1. health and fitness
2. disease
3. aids and hiv

Female Condoms and U.S. Foreign Assistance:
An Unfinished Imperative for Women’s Health
Acronyms
ABC—Abstinence, Be Faithful, or use Condoms
ACMS—Cameroonian Association for Social Marketing
AIDS—Acquired Immunodeficiency Syndrome
AIDSTAR—AIDS Support & Technical Assistance Resources
ART—Antiretroviral Therapy
CCP—Comprehensive Condom Programming
CDD—Catholics for the Right to Decide
CE—European Conformity Marking
CHANGE—Center for Health and Gender Equity
COP—Country Operational Plan
DFID—United Kingdom Department for International Development
DHS—Demographic Health Survey
FC1—First-generation Female Condom (Female Health Company)
FC2—Second-generation Female Condom (Female Health Company)
FHC—Female Health Company
FY—Fiscal Year
GFATM—Global Fund to Fight AIDS, Tuberculosis, and Malaria
GHI—United States Global Health Initiative
HIV—Human Immunodeficiency Virus
HPM—Hunger Project Malawi
JCRC—Joint Clinical Research Center (Uganda)
JSI—John Snow, Inc.
MOH—Ministry of Health
MOHCW—Ministry of Health and Child Welfare (Zimbabwe)
NGI—Next Generation Indicators
NGO—Nongovernmental Organization
OGAC—Office of the Global AIDS Coordinator
PEPFAR—President’s Emergency Plan for AIDS Relief
PrEP—Pre-Exposure Prophylaxis
PSI—Population Services International
RHU—Reproductive Health Unit (Malawi Ministry of Health)
RFA—Request for Applications
RFP—Request for Proposals
STI—Sexually Transmitted Infection
TB—Tuberculosis
TSG—Technical Support Group
UAFC—Universal Access to Female Condoms Joint Programme
UNAIDS—Joint United Nations Programme on HIV/AIDS
UNFPA—United Nations Population Fund
USAID—United States Agency for International Development
USFDA—United States Food and Drug Administration
WASN—Women and AIDS Support Network
WHO—World Health Organization
TABLE OF CONTENTS
ABOUT THE REPORT
5
EXECUTIVE SUMMARY
7
INTRODUCTION: THE GLOBAL FAILURE ON FEMALE CONDOMS
13
PART ONE: THE CASE FOR FEMALE CONDOMS
15
I. Female Condom Products
15
II. Female Condom Qualities: Acceptable, Effective, and Much More
15
Female Condoms are Acceptable
Female Condoms are Effective
Female Condoms Have Numerous Benefits and Advantages
PART TWO: CHALLENGES TO FEMALE CONDOMS
19
I. Problems Stem Predominantly from Lack of Commitment
20
Commodity Challenges
Stockouts
Programming Challenges
Female Condom Training and Health Provider Bias
Cost
PART THREE: THE REALITY AND POSSIBILITY OF U.S. POLICY ON FEMALE CONDOMS
25
I. U.S. Global HIV Prevention and Female Condoms: PEPFAR, USAID, and GHI 25
II. The U.S. and Female Condom Procurement
26
III. The U.S. and Female Condom Logistics
28
IV. The U.S. and Female Condom Programming
28
V. Limitations on U.S. Procurement and Programming of Female Condoms
30
PEPFAR and the Condom Gap
Negative Attitudes or Lack of Awareness among U.S. Government Officials
PEPFAR Funding Restrictions
PEPFAR Data Collection and Reporting Efforts
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
PART FOUR: IMPACT AND CHALLENGES IN THE FIELD: COUNTRY CASE STUDIES
35
I. Zimbabwe35
History and Female Condom Introduction
Revitalizing Female Condoms
Current Program Structure and Support
Successes
Challenges
II. Malawi39
History and Female Condom Introduction
Revitalizing Female Condoms
Recent Developments in Program Structure and Support
Successes
Challenges
III. Cameroon41
History
Current Program
Successes and Challenges
IV. Bolivia43
Background
History
Current Program
Successes and Challenges
V. Strengths and Weaknesses of U.S. Government Field Support for Female Condom Programs
45
U.S. Strengths
Commodity Financing, Coordination, and Logistics
Collaboration and Alignment with other Donors, Governments,
and Stakeholders
Support for Social Marketing
U.S. Weaknesses
Insufficient Funding for Programming
Lack of Female Condom Oversight or Program Tracking
Limited USAID Mission Outreach to Civil Society
VI. Ingredients of an Effective Female Condom Program
48
Table of Contents
PART FIVE: FINDINGS AND RECOMMENDATIONS
51
NOTES
55
BIBLIOGRAPHY
63
ANNEXES
67
Annex A: Female Condom Products
67
Annex B: U.S. Female Condom Procurement for International Programs
71
Annex C: UNFPA and UNAIDS Inter-Agency 10-Step Strategic Approach to Scale Up Comprehensive Condom Programming at the National Level
73
3
4
ABOUT THE REPORT
T
oday, we have a dual protection tool to prevent HIV/STIs and unintended
pregnancy that is designed for women to initiate. It is available now. It is effective.
And it is acceptable. Yet, globally, female condoms continue to be underfunded and
underused due to cost, stigma, and a lack of political will.
Among donors, the U.S. government is a leader in supporting female condoms.
Despite this leadership, female condoms represented just 3.2 percent of total U.S.
condom shipments in 2009.
Since the release of its 2008 report on U.S. foreign assistance and female condoms,
Saving Lives Now: Female Condoms and the Role of U.S. Foreign Aid, CHANGE has seen
improvements in U.S. support for female condoms:
„„ In 2008, the U.S. Congress reauthorized the President’s Emergency Plan for
AIDS Relief (PEPFAR), which for the first time explicitly mentioned both
female and male condoms and the need to increase the availability of and
access to these commodities.
„„ Female condoms are explicitly mentioned in PEPFAR’s most recent guidance
to the field, PEPFAR’s FY 2011 Country Operational Plan Guidance. Guidance
appendices, which are used in the field to guide program planning, state:
“…given the priority placed upon a women and girls-centered approach
in the PEPFAR 5 Year Strategy and GHI, prevention programming should
include interventions that empower women and address gender inequities
in accordance with the epidemiology in each context. Tools like the female
condom, which give women more options for practicing safer sex, are
important options.”
„„ The U.S. has dramatically increased its procurement of female condoms, with
international shipments growing from 1,109,000 in 2003 to a record high of
14,676,000 in 2009.
While we recognize and applaud the increased attention from the U.S. government
to female condom procurement and programming, more efforts are needed to make
female condoms truly available, accessible, and affordable for individuals who would
benefit greatly from their use. The purpose of this report is to inform policy makers,
5
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
donors, and advocates about female condoms and recent U.S. support for procurement,
distribution, and programming of female condoms. The report includes countryspecific case studies to demonstrate what is needed to ensure successful female condom
programming. We hope this information will propagate successful practices and
spark new ideas and strategies to increase support for procurement, distribution, and
programming of female condoms.
This report is based on a review of published literature, in addition to extensive
interviews with experts from organizations and the U.S. government to gather
information that is not available in literature or policy documents. Based on these
interviews and review of existing evidence on female condoms, CHANGE concludes
the report with findings and recommendations to remove barriers that have denied
women, men, and youth access to female condoms, and to ensure stronger U.S. support
for female condoms in the future.
Female condoms are not the magic bullet to stop HIV/AIDS, but they are an
important tool for a combination and rights-based approach to HIV prevention. With
increased and steady support from donors like the U.S., and a commitment to improve
and expand programming and training, female condoms will gradually become
available to all, improving health and saving lives.
Serra Sippel
President
Center for Health and Gender Equity (CHANGE)
EXECUTIVE SUMMARY
I
t would be quite reasonable to assume that the world is already investing
enthusiastically and overwhelmingly in female condoms. On the face of it, pouring
time and treasure into purchasing and promoting a product that can give women the
ability to initiate their own protection from unwanted pregnancy, HIV transmission,
and other sexually transmitted infections (STIs)—all extremely urgent health concerns
for women of reproductive age—seems like an obvious solution. Yet, remarkably,
investment in female condom procurement and programming has been negligible
in comparison to other prevention approaches. While donors and governments have
made some increases in recent years thanks in large part to civil society efforts, they
have remained largely resistant to making the sizable investment in female condoms
warranted by the product’s potential.
This resistance flies in the face of evidence. A number of female condom products
are currently available on public and private markets, with additional products in
development—a testament in itself to consumer demand. Research shows female
condoms to be acceptable by diverse users across a variety of settings, and to
be efficacious in preventing HIV/STIs and pregnancy when used correctly and
consistently. Female condoms also offer an array of unique benefits and advantages to
women, men, and young people who use them. Evidence suggests that when promoted
and programmed alongside male condoms, female condoms increase the total number
of protected sex acts because they are sometimes used in instances that would not
otherwise be protected by male condoms. Qualitative studies have also shown that
women view the female condom as a means for enhancing their ability to negotiate
conditions for safer sex within the relationship.
In spite of good acceptability, high rates of efficacy, and unique benefits, widespread
female condom availability and use has been hampered by a range of factors, most
significant of which is the lack of robust investment due to anemic commitment
from most donors, program implementers, and governments. In 2009, donor support
for female condom commodities represented only 0.38 percent of the total donor
expenditure on global HIV/AIDS, despite the substantial unmet need for condoms.
A problem associated with lack of sufficient investment in female condom
procurement is stockouts, which have plagued many countries that have introduced
the product. And while a steady supply is crucial, the full potential of female condoms
can only be realized with effective and comprehensive programming, which is essential
for creating demand and enabling sustained use. Yet funding for programming is
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
even scarcer than the funding for female condoms themselves, which can result in
poor access and low levels of use. In addition, negative attitudes of health providers
toward female condoms are widely acknowledged by researchers, government officials,
and advocates as a serious obstruction to increased access and use, as the quality and
comprehensiveness of training can be severely compromised.
Finally, cost is regularly cited as a barrier because some donors and program
managers are initially hesitant to invest in female condoms given their cost relative to
male condoms. However, the argument over cost-effectiveness of female versus male
condoms is only ethical if one assumes that female condoms offer no unique advantages
to women, and that the absence of female condoms would result in no reduction of
protected sex acts, neither of which is borne out by research.
As the world’s largest donor to HIV/AIDS and reproductive health programs,
the U.S. government has a critical opportunity to show exemplary leadership in
advancing access to female condoms. This opportunity is heightened given the Obama
administration’s emphasis on integration and gender equality as articulated in the
Global Health Initiative (GHI). Yet commitment to female condoms among U.S.
decision makers is not pervasive throughout the foreign assistance structure, and has
only advanced slowly and sporadically.
The U.S. government is the largest procurer of female condoms, accounting for
nearly 40 percent of female condom donor shipments to developing countries in
2009. When the President’s Emergency Plan for AIDS Relief (PEPFAR)—the U.S.
government’s global initiative on HIV/AIDS—was renewed by Congress in 2008,
the law recognized for the first time that access to both female and male condoms
is a priority for U.S. global HIV prevention efforts. Since PEPFAR reauthorization,
the Office of the Global AIDS Coordinator (OGAC)—the agency that oversees
and coordinates PEPFAR—has included female condoms in important guidance
documents to the field. Advocates have witnessed a significant number of PEPFARfunded countries include female condoms in their country operational plans or their
partnership framework agreements. Furthermore, the U.S. Agency for International
Development (USAID) is an instrumental partner in ensuring effective, country-level
female condom logistics management and distribution, and is a source of financial and
technical support for female condom programming.
However, there are several challenges to scaling up U.S. investment in female
condom procurement and programming that ultimately originate from Washingtonbased policies, procedures, or funding restrictions. OGAC 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
Executive Summary
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.
