planning or HIV/AIDS prevention and treatment programs. Why do you think this is happening? 
  2. Why might donor agencies oppose or be disinterested in scaling-up the female condom? 
  3. Why might governments oppose or be disinterested in scaling-up the female condom?
  4. How can we encourage governments and donor agencies to commit to fully supporting the integration of female condoms into family planning and HIV/AIDS prevention and treatment programs?
  5. Some people say that donor agencies and governments do not want to fully commit to female condoms because the method helps empower women. Is the empowerment of women perceived as a positive or negative contribution to your community and society? How do female condoms fit into this social perception of women’s empowerment?
  6. What must be done to increase the political will for female condoms? Why have arguments about the need for a female-initiated barrier method and increased prevention options been unsuccessful for many decision makers?

Emerging themes and issues:

We are pleased to share with you responses from Day 1 of Week 2, from Bangladesh, Uganda, USA, Zambia, Nigeria and Ethiopia.

We heard from several respondents that there is a need to increase demand for female condoms, especially from women, in order to increase political will and funding for the product. While the "success" of female condom programs in Zimbabwe and Ghana is questionable (which raises the question, "How do we define success?"), in both countries women’s groups have played important roles in bringing female condoms to their countries. Women’s groups saw a need for the product and advocated for their government support in procurement. However, even after Zimbabwe’s government procured female condoms, the product did not succeed at publicly funded sites, in part because of unreliable supply of product throughout the logistics distribution system and lack of training oversight. This suggests that even if a government is responsive to public interest in female condoms, sustaining such interest at the government and donor levels, and ensuring that necessary logistics systems and provider support is established, can be a challenge.

An important issue that the respondent from Bangladesh brought up is the concern that users will substitute female condoms, the more expensive product, for male condoms. In interviews with experts and a review of literature that CHANGE conducted for its report, "Saving Lives Now," it found that making male and female condoms available in the same setting actually increased the overall number of protected sex acts, suggesting that rather than substituting female condoms for male condoms, female condoms act as a supplemental form of protection.

Thank you again for sharing your insights and experiences from the field.
                                                   
                                                       
Day 5.

Questions:

  1. In your experience has civil society found access to female condoms difficult? 
  2. What should be civil society’s role in the distribution and marketing of female condoms? 
  3. Given civil society’s access to populations vulnerable to HIV/AIDS, how can civil society gain a voice in national and regional negotiations around female condom procurement, distribution and programming? 
  4. Are there examples where such collaboration is happening successfully?

Emerging themes and issues:

We appreciate the thoughtful contributions relating to reasons why
donors and/or governments might be disinterested in scaling-up the female condom. We agree with the sentiments expressed by our UK colleague and encourage participants to consider the question she leaves us with. We also suggest expanding the question to, "How can we encourage decision-makers/stakeholders to set aside cultural or personal biases that influence their perception of female condoms? What is needed to convince them that female condoms are a legitimate prevention technology and that, when programmed with appropriate information, counseling, and support, they can meet women’s important health goals?"

We also draw your attention to the contributions of Zimbabwe and Nigeria as useful models for female condom scale-up and acknowledge the dedicated work that they have undertaken to develop and implement a participatory strategy. Civil society organizations play an important role in creating a supportive environment for advocacy, education, and distribution of female condoms. They are critical partners in efforts to scale-up access to female condoms. Numerous examples show what happens when a broad range of stakeholders are not included in planning for introduction and scale-up. Zimbabwe and Nigeria offer a snap-shot of what can happen when donors, governments, health planners, and civil society are included in designing strategic female condom programming.

Are there other examples where government-donor-civil society collaborations are happening around female condom programming? It would be useful to hear from you and learn from your experiences, both the frustrations and the successes.

Our colleague from Zimbabwe also offers some measures of program success. We continue to feel, however, that additional work must be undertaken to reach a global consensus about the most appropriate and useful set of indicators for determining programmatic success. Perhaps the most appropriate indicators will relate to female condom distribution and sales, or perhaps they may relate to health impact measures such as the level of protected sex. We call for your thoughts related to this and suggest that now is an opportune time to generate a broader international dialogue to reach consensus about this important matter.

Clearly, greater advocacy is needed to encourage broad support for female condom programs. The challenge is to foster advocacy with a global and national reach that is based in local realities. Many groups are moving in this direction. How can we support each other synergistically so that advocacy that is both "top-down" and "bottom-up" with the same goal of improving access to a proven prevention technology for the women and couples most at risk? We look forward to hearing your thoughts on this!

Day 6.

Questions:

  1. What is the benefit of including the female condom in national policy statements, standards of care and training protocols related to family planning and HIV/AIDS prevention and treatment?
  2. Is it easier to make these kinds of changes at the local level or the national level? How have these kinds of changes taken place in your country/organization?
  3. Is it more strategic to change policy, standards and protocols at the local level or national level first?
  4. What has been your experience in including female condoms in management information systems?
  5. What has been your experience in including female condoms in logistics and procurement systems?

