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:
- Are female condoms being integrated into family planning
programs in your country?
- Are female condoms being integrated into HIV/AIDS
prevention and treatment programs in your country?
- What is your experience with large-scale or national-level
female condom programs in your country?
- What is the rationale for integrating female condoms into
one type of programming and not the other?
- If your clinic does not offer contraceptive implants, can
you tell us why not? Has the clinic ever considered offering them?
- 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?
- 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:
- 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.
- Do you believe that female condoms are a cost-effective
method for family planning and/or HIV/AIDS prevention and treatment
programs?
- 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?
- 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:
- 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.
- 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?
- How are women getting men interested in using female
condoms in your country?
- 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?
- 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?
- As partners, healthcare providers and community leaders,
how can men’s influence be tapped to strengthen female condom
acceptability and support programming?
- 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:
- 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?
- Why might donor agencies oppose or be disinterested in
scaling-up the female condom?
- Why might governments oppose or be disinterested in
scaling-up the female condom?
- 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?
- 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?
- 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:
- In your experience has civil society found access to female
condoms difficult?
- What should be civil society’s role in the distribution and
marketing of female condoms?
- 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?
- 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:
- 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?
- 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?
- Is it more strategic to change policy, standards and
protocols at the local level or national level first?
- What has been your experience in including female condoms
in management information systems?
- 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:
- Do women in your community want to use additional lubricant
with the female condom?
- What kinds of lubricant do women who are using female
condoms in your community prefer?
- How often do women and couples use saliva as a lubricant
during female condom use?
- How easy is it to obtain their preferred lubricant? How
affordable is it?
- 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?
- 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
- 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.
- 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.
- There is a need to increase demand for female condoms,
especially from women, in order to increase political will and funding
for the product.
- 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.
- 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.
- 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
N of surveys completed
% who have passed content to
others
% who have or will use in
their work
% very satisfied with forum
content
Suggestions for improvement
Additional
quotes/comments
Needs/Requests for more
information
References and resources
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.
- 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