Case studies of countries where female condoms have been introduced,
programmed, or sustained with support from the U.S. government provide valuable
insight. Zimbabwe is regularly cited as a female condom success story and has among
the highest distribution and sales of female condoms in the world; it also enjoys
strong backing from the U.S. government in terms of procurement and program
assistance. Malawi has a growing female condom program that has recently benefitted
from the U.S. government’s support—confined mostly to commodities. Cameroon is
currently scaling up its female condom program in spite of little support from the U.S.
government. While Bolivia’s HIV/AIDS prevalence among the general population is
low, and the national government has only a limited response to HIV/AIDS, the U.S.
government has sustained modest support for female condoms for nearly a decade—
without many of the systems in place that allow female condoms to thrive in countries
like Zimbabwe and Malawi.
In general, these case studies reveal that the U.S. government is excelling when
it comes to female condom commodity financing, coordination, and logistics;
collaboration and alignment with other donors, governments, and stakeholders;
and support for social marketing. U.S. weaknesses include insufficient funding for
programming, lack of female condom oversight or program tracking, and limited
USAID Mission outreach to civil society.
Based on an extensive review of current literature on female condoms, in addition to interviews with
key experts, the findings and recommendations of this report are as follows:
Finding: OGAC has identified a serious “condom gap” affecting several high HIV
prevalence countries in Africa. Yet, OGAC is not allocating enough funding to support
female condom procurement and programming, especially for former focus countries,
which cannot access female and male condoms through the Commodity Fund.
Recommendation: OGAC should centrally finance female and male condom
procurement to help close the condom gap. OGAC should allocate funds directly to the
Commodity Fund so that all countries can be eligible to access this account to procure
female condoms. In addition, OGAC should also allocate robust resources to support
female and male condom programming, especially for former focus countries.
Finding: Communication and coordination between OGAC and USAID officials
on female condoms is limited, contributing to female condoms being overlooked in
decision making on funding priorities. In addition, there is no clear mechanism or
oversight at OGAC or USAID regarding financial and technical support for female
condom programming.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Recommendation: OGAC and USAID should form an interagency task team to engage
in strategic thinking and resource allocation planning on female condoms and the
broader condom gap. OGAC and USAID should also conduct an evaluation of PEPFAR
support for female condom programming, and develop a system to track financial and
technical support for female condom programs.
Finding: Whether the U.S. procures female condoms in a given country is highly
dependent on the personal biases of USAID Mission staff. Some Washington- and
field-based U.S. officials lack awareness of the female condom or hold negative attitudes
about it, in part because there is currently no guidance explaining the importance and
relevance of female condoms in HIV prevention and family planning programs.
Recommendation: OGAC and USAID should expedite the issuance of guidance to U.S.
global health personnel in the field highlighting the evidence on female condoms. The
U.S. should also include the female condom in GHI guidance as an important example
of integrated, woman-centered programming. OGAC and USAID should fund training
for PEPFAR- and USAID-funded doctors, nurses, and counselors about the female
condom.
Finding: The U.S. government continues to release funding instruments that focus
on failed stand-alone abstinence and fidelity programs for HIV prevention. This
contradicts PEPFAR’s new Five-Year Strategy that espouses comprehensive and
evidence-based prevention.
Recommendation: The U.S. government should only fund integrated, comprehensive,
and evidence-based HIV prevention programming that includes female and male
condom programming. Funding announcements should explicitly mention female and
male condoms, as opposed to “condoms,” to provide further incentive for programs to
include female condoms.
Finding: OGAC does not disaggregate female and male condom service outlets
in PEPFAR data collection efforts and does not require countries to report on the
number of male condom distribution outlets. The USAID-funded MEASURE DHS
(Demographic Health Survey) does not collect data on female condom use.
Recommendation: OGAC should revise the Next Generation Indicators (NGI) Reference
Guide to disaggregate female and male condoms and require countries to report on
female and male condom distribution outlets. USAID should disaggregate female and
male condom use in the MEASURE DHS HIV/AIDS Survey Indicators on condom
use.
Executive Summary
Finding: The 2008 reauthorization of PEPFAR includes a preference for abstinence
and fidelity programming. In addition, female and male condom distribution is still
restricted to individuals 15 years of age and older.
Recommendation: Congress should remove all funding directives for abstinence and
fidelity prevention programs and fund comprehensive, integrated, and evidence-based
HIV prevention programs that include female condoms. OGAC should issue new
guidance on prevention that ensures that all women, men, and young people have
access to female and male condom education and distribution in PEPFAR-supported
programs.
Finding: At the country level, the U.S. government has no mechanism to involve civil
society in female condom procurement, distribution, and programming decision
making.
Recommendation: The U.S. should actively include civil society, especially women’s
health and rights groups, in stakeholder meetings and encourage financing mechanisms
that increase government-civil society collaboration in female condom programming.
Finding: The U.S. excels at assisting countries in female condom procurement and
logistics.
Recommendation: The U.S. should expand technical assistance for female condom
logistics and procurement to additional countries to increase HIV prevention efforts.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Female condom advocates from Mexico, Guatemala, Honduras, El Salvador, Costa Rica, and
Dominican Republic pose as new members of CHANGE’s Prevention Now! Campaign.
INTRODUCTION
The Global Failure on Female Condoms
I
t would be quite reasonable to assume that the world is already investing
enthusiastically and overwhelmingly in female condoms. On the face of it, pouring
time and treasure into purchasing and promoting a product that can give women the
ability to initiate their own protection from unwanted pregnancy, HIV transmission,
and other sexually transmitted infections (STIs)—all extremely urgent health concerns
for women of reproductive age—seems like an obvious solution.
A simple glance at the statistics should be compelling enough. According to the
World Health Organization (WHO), HIV/AIDS is a leading cause of death and
disease in women of reproductive age.1 Women comprise slightly more than half
of all adults living with HIV and 60 percent in sub-Saharan Africa.2,3 In developing
countries, 215 million women who wish to delay or space their pregnancies do not
have access to modern contraceptives.4 An estimated 358,000 women die each year
from complications associated with pregnancy and childbirth, with unsafe abortion
accounting for a significant number of maternal deaths.5 Expanded HIV/STI and
pregnancy prevention efforts that include all available methods and services—especially
those that women can initiate and control—are clearly needed now more than ever.
Against this backdrop, scientists continue to research, develop, and test new
behavioral and biomedical prevention options such as microbicides, pre-exposure
prophylaxis (PrEP), and vaccines, with varying success. New and groundbreaking
findings from the CAPRISA 004 vaginal microbicides trial and the iPrex trial with men
on oral PrEP suggest that these interventions are at least partially effective in preventing
sexual transmission of HIV. 6,7 In addition, a recent AIDS vaccine trial based in
Thailand found modest evidence of protection against HIV—the first vaccine efficacy
trial to do so, though the significance of its findings has been debated by experts.8
While these trials demonstrate exciting advancements in prevention research,
they also underscore that these first generation technologies will not be 100 percent
effective. Even male circumcision, which is receiving amplified attention from donors
and governments, has been shown by studies to reduce risk of HIV acquisition by only
50 to 60 percent in men.9
Scientists, policy makers, and advocates acknowledge that there is no single magic
bullet for HIV prevention. “Combination prevention”—the concept that successful
HIV prevention combines evidence-based medical, behavioral, and structural
interventions—is increasingly gaining prominence. As the only effective HIV/STI and
pregnancy “dual” protection methods available today, female and male condoms are
13
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
particularly critical components of a comprehensive, rights-based prevention package.
But when it comes to HIV/STI and pregnancy dual protection technologies that are
designed to be initiated by women and available today, the female condom stands alone.
Yet, remarkably, investment in female condom procurement and programming has
been negligible in comparison to other prevention approaches. Moreover, aside from a
few notable champions among donors and program implementers, the push for access
to female condoms has come almost exclusively from civil society. While donors and
governments have made some increases in recent years thanks in large part to civil
society efforts, they have remained largely resistant to making the sizable investment in
female condoms warranted by the product’s potential.
This resistance flies in the face of evidence. As Part One of this report elaborates, the
two most important questions about female condoms as a prevention intervention—
acceptability and efficacy—have been conclusively established. Part Two examines the
challenges the product faces due to low investment, and Part Three analyzes existing
U.S. foreign policy on female condoms and possibilities for change. Finally, Part Four
explores four country case studies, highlighting best practices, essential elements, and
lessons learned for successful procurement and programming of female condoms, while
Part Five offers recommendations for the U.S. government to strengthen support for
female condoms.
PART ONE
The Case for Female Condoms
T
he importance of female condoms as a prevention method has been widely
recognized by researchers and advocates alike. Years of empirical research confirm
that female condoms have good acceptability among diverse populations, high rates
of efficacy, and numerous advantages for women, men, and young people.10 CHANGE’s
2008 report on female condoms, Saving Lives Now: Female Condoms and the Role of U.S.
Foreign Aid, gives a thorough documentation of female condom characteristics and
benefits.
Female Condom Products
A number of female condom products are currently available to consumers while
others are still in development. These products vary in appearance, design, material,
and regulatory status.i The FC1 and FC2 female condoms, manufactured by the Female
Health Company (FHC), are the most widely distributed female condoms in the
world. They are also the only female condoms approved by the U.S. Food and Drug
Administration (USFDA) at this time. Female condoms that are currently available
or have been previously distributed in some countries include the VA w.o.w., Cupid,
Phoenurse, and the Natural Sensation Panty Condom. Other female condoms, such as
the Woman’s Condom, are just beginning to enter the market. For more information
about female condom products, please see Annex A on page 67.
Female Condom Qualities: Acceptable, Effective, and Much More
ii
Female Condoms are Acceptable
Research shows female condoms to be acceptable by diverse users across a variety of
settings. Studies conducted in more than 40 countries suggest that female condom
acceptability among women and men of various ages, socio-economic statuses, sexual
i
For a summary of female condom products and regulatory issues, please consult a recent article
by Mags Beksinska et al., “Female Condom Technology: New Products and Regulatory Issues,”
Contraception, 83, no. 4 (2011): 316-321. Published electronically September 15, 2010.
ii
The vast majority of scholarly research on the female condom uses the FC1 and sometimes the
FC2 as the condom under study. For the purposes of our report, the term “female condom” refers
to the FC1 or FC2 unless otherwise specified.
15
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
orientations, and geographic locations ranges from 37 percent to 96 percent.11,12 A new
study examining acceptability among female sex workers in the Dominican Republic
reported that “women found the female condom very acceptable, and they also believed
it was the method preferred by their clients and regular partners.”13 This finding is
noteworthy because both men and women approved of consistent female condom use.
Although research on long-term acceptability and use of the female condom is
limited, new findings from Brazil indicate that with proper counseling and adequate
supply, many women will regularly use the female condom for at least one year.
Kalckmann et al. (2009) followed women who received female condom product,
counseling, and education at three separate sites in Brazil and their use of the female
condom for 12 months. Service delivery sites included HIV/STI clinics, primary
care units, and community-based organizations. Researchers found that after one
year, almost 15 percent of the full study sample of 2,469 women—about one in seven
women—reported regular use of the female condom.14 The effect was strongest for
women who received product and education from peers at the community-based sites,
suggesting that female condom peer education may have a larger impact on longer-term
use than efforts through more traditional health outlets.
Female and male condoms, when used
consistently and correctly, are comparable
in effectiveness in preventing HIV/STIs and
pregnancy.