Emerging themes and issues:

Thank you to our colleague from Zimbabwe for the detailed description on the evolution of female condom strategies and programming in that country. The sharing of such experiences can go a long way in informing the actions of others (policy makers, advocates and donors) seeking to increase national access to female condoms. We look forward to learning more about Zimbabwe’s experience and successes as it rolls out its strategy.

The stated role of civil society to normalize female condoms and act as distribution points in Zimbabwe’s plan is particularly noteworthy in light of yesterday’s questions. Colleagues from Zimbabwe and Malawi both noted the importance of including faith-based organizations and churches in efforts to gain acceptance of female condoms. Religious groups and leaders have broad outreach and authority within communities and, as we know, can contribute both positively and negatively to sexual and reproductive health matters. We think it is important, and very useful, to reach out to faith-based groups, educate them about the benefits of female condoms, and include them in the planning and subsequent roll-outs of female condom programs.

We heard again in today's responses that the female condom is inextricably linked with issues of gender in various cultures. While we agree that gender norms and disparities play a major role in female condom acceptability and use, we feel that it is unrealistic to assume that female condom promotion and distribution alone will result in women's empowerment. We understand women's empowerment to be a process of individual and societal change that will require multi-faceted inputs over a longer time period. Female condoms can play a part in this. For example, when they are promoted to couples, female condoms can enable women to engage more actively in condom use negotiation and sexual decision-making, and perhaps allow a measure of control over some aspects of their lives. Female condoms offer both women and their partners another protection option that can improve their sexual and reproductive health. Additionally, since female condoms are designed to work with a woman's anatomy, this can lead women to learn more about their bodies. That knowledge--along with enhanced partner communication--can support women's confidence in negotiating their use. Therein lies the potential contribution of the female condom to women's empowerment.
                                                                 
                                                       
Day 7.

Questions:

  1. Do women in your community want to use additional lubricant with the female condom?
  2. What kinds of lubricant do women who are using female condoms in your community prefer? 
  3. How often do women and couples use saliva as a lubricant during female condom use?
  4. How easy is it to obtain their preferred lubricant? How affordable is it?
  5. Even though female condoms were designed for use during vaginal sex, we have heard reports that some couples choose to use the female condom during anal sex. Is this practice common in your community? If so, what kinds of counseling messages are being provided regarding the use of the female condoms in this way? 

  6. Are there other questions relating to female condom use and promotion that are commonly asked?

Emerging themes and issues:

Today’s responses demonstrate that the female condom offers creative marketing and product placement opportunities. Marketing female condoms with lubrication or in tandem with male condoms are examples of this. We are also reminded that access to more prevention methods can lead to greater levels of protected sex, which benefits individual users and communities. This is an important consideration to bring to decision makers when advocating for female condoms and other sexual and reproductive health commodities. Today’s conversation also serves as a reminder that safe sex can be fun and pleasurable and that positioning safe sex technologies as tools for pleasure-enhancement could be a way to navigate negative perceptions of these products.

We want to thank everyone who has participated in this forum for their thoughtful and candid responses to the questions we have raised. There are clearly many challenges to scaling-up female condom programs. We appreciate this opportunity to have an open discussion about positive and negative experiences from the wide range of individuals working on this issue. It is clear from respondents’ comments that remarkable work is being done to expand access to female condoms, and we encourage the continued sharing of the successes these initiatives achieve and the challenges they face. Finally, we want to acknowledge that increased access to female condoms should be part of the greater goal of providing opportunities for individuals to engage in fulfilling and safe sexual experiences so that they may protect themselves and contribute to the overall health of their communities.

Although we have discussed many of the issues surrounding acceptability and access to female condoms over the last several days, we realize this has been a forum for questions as much as a forum for answers. What are other questions relating to female condom use and promotion that are commonly asked? Please send us the questions that are most frequently asked about female condoms in your community. These questions might be integrated into a set of resource materials that provide brief evidence-based answers to frequently asked questions on male and female condoms.
                                            
                                                       
Cross-cutting themes and issues

  1. Female condoms are being promoted through family planning programs rather than through HIV/AIDS programs. This indicates little progress has been achieved in expanding access to female condoms through HIV/AIDS prevention and treatment programs.
  2. Coordination among donors and governments as well as HIV/AIDS and family planning programmers and civil society is central to a successful female condoms strategy.
  3. There is a need to increase demand for female condoms, especially from women, in order to increase political will and funding for the product.
  4. Civil society organizations play an important role in creating a supportive environment for advocacy, education, and distribution of female condoms. They are critical partners in efforts to scale-up access to female condoms.
  5. Including faith-based organizations and churches in efforts to gain acceptance of female condoms is critical. Religious groups and leaders have broad outreach and authority within communities and, as we know, can contribute both positively and negatively to sexual and reproductive health matters.
  6. Positioning safe sex technologies as tools for pleasure-enhancement could be a way to navigate negative perceptions of these products.
                                                                 
                                                       
Program Example

A participant from Zimbabwe shares, “Zimbabwe is one country where civil society has largely been involved in FC programming. Introduction of the Female Condom in 1997 by the Government of Zimbabwe was in response to a petition that came from civil society. The public sector programme however, faced a set-back due to a number of challenges. Among them the need for a strategy to guide programming. However, from 2005 UNFPA engaged Government and assisted in creating a Technical Support Group on Condom Programming (TSG). The TSG is made up of members from government ministries, civil society organizations, social marketing agencies and donors. 