Female Condoms are Effective
Female and male condoms, when used consistently and correctly, are comparable
in effectiveness in preventing HIV/STIs and pregnancy. Correct use of the female
condom has been estimated by Trussell et al. (1994) to reduce the per-act probability of
HIV transmission by up to 97 percent.15 In other words, the study’s modeling exercise
estimates that perfect use of the female condom by a woman having sexual intercourse
twice a week with an HIV-infected partner could reduce her risk of acquiring HIV by
more than 90 percent.16 Furthermore, laboratory studies have found the female condom
to be impermeable to various STI organisms, including HIV.17
Female condoms also prevent pregnancy. When female condoms are used correctly
with each act of sexual intercourse during one year, only five unintended pregnancies
will occur per 100 women.18 With typical female condom use, there will be 21
unintended pregnancies per 100 women in the span of one year.19
Many users value the female condom precisely for its efficacy and dual protection
properties. A study in Zimbabwe assessing acceptability and uptake of female
condoms documented high interest from women in using the female condom for dual
protection.20 In many countries where the female condom has been socially marketed,
including Zimbabwe, the product was positioned as contraception to avoid stigma
associated with HIV and disease. However, it is important for program planners and
health educators to recognize that some women appreciate and use the female condom
for both HIV/STI and pregnancy prevention, and to tailor their messages and programs
accordingly.
Female Condoms Have Numerous Benefits and Advantages
Female condoms offer an array of unique benefits and advantages to women, men, and
young people who use them. Female condoms made of polyurethane or nitrile, such
Part One: The Case for Female Condoms
as the FC1, FC2, and the Woman’s Condom, can be used with water- and oil-based
lubricants. This is critical because in some parts of the world water-based lubricants
are difficult to find. Some female condoms can be inserted a few hours in advance,
thus avoiding interruption of sexual activity to initiate protection. As one female study
participant in El Salvador attested, “We [women] can put it on ahead of time. If…
we already know that he doesn’t like to use a condom, we can go to the bathroom a
half-hour ahead of time and put it on.”21 Some users report increased pleasure and
stimulation from the FC2 female condom, with the inner ring “tickling men” and the
outer ring “tickling women.”22
Female condoms are particularly valuable for women living with HIV, as they
provide a female-initiated option to pursue safe sex and prevent HIV transmission,
reinfection, or superinfection. And although no female condom has received USFDA
approval for anal intercourse, some men and women report use of the female condom
for protection during anal intercourse—the sexual behavior with the highest probability
of HIV transmission. Consequently, in some countries including the United States,
health departments urge providers to promote “off-label” use of the female condom for
anal intercourse, rationalizing that some protection is better than none.
Female condoms are a value-added complement to male condoms. Studies from
Madagascar, Kenya, India, Brazil, and the United States found that female condom
promotion and use increases the total number of protected sex acts, which helps
reduce rates of STIs and the risk of HIV infection.23,24 Rather than replacing use of male
condoms, female condoms are sometimes used during acts of sexual intercourse that
would not otherwise be protected by male condoms, thus boosting the overall number
of sex acts where protection is used. For example, some studies show that women, when
provided with the additional option of female condoms, tend to alternate use of female
and male condoms depending on the sexual partner and circumstances.25 Formative
research on female condoms in Central America, funded by the U.S. Agency for
International Development (USAID), found that some men who refuse to use a male
condom are willing to have their partner use a female condom, demonstrating that the
female condom offers unique protection.26 While studies have documented individuals
replacing some use of male condoms with female condoms, the net level of protection
achieved by offering two methods is typically greater than through male condom
distribution alone.
Qualitative studies have shown that women view the female condom as a means
for enhancing their ability to negotiate conditions for safe sex within the relationship,
particularly when women obtain female condoms within the context of an intervention
focused on women’s sexuality and empowerment.27 Female or male condom use
typically requires negotiation between partners. However, because the female condom
is designed for women to initiate and wear, it offers women an important negotiation
tactic if their partners refuse male condom use. According to a female participant in
a study in Kenya, “When [my husband] comes to the house and doesn’t want to use a
male condom I tell him that we too have ours here, and if using the male condom is
a problem then let’s use the female condom. At first he didn’t want to use the female
condom but now we have used it and we don’t have any problem.”28 A female sex worker
Because the female condom is designed for
women to initiate and wear, it offers women
an important negotiation tactic if their
partners refuse male condom use.
17
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
in El Salvador had a similar experience negotiating female condom use. “For me, a
client passed by who told me that he wanted to do it without anything. I told him that I
had a female condom. I used it and he liked it.”29
The strategy of using female condoms as a negotiation tool has also been promoted
by organizations that address domestic violence. In Uganda, where the female condom
was recently reintroduced by the government, organizations such as the Center for
Domestic Violence Prevention receive requests from women for female condoms
in situations of marital rape. According to the organization, when these women are
sometimes able to negotiate condom use, men come up with excuses or resist using
male condoms. The women say that if they had female condoms with them, they could
put them on before they have sex, giving them an additional tool for negotiation and
protection.30
Women rally in support of expanding global access to female condoms at the 2008 International
AIDS Conference in Mexico City.
PART TWO
Challenges to Female Condoms
I
n spite of good acceptability, high rates of efficacy, and unique benefits, widespread
female condom availability and use has been hampered by a range of factors,
the most significant of which is the lack of robust investment due to anemic
commitment from most donors, program implementers, and governments.
Acceptability and efficacy are generally the most important criteria for rolling out
a prevention intervention. For some interventions, in fact, demonstrated efficacy is
sufficient to trigger an outpouring of donor investment. For example, soon after studies
confirmed that male circumcision decreases the risk of HIV acquisition for men,
donors launched major initiatives to fund and program male circumcision as HIV
prevention. While questions have been raised about male acceptance of circumcision
and the impact of circumcision on male condom use, these questions have not
dampened donor enthusiasm for this intervention.
By contrast, the threshold for justification of female condom investment seems
strikingly high. Acceptability and efficacy studies by themselves have clearly not been
enough to spark massive donor interest. For example, during the mid 1990s, dozens
of female condom acceptability studies were carried out with overwhelmingly positive
results, as documented by WHO.iii Some countries that participated in these studies had
leftover stocks of female condoms, but these countries were not given additional donor
support for procurement or programming.31 Countries were expected to continue
female condom programs without donor support, and donors have since set their sights
on new prevention interventions, such as male circumcision, as referenced above.
In the absence of sufficient donor support for female condoms, civil society groups
have sought to pressure donors and governments through advocacy campaigns.
Still, these advocates have found that, unlike with other prevention technologies and
interventions, they are often challenged by donors and government ministries to prove
that women and couples will use them—even before any significant effort has been
invested in their promotion and use.32
iii
For WHO’s seminal review of female condom acceptability studies, please consult the
following: UNDP/UNFPA/WHO/World Bank Special Programme of Research on Human
Reproduction, The Female Condom: A Review (Geneva: WHO, 1997).
19
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Figure 1. 2009 Donor Expenditure on Global HIV/AIDS
Spending on Female Condom Commodities:
US$29.2 Million (0.38%)
Total Spending on Global HIV/AIDS, US$7.6 Billion
Problems Stem Predominantly from Lack of Commitment
The timid approach to female condoms by donors and governments has undermined
incipient female condom programs.
Commodity Challenges
Donor investment in female condom
commodities in 2009 was approximately
0.38 percent of the total donor expenditure
on global HIV/AIDS.
Funding dispersed by donors in 2009 for the global HIV/AIDS response was about
US$7.6 billion.33 Within this figure, donor support for female condoms represents the
tiniest sliver. According to the United Nations Population Fund (UNFPA), in 2009,
donorsiv spent about $29.2 million on female condom commodities for developing
countries.34 In other words, donor investment in female condom commodities in 2009
was approximately 0.38 percent of the total donor expenditure on global HIV/AIDS.
Advocates find the situation to be even more frustrating given that donor financing
of female and male condoms falls far short of projected need. In 2009, approximately
2.8 billion female and male condoms were supplied to developing countries by donors.35
The Reproductive Health Supplies Coalition estimates that donors must finance at least
4.4 billion condoms by 2015 to address the family planning and HIV prevention needs
of developing countries that are not able to procure their own condoms.36
iv
UNFPA’s donor expenditure estimates exclude the Global Fund to Fight AIDS, Tuberculosis, and
Malaria (GFATM) and the World Bank. Including these donors would not dramatically alter the 0.38
percent figure.
Part Two: Challenges to Female Condoms
Figure 2. Female Condoms and the WHO Essential Medicines List
While donor financing of female condom commodities is vital for many developing
countries, national government investment—however modest—is just as important,
especially for programs sustained over the long run. National governments often look to
WHO to help inform their health resource allocation decisions. Many governments consult
WHO’s Model List of Essential Medicines for guidance on which medicines and medical
devices are essential to satisfy priority health needs of populations. They then create their
country-specific essential medicine lists and align their budgets accordingly.
Female condoms are not listed on WHO’s current essential medicines list, only
“condoms.”37 As it follows, female condoms are rarely prioritized in country-level lists and
budgets. Donor contributions for female condoms are often left without complementary
allocations from national governments, which hinders female condom availability and
program longevity.
Stockouts
A problem associated with lack of sufficient investment in female condom procurement
is stockouts. An obvious component to successful delivery and programming of any
prevention method is to ensure that enough high-quality product is available to keep
pace with consumer demand. When demand exceeds the amount of product supplied,
stockouts occur. Unfortunately, female condom stockouts are common in countries that
have introduced the method. One reason for this is donor preference for pilot projects.
Pilot programs fund product introduction and related activities in targeted areas for a
short duration; they do not support long-term programs. As such, female condom pilot
programs can initially generate high interest and curiosity in the product. However,
projects come to a close just as demand starts taking off. Female condoms disappear
from shelves and communities, leaving women and men empty-handed. This was the
case in Cameroon, where initial donor investment helped launch the product in 2002,
yet donors—including the U.S. government—withdrew support shortly thereafter,
contributing to a major stockout in 2006.38
Understandably, stockouts lead consumers to reduce reliance on a product they
would otherwise use regularly.
Programming Challenges
While a steady supply is extremely important, the full potential of female condoms can
only be realized with effective and comprehensive programming, which is essential
for creating demand and enabling sustained use. Yet funding for programming is even
scarcer than funding for female condoms themselves.
While programming is often viewed in the traditional sense of health promotion
activities, it can also be regarded as a broader set of structural factors that ensure
a health intervention’s success. Using the latter definition of programming, truly
comprehensive female condom programs consist of a strategic mix of human, financial,
and technical resources employed over the long run. UNFPA and the Joint United
Nations Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team developed a
10-Step Framework for Comprehensive Condom Programming (CCP) that serves as a
blueprint for building an effective female and male condom program (See Annex C for
The full potential of female condoms
can only be realized with effective and
comprehensive programming, which
is essential for creating demand and
enabling sustained use.
21
22
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
a full description). The CCP Framework underscores that programs are multifaceted
and require committed resources, time, and strategic thinking from stakeholders in
order to succeed. This point cannot be emphasized enough for the female condom.
Systems and activities such as those highlighted in the CCP framework must be put in
place to create an environment where female condoms can flourish, as has been the case
in countries like Zimbabwe and Malawi.
Despite the importance of quality programs, donors have rarely provided sufficient
funding for them. This can result in poor access and low levels of use. According
to Bidia Deperthes, HIV/AIDS technical advisor for comprehensive condom
programming at UNFPA, “while the majority of donors willingly contribute essential
commodities, including male and female condoms, little money is allocated to laying
the groundwork needed to create awareness and demand, and to train women to
use condoms correctly and consistently.”39 This view is echoed by Lucie van Mens,
coordinator of Universal Access to Female Condoms (UAFC) Joint Programme, who
says that it is a struggle to “make donors understand that investment in programming,
and not only procurement, is vital for success.”40 As a result, female condoms—the
product—often get blamed for failure when in fact inadequate programming and the
lack of sustained resources are larger culprits.
Figure 3. UNFPA and UNAIDS Inter-Agency Task Team 10-Step Strategic
Approach to Scale Up CCP at the National Level41
Step 1. Establish a National Condom Support Team
Step 2. Undertake a Situation Analysis
Step 3. Develop a Comprehensive and Integrated National Strategy for Male
and Female Condoms
Step 4. Develop a Multi-Year Operational Plan and Budget
Step 5. Link the Multi-Year Operational Plan with the National Commodity
Security Plan
Step 6. Mobilize Financial Resources
Step 7. Strengthen Human Resources and Institutional Capacity
Step 8. Create and Sustain Demand for Condoms
Step 9. Strengthen Advocacy and Engage the Media
Step 10. Monitor Program Implementation Routinely, Conduct Research,
and Evaluate Outcomes
Part Two: Challenges to Female Condoms
Female Condom Training and Health Provider Bias
An important component of female condom programming is the education and
training that women, men, and young people receive. Components of an effective
female condom education program are well-documented in the literature. Among many
things, these include: grounding in health behavior theory, accurate and comprehensive
education about benefits and drawbacks, opportunity to practice insertion, discussion
around realistic expectations with use, lessons in condom negotiation with sexual
partners, and information on female genital anatomy.42 Effective training helps
overcome initial concerns about the female condom, such as size, noise, or difficulty
with insertion, in addition to dispelling misperceptions, myths, and negative attitudes.
Good training programs also educate and involve men in female condom use. While
many men are supportive partners, some men are skeptical or unreceptive toward
female condoms. Social marketing programs in Zimbabwe and Malawi have trained
male barbers to sensitize their male clients to female condoms, and UNFPA has
led focus groups in Guyana and Trinidad and Tobago to better understand men’s
perceptions and needs when it comes to understanding and using female condoms.43
Training and education on the female condom, however, can only be as effective as the
trainers, medical professionals, and counselors charged with carrying them out.
Negative attitudes of health providers toward female condoms are widely
acknowledged by researchers, government officials, and advocates as a serious
obstruction to increased access and use. According to Weeks et al. (2010), “one of the
greatest continuing barriers to female condom uptake results from negative provider
reactions to it and their own lack of familiarity or comfort with explaining its proper
use. The initial responses of many health and service providers, including primary care
physicians, pharmacists, clinicians, and even HIV counselors, tend to be dismissive
and denigrating of female condoms.”44 As a result, the quality and comprehensiveness
of female condom training can be severely compromised, leaving individuals without
the full range of information and skills needed to use female condoms confidently and
correctly. More efforts must be made by governments and donors to invest resources
in equipping health providers with the knowledge and skills to talk confidently and
comfortably about female condoms with consumers.
Good training programs also educate and
involve men in female condom use.
Cost
Some donors and program managers are initially hesitant to make substantial
investments in female condoms because of their cost relative to the male condom.
Purchased in bulk by USAID in 2009, the FC2 female condom cost US$0.55 each,
while male condoms cost only US$0.03724.45 This FC2 price is significantly less than
the 2008 unit price of the FC1, which cost USAID US$0.80 or US$0.86, depending
on the contract.46 The cost differential between female and male condoms exists
because the FC2 is more costly to manufacture and far fewer female condoms are
purchased. However, the FC2 pricing schedule is based on volume. This means that as
demand increases, FHC’s scale-up of production will shift the basic FC2 cost structure
23
24
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
downward.47 In other words, as donors increase their investments in the female
condom, cost becomes less of an issue.
Female condom programming costs can also decline over time. When Population
Services International (PSI) first started female condom promotion in Zimbabwe, the
cost per unit was US$4.50. However, as the program expanded and began increasing
sales, the product plus programming cost dropped to less than US$1 per unit.48 In 2008,
net unit costsv for female condoms in countries where PSI sold more than 30,000 units
ranged from US$0.99 in the Central African Republic to US$6.26 in Lesotho.49 The
Zimbabwe case demonstrates potential cost-effectiveness for other female condom
programs, if they are adequately managed and sustained over time.
While female condoms are more expensive than male condoms, female condom
use that averts HIV acquisition or transmission is highly cost-effective as compared
with the costs of antiretroviral therapy (ART) for life.50 Female condoms can also be
cost-effective when compared with other HIV prevention options, such as voluntary
counseling and testing, which PSI reports as costing US$24.43 per unit delivered in
2008.51 Some researchers have found that there are few circumstances where the female
condom could be cost-effective when compared with the male condom—the female
condom’s most logical alternative.52 However, the argument over cost-effectiveness of
female versus male condoms is only ethical if one assumes that female condoms offer
no unique advantages to women, and that the absence of female condoms would result
in no reduction of protected sex acts, neither of which is borne out by research.
v
These costs include the commodity, procurement fees, packaging, and programming.
PART THREE
The Reality and Possibility of U.S. Policy on Female Condoms
I
n a single product, effectively-programmed female condoms integrate attention
to family planning, HIV prevention, and gender equality. Within this context, the
procurement and programming of female condoms should be a central component
of U.S. global health policy, especially given the Obama administration’s emphasis on
integration and gender equality as articulated in the Global Health Initiative (GHI).
As the world’s largest donor to HIV/AIDS and reproductive health programs, the U.S.
government has a critical opportunity to show exemplary leadership in advancing
access to female condoms. Yet commitment to female condoms among U.S. decision
makers is not pervasive throughout the foreign assistance structure, and has only
advanced slowly and sporadically.
U.S. Global HIV Prevention and Female Condoms:
PEPFAR, USAID, and GHI
The President’s Emergency Plan for AIDS Relief (PEPFAR), authorized in 2003 and
renewed in 2008, is the U.S. government’s response to global HIV and AIDS. Among
PEPFAR’s targets for fiscal years 2010-2014 are to support the prevention of more than
12 million new HIV infections, provide direct support for more than four million
people on treatment, and provide care for more than 12 million people, including five
million orphans and vulnerable children.
The original Global AIDS Act created the Office of the Global AIDS Coordinator
(OGAC) within the Department of State to oversee PEPFAR. OGAC continues
to be responsible for the oversight and coordination of all financial resources and
international activities of the U.S. government to address the HIV/AIDS pandemic. By
law, all U.S. funding that is spent on global HIV/AIDS is considered PEPFAR funding.53
Prior to PEPFAR, USAID was the government agency primarily responsible for
coordinating U.S. efforts to combat global HIV/AIDS. In addition to supporting
programming, USAID allocated its global health funding to procure female and male
condoms for HIV prevention and family planning. Although OGAC is now responsible
for overseeing U.S. international HIV/AIDS assistance, female and male condom
procurement under PEPFAR is coordinated through USAID.vi USAID also provides
technical assistance for female and male condom programming and collaborates with
OGAC on program guidance.
vi
At this time, USAID only procures female and male condoms that have regulatory approval
from USFDA.
25
26
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Launched in May 2009 by President Obama, the GHI is a six-year (2009-2014),
US$63 billion initiative that focuses on HIV/AIDS, malaria, tuberculosis (TB), child
health, nutrition, family planning, maternal health, and neglected tropical diseases.54
Several key principles guide the initiative, including a focus on women, girls, and gender
equality; strategic coordination and integration; country ownership; collaboration
with multilateral organizations; health system strengthening; improved metrics; and
promotion of research and innovation. Administration officials refer to PEPFAR as the
cornerstone of the GHI.
The U.S. and Female Condom Procurement
Whereas the Global AIDS Act of 2003 did not
mention female condoms, only “condoms,”
the 2008 PEPFAR reauthorization legislation
recognizes that access to and availability of
both female and male condoms is a priority
for U.S. global HIV prevention efforts.
The U.S. government plays an important role in shaping global trends in reproductive
and sexual health supplies. U.S. funding for international family planning and HIV
prevention commodities represented more than one-third of global donor support in
2009.55 This leadership has also extended to the female condom, where in 2009, the U.S.
government accounted for nearly 40 percent of female condom shipments to developing
countries.56
The U.S. government has been a strong supporter of female condom research
and development. USAID was instrumental in bringing the FC1 female condom to
market by supporting effectiveness and early acceptability studies, which are required
for USFDA approval of female condoms.57,58 USAID also supported PATH in its
development of the Woman’s Condom; the National Institute of Child Health and
Human Development is now conducting the contraceptive efficacy trial.
In addition, recent changes in U.S. international law and policy have created new
opportunities for U.S. support for female condom procurement and programming.
Whereas the Global AIDS Act of 2003 did not mention female condoms, only
“condoms,” the 2008 PEPFAR reauthorization legislation recognizes that access to
and availability of both female and male condoms is a priority for U.S. global HIV
prevention efforts.
Building on the PEPFAR reauthorization law, OGAC released a Five-Year Strategy
for PEPFAR in 2009 that reflects the core GHI principles and creates new and strategic
opportunities for increased female condom support. The strategy underscores that
prevention “remains the paramount challenge of the HIV epidemic…and truly halting
and reversing this epidemic will require a comprehensive, multisectoral prevention,
treatment, and care response.”59 In PEPFAR’s Five-Year Strategy Annex on the GHI,
OGAC states that it will adopt a woman- and girl-centered approach to health. It
recognizes that “women are the gateway to healthy families and key to achieving
long-term development goals,” and that a woman-centered approach “takes into
account the realities of women’s and girls’ lives as shaped by gender norms, service
availability, and larger structural factors.”60 OGAC further acknowledges that PEPFAR
is “working to expand the linkages between reproductive health and HIV care and
treatment services.”61 While the PEPFAR Five-Year Strategy does not explicitly mention
female condoms, some OGAC officials interviewed affirmed that the female condom
epitomizes a woman-centered approach and integrates HIV prevention and family
planning in one product, and thus is critical to GHI’s goals.
Part Three: The Reality and Possibility of U.S. Policy on Female Condoms
Other recent documents go further, in a sign that female condoms are increasingly
visible among U.S. decision makers. To assist U.S. officials overseas in developing their
operational plans, OGAC sends guidance to help explain technical requirements,
best practices, and what programs should consider to align with U.S. congressional
and administrative requirements and policies. PEPFAR’s 2010 Fiscal Year Country
Operational Plan (COP) Guidance asked country programs in their technical assistance
narratives on sexual prevention to “describe the availability of male and female condoms
in your country and the USG contribution to that supply” and to “discuss any problems
or stock-outs with procurement and distribution of condoms.”62 Female condoms are
also explicitly mentioned in OGAC’s most recent guidance to the field, PEPFAR’s Fiscal
Year 2011 Country Operational Plan Guidance. Guidance appendices, which are used in
the field to guide program planning, state: “…given the priority placed upon a women and girls-centered approach in the
PEPFAR 5 Year Strategy and GHI, prevention programming should include
interventions that empower women and address gender inequities in accordance with
the epidemiology in each context. Tools like the female condom, which give women
more options for practicing safer sex, are important options.”63
OGAC officials report that most country operational plans now mention female
condoms, which has not been the case in the past. It remains to be seen whether the
increase in the number of countries including female condoms in their COP translates
to a commensurate growth in female condom procurement and programming in these
countries.
Such increases in U.S. government support for female condoms at the country level
would continue a recent trend. The U.S. has supplied female condoms to 36 countries
since 2000 and to 22 countries from 2009 to 2010.64 It has dramatically increased its
distribution of female condoms in recent years, with shipments growing from 1,109,000
in 2003 to a record high of 14,676,000 in 2009.65
However, even considering these numbers, female condoms represented just 3.2
percent of total U.S. condom shipments in 2009. By this measure, and in comparison to
the articulated demand, U.S. government investment in female condom procurement
falls short.