Of course it has not been practical to include all NGOs in the TSG, a common challenge faced with representation with any national body. Zimbabwe however, went around this by getting representation from the umbrella body of AIDS Service Organizations- The Zimbabwe AIDS Network. In addition other NGOs running national programmes such as Population Services Zimbabwe and Population Services International are active members of the TSG and have been involved at every stage from needs assessment, through to development of the strategy and its implementation. 

This Technical Support Group on Condom Programming (TSG) has literally moved mountains in supporting the government to revive the Female condom programme. Together with UNFPA, the TSG assisted government in doing a Female Condom Research Review, and a Female Condom Situation Analysis in 2005 as the basis for developing an evidence-based 5 year National Female Condom Strategy. Following generation of this data, the same TSG worked with government in organizing a National Stakeholders' meeting at the beginning of 2006. This National stakeholder group had a much broader civil society representation. Of the over 60 participants that attended this national consultation, close to two thirds were from civil society organizations, e.g. representatives from Heads of Christian Denominations, Interfaith Network, Men's Forum on Gender, Women's Action Group, Women and AIDS Support Network, Business Council on AIDS, Network of People Living with HIV, to mention a few. At this meeting results of the FC Situation Analysis were shared, and from this, the stakeholders outlined priorities and drew a clear and concrete road-map on scaling-up the FC programme, which culminated into the Zimbabwe National Female Condom Strategy 2006-2010, signed by the Secretary for Health (attached). UNFPA Country Office has supported this larger stakeholder group to meet every year for purposes of reviewing progress on implementation of the Female Condom Strategy and planning for the following year, the last one having been in December 2007. In addition, the National FC Strategy clearly outlines the division of labour among the different organizations. Paragraph 10.9 of the strategy states that ''NGOs, especially those working with both men and women as well as community leaders e.g. Padare, Women and AIDS Support Network, Women’s Action Group, and Musasa Project, will be instrumental in carrying out advocacy activities in order to foster acceptance of the female condom. In phase 2 and 3 these organizations will, where they exist, also serve as a distribution point through their provincial and district chapters", see chapter on Role of partners - page 27 and 28 of the National FC Strategy (attached). You may also be interested to know that the national FC capacity development plan includes all sectors; public, NGO and social marketing sectors.  Having identified training needs, common training tools were developed and master trainers were trained from public sector, social marketing and NGOs sectors. The trained trainers formed provincial training teams that have been cascading training and trained close to 2 000 service providers from different sectors. Zimbabwe has a National HIV/AIDS M&E Framework that collects data from the lowest Community Based Organizations. The FC monitoring plan was therefore developed to collect data from the lowest level Community Based Organization and community worker and feeds into the national M&E system.

 Progress made since 2005 has been phenomenal. Public sector FC distribution grew by 66.8% in 2006 and 90.2% in 2007. On the other hand, social marketing sales increased by 51.9% in 2006 and 58.2% in 2007.”                                                                                                                            
Post-forum survey results

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References and resources
Family Health International   Research Briefs on the Female Condom http://www.fhi.org/en/RH/Pubs/Briefs/FemCondom/index.htm

Horizons/Population Council. The Female Condom: Dynamics of Use in Urban Zimbabwe.
www.popcouncil.org/horizons/fcz.html

PATH  Outlook, Vol. 22. No. 2 May 2006.
The Female Condom: Significant Potential for STI and Pregnancy Prevention (Outlook, vol. 22,         no. 2)
Spanish
The Female Condom: Significant Potential for STI and Pregnancy Prevention (Outlook, vol. 22,         no. 2)

PreventionNow! Resources Page – (contains links to many great resources)
http://www.preventionnow.net/index.php?option=com_content&task=view&id=14&Itemid=30

UNFPA/PATH: Female Condom: Powerful Tool for Protection
http://www.unfpa.org/upload/lib_pub_file/617_filename_female_condom.pdf

WHO The Female Condom: a guide for planning and programming
http://who.int/reproductive-health/publications/RHR_00_8/RHR_00_8_chapter5.en.html

Female Health Company FC and FC2 Resource Page
http://www.femalehealth.com/resources.html

CHANGE Saving Lives Now: Female Condoms and the Role of U.S. Foreign Aid
www.preventionnow.net/images/savinglivesnowfinal.pdf

Organizing groups 
The INFO Project, PATH, and Center for Health and Gender Equity (CHANGE) with support from partners of the Implementing Best Practices (IBP) Initiative and WHO/RHR.

Contributing experts/facilitators 
  • Lauren Sisson, the Center for Health and Gender Equity (CHANGE)
  • Maggie Kilbourne-Brook, PATH
  • Patricia Coffey, PATH
  • Serra Sippel, the Center for Health and Gender Equity (CHANGE)

Moderators
  • Heather Sanders, JHU/CCP