Figure 4. FC2 Registration and The Case of Mexico
FC2 female condom registration is required in all countries before it can be imported for
private or public sector distribution.67 Product registration is an important measure for
quality assurance. USAID will only procure FC2 female condoms for a given country if
the country’s registration and importation requirements have been met. Registering the
FC2, however, can be a very labor- and time-intensive endeavor, as has been the case
in Mexico. Mexico has a relatively long history with female condoms; nongovernmental
organizations (NGOs) and commercial outlets have distributed and sold the FC1 female
condom for almost a decade. FC2 registration was initiated in June 2008 and was not
awarded until June 2010 because of issues with quality assurance paperwork.68 Officials
at the Mexican Ministry of Health (MOH), as well as members of the Mexican Congress,
resorted to petitioning the regulatory agency to expedite FC2 registration.69 Currently, a
quality testing monograph is being finalized by the regulatory agency. Until this process
concludes, no FC2 female condoms can be imported into the country, leaving women
and men without access to this life-saving tool.
Female condoms represented just
3.2 percent of total U.S. condom
shipments in 2009.
27
28
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Figure 5. The Commodity Fund
In 2002, USAID established the Commodity Fund to help overseas Missions address
the global need for HIV prevention. The Commodity Fund is a central procurement
account that provides USAID Missions with female and male condoms for HIV prevention
programs free of charge, so that they do not have to spend money on condoms that
would otherwise go to other HIV interventions. Condoms from the Commodity Fund
are solely for HIV prevention or dual protection. Missions that want to procure female
condoms for family planning programs without an HIV component are not eligible to
receive free female condoms through the Commodity Fund and must pay for the method
out of their Mission budgets.
Beginning in 2006, the U.S. government decided that because HIV/AIDS funding
levels for the 15 PEPFAR focus countries were significantly higher than those for nonfocus countries, the focus countries must pay for female and male condoms from
their own budgets. Even though PEPFAR reauthorization in 2008 eliminated focus
country designation in the law, this policy still applies to the former focus countries. The
Commodity Fund’s budget for FY2009 was about US$20.3 million, and the budget
request for FY2010 was US$27 million.70
The U.S. and Female Condom Logistics
Commodity security, including effective logistics management and distribution
systems, is essential for the success of the female condom. Through a USAID-funded
contract implemented by John Snow, Inc. (JSI) and subcontractors, the USAID |
DELIVER Project works to ensure that supplies of contraceptive and HIV commodities,
including the female condom, align with the quantity, quality, and distribution needs of
each country covered by the project. JSI assists host governments and USAID Missions
in forecasting future need for a variety of products and helps determine demand for an
array of public health pharmaceuticals, contraceptives, and female and male condoms.
The project also provides partners with software to help to calculate need, and in some
countries, the project assists in the management and distribution of commodities.71
USAID is reported as being a strong and reliable procurement partner.
USAID | DELIVER operates only in countries where USAID Missions have
requested and can pay for such support; currently it has offices in 38 countries. If any
of these 38 countries receive donor-financed female condom shipments, irrespective of
the donor, USAID | DELIVER is involved with coordinating that supply, as requested by
the USAID Mission.72 However, the project is not involved in female condom logistics
management in countries that lack a USAID | DELIVER office, even if the country
receives U.S. government-procured female condoms.
The U.S. and Female Condom Programming
Neither OGAC nor USAID directly programs female condoms. Using PEPFAR money,
USAID issues contracts to, or enters into cooperative agreements with, international
or local organizations to carry out female condom education programming or social
marketing in countries that receive U.S. global HIV/AIDS assistance. For example, in
2009, USAID funded PSI’s female condom programs in 19 countries.73 In addition to
Part Three: The Reality and Possibility of U.S. Policy on Female Condoms
providing financial support for programming, OGAC and USAID have the option of
issuing technical assistance or guidance to the field on female condom programming.
According to USAID, if Missions ask headquarters for technical assistance for female
condom programming, USAID will provide it.74 OGAC and USAID also collaborate on
various guidance documents for the field; currently they are in the process of finalizing
female condom guidance.
From 1997 to 2007, USAID funded female condom social marketing and
programming through AIDSMark, a cooperative agreement with PSI and six other
partners.75 This agreement ended in December 2007 and was replaced with AIDSTAR
(AIDS Support & Technical Assistance Resources). The AIDSTAR mechanism is an
indefinite quantity contract managed out of the Office of HIV/AIDS in USAID’s Bureau
for Global Health that provides access to technical expertise and support for program
implementation across a range of HIV/AIDS-related technical areas.76 It is available to
U.S. government country teams, USAID/Washington operating units, Missions, and
other U.S. government agencies. For example, USAID Missions can submit task orders
under AIDSTAR for HIV/AIDS programming support that will then be awarded to
an AIDSTAR prime contractor, such as PSI.vii It is difficult to determine the amount of
AIDSTAR support for female condom programming because this analysis requires each
of the prime contractors to do a budget breakdown of all their task orders.
USAID Missions are charged with initiating, designing, and managing their own
task orders, meaning that there is no outside force encouraging or requiring USAID
Missions to include female condom programming in their task orders. AIDSTAR
task orders are supporting female condom programming only in Zambia (PSI) and
Guyana (Management Sciences for Health).77,78 When asked why the USAID Mission in
Zambia chose to include female condoms in its AIDSTAR task order, USAID/Zambia
responded that it was a matter of market share for female condoms and equity of
access to health services by men and women, the latter of which is required by the host
government, the Mission, and PEPFAR.79
PEPFAR Partnership Framework agreements, which were newly mandated under
PEPFAR reauthorization in 2008, present another opportunity to advance female
condom programming. Partnership Frameworks provide an overarching joint fiveyear strategy for cooperation on HIV/AIDS between the U.S. government and the
partner government or regional authority. Each framework establishes plans and sets
measurable objectives and targets for provision of technical assistance and support
for service delivery, policy development, and coordinated financial commitments in
the country or region.80 Partnership Frameworks are developed under the authority
of OGAC and the in-country ambassador and support staff, with participation by the
country government and civil society partners. They then serve as the blueprint for
country- or region-specific implementation plans, which go into greater detail about
vii
AIDSTAR consists of 13 prime contractors that are divided into two sectors: AIDSTAR I and
AIDSTAR II. The seven contractors under AIDSTAR Sector I specialize in technical assistance
for program implementation and HIV/AIDS technical areas, whereas the six contractors under
AIDSTAR Sector II focus mostly on management systems, capacity building, and technical
leadership. When USAID Missions submit task orders for female condom programming
funds through the AIDSTAR mechanism, they likely go to the AIDSTAR Sector I contractors
for bidding. These contractors include: PSI, Family Health International, JHPIEGO, JSI,
Management Science for Health, PATH, and RTI International.
29
30
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
activities. According to the U.S. government, Partnership Frameworks espouse the GHI
principles of strengthened country capacity, ownership, and leadership.
To date, 21 country- and region-specific Partnership Frameworks have been signed
and made available to the public. Even though Partnership Frameworks are high-level
documents—meaning that they do not get into great detail—seven of the 21 agreements
specifically mention advancing female condoms through U.S. or national government
procurement and distribution or through policy change.viii These are Angola, Botswana,
Central America, Kenya, Namibia, Rwanda, and Tanzania. Because they are guided by
what is written in the Partnership Frameworks, program implementation plans for these
countries and regions should include activities related to female condoms. The absence
of female condoms in the Partnership Framework, however, does not necessarily
preclude the incorporation of female condoms in implementation plans. For example,
Malawi signed a Partnership Framework agreement without specific mention of female
condoms, but the country still includes female condom activities in its implementation
plan.81
Country-level decision makers primarily determine whether “female condoms”
make it into Partnership Frameworks or the implementation plans. OGAC, saying that
it must remain non-prescriptive and that countries need to set their own priorities, has
not promoted female condom inclusion in the Partnership Frameworks.
It is also unclear how the U.S. government ensures robust participation of civil society
partners in the development of the Partnership Frameworks, especially that of marginalized
groups. There is no way to discern in the framework documents which civil society groups
were consulted and how civil society recommendations were incorporated. Given that
civil society advocacy has been one of the strongest forces putting female condoms on the
political agenda, the U.S. may be missing opportunities to include female condoms in the
frameworks without meaningful participation of all interested civil society stakeholders.
Limitations on U.S. Procurement and Programming
of Female Condoms
There are several challenges to scaling up U.S. investment in female condom
procurement and programming that ultimately originate from Washington-based
policies, procedures, or funding restrictions.
PEPFAR and the Condom Gap
In the case of female condoms, evidence
suggests that the condom gap—especially
among the former PEPFAR focus countries—
is due to inadequate funding from OGAC for
female condom commodities.
In a January 2011 meeting of the PEPFAR Scientific Advisory Board, OGAC
officials called attention to a burgeoning “condom gap,” highlighting findings from
a forthcoming report on the acute lack of availability of female and male condoms
in many countries in Africa with high HIV prevalence.82 OGAC officials identified
barriers that it and other donors should address, such as insufficient support for
condom provision and demand creation, ineffective funding mechanisms, and
confusion over the U.S. government position on condoms.83 In the case of female
viii
CHANGE performed content analysis for female condoms in each PEPFAR Partnership
Framework. All publicly available Partnership Frameworks can be found at http://www.pepfar.
gov/frameworks/index.htm
Part Three: The Reality and Possibility of U.S. Policy on Female Condoms
condoms, evidence suggests that the condom gap—especially among the former
PEPFAR focus countries—is due to inadequate funding from OGAC for female
condom commodities, which is related more broadly to issues of strategic planning and
resource allocation.
As noted above, USAID coordinates female and male condom procurement for
PEPFAR activities through the Commodity Fund, which was established in 2002 to
provide U.S. Missions with female and male condoms at no cost to the Mission to
address the need for HIV prevention. It is important to note that the Commodity
Fund is a USAID account that the agency supports with its own budget for global
HIV/AIDS. OGAC does not financially support the Commodity Fund, even though
OGAC has a significantly larger budget for global HIV/AIDS than USAID. While the
Commodity Fund is “PEPFAR” funding because, as previously stated, all U.S. funding
spent on global HIV/AIDS is considered PEPFAR funding, it is incorrect to assume that
OGAC substantially invests in female condom procurement and programming. Public
documents do not reveal how much OGAC spends on female and male condoms, as
OGAC includes these expenditures within a broader category of spending on “other
prevention” activities aimed at reducing sexual transmission of HIV. But it is apparent
that OGAC spending on female and male condoms represents only a small portion of
total OGAC spending. In fiscal year 2009, the Other Sexual Prevention category, funded
at $268.3 million, made up only 5.2 percent of total approved OGAC funding.84
Therefore, former PEPFAR focus countries—which cannot access the Commodity
Fund—have little incentive to procure female condoms. As a result, female condom
procurement in these countries has lagged. As indicated in Figure 5, PEPFAR
focus countries were no longer eligible to access the Commodity Fund as of 2006,
even though the “focus country” designation was eliminated in the 2008 PEPFAR
reauthorization law. This policy change was made in part because PEPFAR focus
countries have much larger HIV/AIDS budgets than non-focus countries and should
accordingly have enough resources to budget for female and male condoms, if
prioritized by the U.S. Mission. Even so, these focus countries must work within finite
prevention budgets and even smaller condom budgets, which put female condoms at a
disadvantage given their cost per unit (US$0.55) compared with that of male condoms
(US$.04). Barring any incentive or policy from OGAC encouraging procurement of
female condoms, country coordinators have little reason to request the higher-priced
product.
OGAC’s limited support for female condom procurement and programming
may be symptomatic of broader issues with strategic planning and resource
allocation. CHANGE’s interviews with officials at OGAC and USAID revealed that
communication between the two agencies on female condoms is limited. Consequently,
female condoms tend to be overlooked in decision making on funding priorities.
OGAC, moreover, is the ultimate decision maker when it comes to PEPFAR funding
and resource allocation at the central level. If condoms are a priority to OGAC, this
would be reflected by actions such as the provision of ample central funding to increase
female and male condom availability at the country level.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Negative Attitudes or Lack of Awareness among U.S. Government Officials
Officials at OGAC and USAID consistently mention the barriers posed by lack of
awareness and/or negative attitudes of headquarters officials and Mission field staff.
Currently, OGAC and USAID have no specific policy guidance for the field to promote
female condoms or provide incentives to procure and program them, though female
condom guidance is under development. This information and communication
vacuum has contributed to a scenario at the country level where female condom
promotion depends on the personal beliefs of the USAID Health, Nutrition, and
Population officer, the USAID Mission director, or the U.S. ambassador, which has in
some cases presented significant hindrances.
Some Missions seem to have tried female condom programming, but have given
up when faced with obstacles common to launching a new program on women’s
reproductive health. For example, in 2009, as chair of the UNFPA Civil Society
Advocacy Working Group, CHANGE facilitated a joint meeting in Swaziland with civil
society female and male condom advocates and a PEPFAR field official. The advocates
highlighted the importance of female condoms and asked for U.S. support for their
programming. In response, the PEPFAR official said that female condoms are not very
accepted in Swaziland because of gender roles, and that until gender roles change, they
are not worth the investment.
Another example comes from Uganda, where the Ministry of Health (MOH)
decided to reintroduce female condoms in 2009 largely because women vocally
demanded access to them. When advocates met with a USAID official in Uganda to
ask for their support, the official said they needed evidence that civil society wanted
them—in spite of the advocates giving them just that. Despite demonstrated support
from diverse sectors of Ugandan society, the U.S. government has no concrete plans
to support female condoms in the country.ix Rather, in August 2009, Mike Strong,
coordinator of PEPFAR in Uganda, was quoted by TIME.com as saying about female
condoms, “Why should we divert attention from pills, IUDs and male condoms to
what’s really a niche market?”85
PEPFAR Funding Restrictions
Within the Global AIDS Act of 2003, the U.S. Congress mandated that 33 percent of
PEPFAR prevention funds be allocated for abstinence-until-marriage programs starting
in 2006. Consequently, OGAC adopted the “ABC approach”—“Abstinence, Be Faithful,
or use Condoms”—and defined abstinence-until-marriage programs as those that
exclusively teach abstinence and/or being faithful. Implementation guidance further
restricted condom distribution to individuals 15 years and older.
When the U.S. Congress reauthorized PEPFAR in 2008, it removed the 33 percent
“abstinence-until-marriage earmark.” However, it was replaced with a requirement
that the Global AIDS Coordinator issue justification to Congress if PEPFAR programs
ix
For the first time ever, USAID is slated to ship female condoms to Uganda. According to
officials at USAID, 6,000 FC2 female condoms will be shipped and donated to the Joint Clinical
Research Center (JCRC) in 2011. JCRC is a nongovernmental institution that provides ART
services and care to approximately 10,000 Ugandans at its Kampala-based clinic. The FC2
female condoms are for distribution among JCRC’s clients, though it is unclear what this
distribution will look like in terms of training and education.
Part Three: The Reality and Possibility of U.S. Policy on Female Condoms
in countries with generalized epidemics spend less than 50 percent of PEPFAR
HIV prevention funds on programs that promote abstinence, delay of sexual debut,
monogamy, fidelity, and partner reduction—henceforth referred to as “abstinence and
fidelity” activities. While PEPFAR programs are not mandated to spend 50 percent
of their HIV prevention budgets on abstinence and fidelity activities, this reporting
requirement continues to emphasize abstinence and fidelity sometimes to the exclusion
of comprehensive approaches, such as those that include education about female and
male condoms.
PEPFAR’s new Five-Year Strategy issued under the Obama administration does not
include any language about abstinence and states that PEPFAR’s prevention programs
will focus on scaling up high-impact, evidence-based, comprehensive prevention
programs. OGAC officials have said that there is no guidance to field staff favoring
implementation of abstinence and fidelity programming. Nevertheless, PEPFAR is
still funding these programs. For example, a U.S. Department of Health and Human
Services Request for Applications for Nigeria, dated March 2010, states that prevention
programs should include “coordination of the ‘Abstinence and Be Faithful’ initiative
through education on abstinence targeted among in- and out-of-school youths, and
fidelity among married couples and those in monogamous relationships.”86 Condom use
was mentioned briefly at the end of the request, but the inclusion of condom education
or distribution is not required of applicants. The disconnect between OGAC’s stated
position on comprehensive prevention and program funding instruments that favor
abstinence and fidelity activities results in lost opportunities to fund comprehensive
prevention programs that include female and male condoms.
Additionally, new guidance on condom promotion has not been issued and, per
existing guidance, female and male condom distribution is restricted to individuals 15
years of age and older, despite evidence that many young people need comprehensive
prevention messages before age 15. Prevention advocates are awaiting OGAC’s
promised new PEPFAR guidance on comprehensive prevention that will supplant
existing guidance on the ABC approach.
Another funding restriction under PEPFAR that precludes access to female and male
condom information and services is the so-called “conscience clause.” The original
PEPFAR law contained a provision that enabled organizations receiving U.S. funding
to elect which prevention and treatment services they wish to provide. This clause
allowed organizations receiving public funding to carry out prevention programs based
on their own philosophy, even if it is in conflict with human rights and evidence-based
interventions. For example, millions of dollars go to organizations for HIV prevention
services, even if they refuse to discuss safer sex options like female and male condoms
in preventing the spread of HIV.
The disconnect between OGAC’s stated
position on comprehensive prevention and
program funding instruments that favor
abstinence and fidelity activities results in
lost opportunities to fund comprehensive
prevention programs that include female
and male condoms.
PEPFAR Data Collection and Reporting Efforts
In August 2009, OGAC released its Next Generation Indicators (NGI) Reference Guide,
which offers guidance to PEPFAR country teams and programs on indicators to use
for data collection and reporting. The indicators were developed by PEPFAR technical
working groups that included the participation of multilateral partners like WHO,
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
PEPFAR-funded implementers, and civil society. OGAC acknowledges that its list of
indicators is not exhaustive, but taken together, the indicators “promote responsible
program monitoring across and within PEPFAR funded technical areas.”87 While
some indicators are “essential” and must be reported to headquarters, others are
simply “recommended.” None of the NGI indicators mention female condoms, only
“condoms.” Furthermore, there is only one indicator specific to PEPFAR output on
Program managers and OGAC officials
condoms: the “number of targeted condom service outlets.”88 This condom indicator
routinely ask to see more evidence of female is only recommended, meaning that PEPFAR country programs are not required
condom uptake and utilization—yet very few
to use this data collection indicator, let alone report findings back to OGAC. By
are collecting this data on a national scale.
not requiring countries to report on condom distribution—and specifically female
condom distribution—the U.S. government has no mechanism to monitor and evaluate
PEPFAR’s condom efforts.
PEPFAR is not alone in its lack of data collection on female condoms. MEASURE
DHS (Demographic Health Survey), which is funded by USAID, is the premier data
collection and analysis vehicle for nationally representative statistics on health issues
such as HIV/AIDS, family planning, and maternal health. MEASURE DHS does
not disaggregate female and male condom use in its HIV/AIDS Survey Indicators
pertaining to condom use; its indicators refer only to “condoms.”89 This has contributed
to the dearth of country-level data on female condom distribution and use and is
particularly detrimental to scaling up female condom activities. Program managers
and OGAC officials routinely ask to see more evidence of female condom uptake and
utilization—yet very few are collecting this data on a national scale.
Women from El Salvador and Honduras practice inserting the FC2 female condom into a pelvic
model at a February 2011 workshop on female condom advocacy, organized by CHANGE.
PART FOUR
Impact & Challenges in the Field: Country Case Studies
W
hile the female condom may be available in more than 120 countries, only
a handful of countries have been able to develop and sustain the right
mix of political commitment, donor investment, public and private sector
infrastructure, and civil society involvement to support a strong female condom
program. In many of these countries, the U.S. has played a prominent role, in spite of
some of the U.S. foreign policy and funding barriers previously mentioned. This section
will describe female condom efforts in four countries where the U.S. has provided some
degree of financial or technical support for the product and will compare and contrast
program successes, challenges, and lessons learned.
ZIMBABWE
“A strength of Zimbabwe’s program is investment in the female condom as a program
and not a project.” —Kumbirai Chatora, PSI/Zimbabwe
History and Female Condom Introduction
Zimbabwe is regularly cited as a female condom success story and has among the
highest distribution and sales of female condoms in the world.90 Women’s rights
and reproductive health organizations played a significant role in bringing female
condoms to Zimbabwe by identifying a need for the product and advocating for their
government’s support in procurement. Women and AIDS Support Network (WASN)
organized a successful, nationwide petition drive in support of female condoms that
coincided with the government’s efforts. The government of Zimbabwe launched
the FC1 female condom in 1997, making it available without branding in the public
sector through 30 pilot districts.91 In addition, PSI/Zimbabwe introduced the ‘Care
Contraceptive Sheath’—the first branded female condom in Africa.92
PSI/Zimbabwe used mass media to position Care female condoms as contraception
so that use was not associated strictly with HIV prevention, a potentially stigmatizing
position. PSI/Zimbabwe employed innovative social marketing strategies to promote
the female condom, using hair salons in low-income, urban areas as training,
distribution, and retail outlets. With funding from USAID and the United Kingdom
Department for International Development (DFID), PSI/Zimbabwe trained female
Zimbabwe is regularly cited as a female
condom success story and has among the
highest distribution and sales of female
condoms in the world.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
hairstylists from 500 salons in low-income neighborhoods to demonstrate correct
use, discuss common misperceptions, and answer questions on female condoms.93
The public sector program, however, faced setbacks, including a lack of programming
strategy. Despite this, between 2002 and 2004, the percentage of Zimbabwean women
who reported ever using the female condom increased from 15 percent to 28 percent.94
Revitalizing Female Condoms
In recent years, many factors have reenergized and strengthened female condom
procurement, distribution, and programming. In 2005, UNFPA launched the Global
Female Condom Initiative aimed at scaling up access to and use of female condoms
through financial and technical support to country programs. Zimbabwe was enrolled
in this initiative, which is now part of UNFPA’s broader CCP efforts.
Recognizing the need for a more strategic urban/rural and public/social
marketing approach in Zimbabwe, UNFPA worked with the government to form a
Technical Support Group (TSG) on female and male condom programming.95 The
TSG, consisting of representatives from the Ministry of Health and Child Welfare
(MOHCW), the Zimbabwe National Family Planning Council, PSI/Zimbabwe,
Business Council on AIDS, civil society organizations, and donors, assisted the
government in undertaking a female condom research review as well as a situation
analysis to provide evidence for the development of a national female condom strategy.
These efforts fed into a National Stakeholder Meeting in 2006 aimed at creating a
roadmap to scale up Zimbabwe’s female condom program. In addition to representation
from government ministries, diverse civil society organizations participated in the
meeting, including the Interfaith Network, Men’s Forum on Gender, Women’s Action
Group, WASN, Business Council on AIDS, and the Network of People Living with
HIV.96 This meeting culminated in the development of the Zimbabwe Five Year
National Female Condom Strategy (2006-2010), which harmonized with the national
AIDS response and reproductive health program.97 Since then, the stakeholders have
been involved in rolling out the female condom strategy.
Current Program Structure and Support
Today, the MOHCW oversees and demonstrates a strong commitment to the female
condom program. Yet, Zimbabwe still relies on donor support for both its female and
male condom programs; its major funders are UNFPA, USAID, and DFID. UNFPA has
largely financed Zimbabwe’s female condom program implementation and public sector
capacity-building.98 For example, UNFPA supports a National Condom Coordinator
who is housed in the MOHCW. UNFPA also funds service provider trainings and has
procured female pelvic models for training and distribution among health personnel.
USAID pays for the vast majority of Zimbabwe’s condoms, both female and male.
Using the Commodity Fund, USAID purchased and shipped approximately 5.5 million
FC1 female condoms in 2008 and nearly 10 million FC1 and FC2 female condoms in
2009—the largest ever U.S. female condom shipment during a calendar year.99 The main
recipients of U.S.-funded female condoms are the public sector (MOHCW and the
Zimbabwe National Family Planning Council) and social marketers (PSI/Zimbabwe).100
Part Four: Impacts and Challenges in the Field: Country Case Studies
USAID and DFID support female condom logistics in Zimbabwe. USAID gives
annual funding to the USAID | DELIVER Project that provides condom forecasting,
logistics, distribution and reporting for female and male condoms. USAID | DELIVER
distributes female and male condoms directly to service delivery points in the public
sector and selected NGOs on behalf of the Zimbabwe National Family Planning
Council.101 Female condoms are distributed for free through government institutions
such as clinics and government offices, as well as through community-based
distributors. According to OGAC, the National Family Planning Council’s distribution
system “routinely achieves nearly 95% coverage of public sector health care facilities and
maintains stockout rates below 5 percent for male condoms.”102 The stockout rate is the
same for female condoms.103
Social marketing and sales of female condoms are implemented by PSI/Zimbabwe
with support from USAID and DFID. Today, PSI/Zimbabwe has trained more
than 2,000 hairdressers operating in more than 1,700 hair salons in low-income
neighborhoods.104 A two-pack of Care female condoms sells for about US$0.20.105 In
addition to the hair salon initiative, program implementers have pursued alternative
channels of distribution and programming, such as barber shops targeting men,
commercial sex worker networks, and support groups for people living with HIV and
AIDS. For instance, women living with HIV and AIDS have been trained to conduct
interpersonal communication trainings on positive prevention and have sold Care
female condoms to support groups.106
Successes
“Women say they feel safe, because they can buy [Care] and put it on themselves,
so they are sure the condom is there to protect them.” —Patience Kunaka,
Communications Manager, PSI/Zimbabwe
A total of 4.7 million female condoms were distributed through public sector and social
marketing channels in Zimbabwe in 2009.107 Public sector distribution has climbed
since 2004, reaching a high of 2.6 million units distributed in 2009.108 The public sector
program now accounts for the majority of female condoms accessed by users in the
country. Growth of the public sector program stems largely from local-level promotion
and demand generation performed by community-based distributors and behavior
change facilitators.
Likewise, sales of Care female condoms have flourished. Between 1997 and 2009,
annual sales of Care increased from 120,720 to 2.1 million.109 The hair salon initiative
is responsible for a significant proportion of female condom sales in Zimbabwe and
has strongly influenced knowledge of and demand for female condoms. According to
Peter Halpert, health director of USAID/Zimbabwe, “the result has been a 135 percent
increase in [Care] sales between 2005 and 2009.”110
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Figure 6. Zimbabwe Public Sector and Social Marketing Female Condom
Distribution and Sales, 2000-2010
Female Condom Units Distributed or Sold
Source: MOHCW data
6,000,000
Social Marketing
5,000,000
Public Sector
Total
4,000,000
Linear Trend (Total)
3,000,000
Exponential Trend (Public Sector)
2,000,000
1,000,000
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Zimbabwe Public Sector and Social Marketing
Public sector distribution and social marketing sales figures shown in Figure 6
Female Condom Distribution and Sales 2000-2010
underscore the strength of Zimbabwe’s total market approach to female (and male)
condoms. Total market approach can be understood as when public, private, NGO,
and/or donor-financed social marketing sectors are integrated into “one market” that
can be segmented into target populations. As illustrated in Figure 6, female condoms
hit peak distribution at more than five million units in 2008, with social marketing
sales accounting for the majority distributed—mainly because of low prices resulting
from hyperinflation. Even though social marketing sales declined in 2009 and 2010,
overall distribution these years remained steady because of the increases in public
sector distribution. Zimbabwe’s female condom distribution has been very successful
in light of economic and political challenges thanks in large part to the flexibility and
responsiveness of its complementary public and private sector approaches.
Challenges
In spite of numerous successes, Zimbabwe’s female condom program has faced
obstacles. In 2008, violence around elections and the temporary suspension of NGO
activity made it difficult to deliver female condom services and training. Today,
water shortages and power outages affect PSI/Zimbabwe’s hair salon operations, and
many salons have reduced their hours or closed.112 Hyperinflation and the collapse of
Zimbabwean currency also hinder female condom sales and distribution. The U.S.
dollar is now being used for many transactions, yet Zimbabweans do not have access to
U.S. coins, making it difficult to purchase the Care two-pack at US$0.20 each.113
A related challenge is the price of female condoms relative to male condoms. For
the cost of a two-pack of Care female condoms, consumers can purchase six male
condoms.114 Even seemingly affordable prices have become more burdensome in light
of Zimbabwe’s economic situation.
Part Four: Impacts and Challenges in the Field: Country Case Studies
Finally, negative health worker attitudes continue to be one of the greatest barriers
to female condom uptake at public health sites.115 Since the 2006 launch of the female
condom strategy, UNFPA has prioritized health worker trainings at service delivery
sites to help mitigate this problem and to ensure women build skills needed to negotiate
female and male condom use.
MALAWI
“The female condom is actually empowering women to become more assertive and
to stand up for their own health issues.” —Sandra Mapemba, Condom Programme
Coordinator, UNFPA/Malawi
History and Female Condom Introduction
The FC1 female condom was first piloted in Malawi in 2000 with funding from
UNFPA, but registered little success. Initially the product was sent to clinics for
distribution without first training providers, which led to misinformation and low
uptake.116 In 2004, the FC1 female condom was then re-piloted in 22 areas across the
country, and subsequent studies found greater acceptability.117 From 2006 onward,
programs have been scaled up with the goal of making female condoms available across
Malawi by 2010.118
Similar to Zimbabwe, Malawian civil society and grassroots advocates played
an active role in helping to raise the urgency of female condoms with donors and
the government. Hunger Project Malawi (HPM), a nongovernmental organization
(NGO) that strives to end hunger and poverty, began working with female condoms
among rural populations in 2003 with support from UNFPA. HPM was one of several
organizations that convened a landmark NGO female condom meeting in 2006 to urge
the government to increase availability and access to the method. The meeting ended
with the creation of an advocacy document endorsed by more than 10 NGOs.119
In addition to NGO advocacy, UNFPA was instrumental in raising the visibility of
female condoms with the Malawian MOH and other important stakeholders. UNFPA
and the MOH organized a joint meeting in 2006 for regional participants with the
objective of addressing the gaps in coordination, supply, distribution, and access to
female condoms. Officials from the MOH signaled strong support for female and male
condoms as dual protection methods and committed to support meeting outcomes to
increase their availability.
Similar to Zimbabwe, Malawian civil society
and grassroots advocates played an active
role in helping to raise the urgency of female
condoms with donors and the government.
Revitalizing Female Condoms
Commitment to female condoms and coordination among the MOH–Reproductive
Health Unit (RHU), PSI/Malawi, donors such as UNFPA and its CCP initiative, and
civil society organizations allowed for strategic public-private sector reintroduction
of the FC2 female condom in 2008, after the product was registered. That year, the
government began distributing unbranded FC2 female condoms for free through the
public health system. At the same time, PSI/Malawi, with support from the MOH
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
and UNFPA, launched a social marketing campaign featuring a branded Care female
condom, drawing inspiration and best practices from Zimbabwe.
Recent Developments in Program Structure and Support
In 2009 and 2010, new donors including USAID and the Global Fund to Fight
AIDS, Tuberculosis, and Malaria (GFATM) began financing commodities, and
female condoms were added to the mainstream national supply chain. USAID began
supporting female condom procurement upon request from the MOH. In 2009, 1.5
million FC2 female condoms were shipped to stock Malawi’s public sector and were
paid for using the Commodity Fund.120 USAID has committed to shipping 5.2 million
FC2 female condoms between 2010 and 2011, with 3.5 million units obligated in
2010.121 GFATM has committed to procuring 200,000 units apiece in 2010 and 2011,
and an additional 500,000 units in 2012.122 These new donors supplement existing
funding from donors such as UNFPA, which has provided assistance for female
condom commodities, social marketing, and public sector capacity building, including
financial support for a CCP focal person within the RHU.123
In terms of female condom logistics, UNFPA and the RHU controlled female
condom supply and distribution prior to 2009. This changed in July 2009 when the
USAID | DELIVER Project transitioned female condoms to the national supply chain,
in response to advocacy from UNFPA and commitment from the MOH.124 Supply and
distribution are now centrally managed by the Health Technical Services and Support
division of the MOH and Central Medical Stores—the mechanism that provides
pharmaceuticals and medical supplies to Malawian government health facilities. USAID
| DELIVER now provides supply management and forecasting support. Key donors
receive monthly condom stock reports through USAID | DELIVER to help ensure
commodity needs are being met. Because female condoms have entered the main
supply chain, district health authorities now have the option to include female condoms
in their budgets.125
Today, the MOH–RHU, with financial support from UNFPA and USAID, continues
to coordinate Malawi’s female condom efforts, which reach clients through the
public sector, social marketing, workplace programs, and NGOs.126 PSI/Malawi, with
UNFPA and USAID support, works with salon owners to conduct trainings with
staff on educating and promoting female condoms through information-sharing and
demonstrations. Care female condoms are sold mainly in beauty salons, as well as
pharmacies and private clinics. A two-pack of Care female condoms sells for about
US$0.25—a price that is subsidized by UNFPA.127 Recently, barber shops have been
included as education and distribution sites as a way to engage men. PSI/Malawi is also
looking to expand its reach with partners in rural areas such as the Farming and Milk
Producers’ Associations and with marginalized populations such as sex workers.
Successes
“In the past men…would direct things and at the expense of women’s health. I am
glad that women have a choice to protect themselves against STIs and unwanted
pregnancies using this new condom.” —Martha Banda, Beautician, Malawi
Part Four: Impacts and Challenges in the Field: Country Case Studies
Malawi’s female condom program is starting to show real results. Some 2,400 Malawian
hairdressers now sell FC2 female condoms and serve as advocates. In 2009, 28 district
hospitals, 100 health centers, and 58 NGOs were distributing female condoms.128
According to UNFPA, over the course of three years, female condom distribution
through the public sector alone increased from 124,000 in 2005 to nearly one million in
2008.129 Care female condom sales have more than doubled since the product launch,
from almost 40,000 units in 2008 to 90,000 units in 2009.130
Challenges
In spite of these successes, many challenges still confront Malawi’s growing female
condom program. Stockouts are an issue cited by many stakeholders, especially those
located in rural areas. According to a provider at the STI Clinic in Balaka District
Hospital, “When women come for female condoms we can only give five at a time,
whereas we give 20 male condoms. They have to keep coming back and sometimes we
have no [female] condoms to give them…. We’ve only had male condoms, but they
are no use to the women whose husbands or boyfriends refuse to use them. We need a
better supply of female condoms so that we can provide adequately for everyone.”131
Another obstacle concerns provider training and health workforce strengthening.
Female condoms require service providers to have the right skills and knowledge to
promote the product to clients in a nonjudgmental, supportive way. Negative attitudes
and lack of proper training among service providers is still a problem in Malawi.
Moreover, health care worker turnover is high, which makes it difficult for trainings to
keep pace with personnel.132
Lastly, resources for programming continue to be a challenge in Malawi especially
as demand increases. For example, there has been no money to procure pelvic models
for female condom demonstrations, which are valuable for showing women and men
how female condom insertion works.133 At this point, UNFPA has largely shouldered
the costs of Malawi’s female condom programming. With USAID recently coming to
the table with female condom commodities, there is a ripe opportunity for the U.S.
government to ensure these female condoms have the maximum impact by supporting
programming.
CAMEROON
“As a woman, I have the right to negotiate for safer sex with the use of the female
condom in order to protect myself from any STIs.” —
­ Joy, volunteer with Society for
Women and AIDS Cameroon
History
Cameroon is a country that is currently scaling up its female condom program in spite
of limited support from the U.S. government. Cameroon initiated its female condom
efforts in 2002. The Cameroonian Association for Social Marketing (ACMS), a PSI
affiliate, worked with the Cameroonian government, UNFPA, and USAID to develop
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
the brand “Protectiv” for the FC1 female condom.134 ACMS/PSI’s activities included
education through women’s groups and a poster campaign. Social marketing was
complemented by a commercial sales network. USAID shipped more than 300,000 FC1
to ACMS/PSI between 2002 and 2006, and UNFPA began its commodity support by
furnishing 300,000 FC1 units in 2006.135 However, minimal funding for programming
and irregular product supply at the time made it difficult to expand the program, and
stockouts were widespread.136 For instance, USAID’s commodity support for Cameroon
nosedived dramatically to fewer than 10,000 units shipped between 2007 and 2009.
Current Program
Female condom efforts in Cameroon have been recently reinvigorated through a new
initiative—the Universal Access to Female Condoms (UAFC) Joint Programme. UAFC
is a partnership among Oxfam Novib, World Population Foundation, i+solutions, and
the Netherlands’ Ministry of Foreign Affairs. UAFC is funding a female condom pilot
program in Cameroon (January 2009 to December 2011) whose goal is to distribute 3.4
million female condoms.138 Similar to Zimbabwe and Malawi, UAFC coordinates with a
variety of stakeholders including the MOH and the National AIDS Control Committee;
the Ministry of Mines, Industry, and Technological Development; multilateral
organizations like UNFPA and UNAIDS; LANCOME—the Cameroonian laboratory
for quality testing; retail shops; community- and faith-based organizations; and women’s
groups such as the Society for Women Against AIDS in Africa.139 On the supply
side, i+solutions works with ACMS to develop procurement tables, though ACMS is
ultimately responsible for supply chain management within Cameroon.140 Both FC2 and
VA w.o.w. female condoms are registered in Cameroon and procured and distributed
by UAFC in re-packaged and re-branded form. They are then distributed by trained
hairdressers, peer educators, health workers, and taxi drivers, who offer interpersonal
communication and education about the product. Female condoms are also sold in
small retail stores, pharmacies, and health centers.
While UAFC is focusing on the private sector, UNFPA/Cameroon has increased
its female condom activity primarily through public sector capacity-building.
UNFPA/Cameroon provides technical assistance to the MOH in developing plans
for procurement and distribution of female and male condoms.141 It also purchases
female condoms that are then distributed for free through the public sector and
to a smaller degree through ACMS’ social marketing efforts. Finally, UNFPA/
Cameroon implements a joint sexual and reproductive health project with the African
Development Bank that supplies female and male condoms to health districts and trains
service providers on condom promotion and use.142 UNFPA procured some 500,000
FC2 female condoms from 2008 to 2010 for its programs, complementing the social
marketing efforts supported by UAFC.143,144
UAFC is funded by the Netherlands Ministry of Foreign Affairs, Danish
International Development Agency, Swedish International Development Cooperation
Agency, the Norwegian Agency for Development Cooperation (2008 only), the William
and Flora Hewlett Foundation, and Oxfam Novib; funding will expire in December
2011. USAID is not currently providing financial support to UAFC; however, the U.S.
Part Four: Impacts and Challenges in the Field: Country Case Studies
government did support ACMS/PSI and its female condom activities in 2009.145 The
U.S. government does not have a USAID Mission in Cameroon, and USAID only offers
limited support to Cameroon’s HIV/AIDS programs at present. For instance, in 2009,
Cameroon received a modest US$500,000 in bilateral aid from PEPFAR.146
Successes and Challenges
The UAFC female condom program has already produced notable successes. The
program secured support for female condoms from key political figures, such as the
Prime Minister, the Minister of Health, and the Minister of Women’s and Family’s
Affairs.147 In addition, UAFC has cultivated a female condom “champion” in the
Cameroonian musician Manu Dibango, who performed at the launch of UAFC’s
program in November 2009. In 2009, ACMS/PSI trained 483 peer educators and
involved 32 health facilities and 31 pharmacies in the distribution and sales of female
condoms.148 Around 700,000 female condoms were sold in Cameroon in 2009,149
compared with less than 350,000 distributed in 2008.150
When it comes to challenges, ACMS/PSI reports that monitoring and evaluation
of interventions in the field is an ongoing difficulty. There could also be increased
coordination and collaboration between UAFC and UNFPA. However, one of the
largest challenges is finding donor support for female condom activities after UAFC’s
funding expires in 2011.151
BOLIVIA
“The female condom is little known for cultural reasons among poor and indigenous
women. It is necessary to create a comprehensive strategy that takes into account the
diversity in perceptions and practices of the Bolivian population.” —Teresa Lanza,
Catholics for the Right to Decide (CDD)/Bolivia
Background
Bolivia’s context in terms of HIV/AIDS and national health spending is much different
from Zimbabwe, Malawi, and Cameroon, and its female condom programming history
reflects this. Bolivia’s HIV/AIDS prevalence in the general population is low, with
concentrated levels among men who have sex with men and to a lesser extent among
commercial sex workers. The Bolivian government’s response to HIV/AIDS has been
limited and dependent almost completely on foreign aid, which makes the country an
interesting case study on whether and how a female condom program can succeed in
light of these circumstances.
History
The FC1 female condom was launched as a pilot project in Santa Cruz, Bolivia in
1996.152 At the time, the Bolivia Social Marketing Project—a PSI affiliate—provided
technical assistance to Bolivian NGO PROSALUD to develop and implement social
marketing programs for various prevention methods, including female condoms.153
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
PROSALUD was founded in 1985 with technical and financial assistance from USAID
and now supports a network of primary and secondary care facilities that serves more
than half a million low- and middle-income Bolivians in peri-urban areas. In the early
phases of its social marketing program, PROSALUD reported modest female condom
sales, approximately 208,885 FC1 from 1996 to 2004.155 Its target populations were
youth, rural communities, and women of reproductive age.156 While PROSALUD offers
subsidized services throughout Bolivia, none of its services are provided for free, except
for those offered in partnership with the MOH.157
PROSALUD continued its female condom social marketing program in spite of
losing technical assistance from PSI/Bolivia when the affiliate closed its office in the
early 2000s.158 USAID began shipping female condoms to PROSALUD in 2004, using
the Commodity Fund to purchase the condoms. From 2004 to 2009, USAID shipped
173,000 FC1 female condoms to PROSALUD.159 Bolivia also received modest numbers
of female condoms from GFATM and UNFPA from 2006 to 2007.160
Current Program
Today, PROSALUD is one of just a few entities distributing female condoms in Bolivia.
USAID continues to provide commodities for PROSALUD and shipped nearly
100,000 FC1 female condoms from 2008 to 2009.161 PROSALUD’s health commodity
distribution network reaches municipal and commercial pharmacies, NGOs, and public
services, and female condoms have been distributed through these and other channels
including brothels and motels. According to CDD/Bolivia, some pharmacies used to sell
the female condom at the relatively high price of US$1.20 per unit, but they no longer
sell them.162 PROSALUD also works with the project, Socios para el Desarrollo (Partners
for Development), to promote and distribute female condoms to a single target
population: commercial sex workers.163 Although PROSALUD’s financial and technical
support from USAID is set to expire soon, USAID will likely continue to support its
social marketing program.164 PROSALUD plans to distribute the FC2 female condom
once registration is secured.
Currently, there is no free public sector distribution of female condoms. The MOH
does not view female condoms as a priority.165 Only a handful of NGOs are involved
with female condom distribution, and there are not many organizations that currently
possess PROSALUD’s capacity or infrastructure that could take it on.166 Meanwhile,
UNFPA/Bolivia is just beginning to map out a strategy for female condoms. It plans
to convene a stakeholder meeting to develop a strategic plan for female and male
condoms, as part of a broader initiative on contraceptives.167 UNFPA/Bolivia intends
to reach out to the MOH, USAID, NGOs, and civil society—including commercial sex
workers and women living with HIV.
Finally, FC2 product registration in Bolivia is underway. As referenced earlier,
countries require the FC2 female condom to be registered before it can be imported
for public or private sector distribution. A local company must be identified to act as
registration holder for the country, meaning that the company compiles and submits
a dossier of registration information to the appropriate regulatory body.168 In August
2009, USAID/Bolivia contacted FHC for the necessary registration documents
Part Four: Impacts and Challenges in the Field: Country Case Studies
because PROSALUD wanted to register the product. FHC notified UNFPA/Bolivia of
PROSALUD’s plans, and after consultation with PROSALUD, UNFPA assumed the lead
and submitted the registration request to the appropriate regulatory agency.169
Successes and Challenges
Bolivia is unique in that female condoms have been available in the country for the past
15 years, and programming efforts have been led almost exclusively by NGOs, which
are typically well-positioned to reach marginalized populations in need of services.
And although PROSALUD’s sales are not high compared with other countries, the
organization has been able to create and maintain a demand for female condoms.170
On the other hand, even though the female condom has been available in Bolivia
for 15 years, it is not very accessible. Poor and indigenous women—a key population
for female condom use—know very little about the female condom.171 One reason may
be that social marketing efforts have focused heavily on sex workers, sometimes to the
exclusion of other at-risk populations.
Bolivia also differs markedly from other countries with female condom programs in
that there is a lack of strategy guiding efforts, limited coordination among stakeholders,
and little interest from national authorities to take the lead. For example, UNFPA/
Bolivia reports that it has not yet spoken with the USAID Mission in the country
about female condoms.172 However, in 2010, the MOH, USAID, and FHC met for
the first time to discuss registration of the FC2 and strategies for female condom
reintroduction.173
Communication and advocacy between Bolivian NGOs and the USAID Mission
have also been tenuous. For example, CDD/Bolivia has never advocated with the
USAID Mission because of concern about backlash from not signing the Global
Gag Rule (Mexico City Policy), even though it was repealed by President Obama in
2009.174 Furthermore, delicate diplomatic relationships between the Bolivian and U.S.
governments make it difficult for Bolivian NGOs to approach the U.S. government
with any requests. As a result, civil society and NGOs are not able to effectively weigh in
with the USAID Mission on female condoms—a critical missed opportunity given that
USAID Missions make the procurement decisions.175
Poor and indigenous women—a key
population for female condom use— know
very little about the female condom.
Strengths and Weaknesses of U.S. Government Field Support for
Female Condom Programs
Zimbabwe and Malawi—two promising examples of female condom programs in
developing countries—benefit significantly from U.S. government support. However,
as Bolivia illustrates, U.S. investment in female condoms alone does not automatically
translate into an effective program in the absence of buy-in from and coordination with
other major stakeholders. In fact, strong U.S. government support is not a prerequisite
for an effective female condom program, as evidenced by Cameroon. Nevertheless,
these four countries offer important lessons about where and how the U.S. is excelling
in its field-level support for international female condom programs and where
improvements can be made.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
U.S. Strengths
Commodity Financing, Coordination, and Logistics
Perhaps the U.S. government’s greatest
contribution to country programs has
been its ability to ensure a robust, steady,
and well-coordinated supply of female
condoms.
Perhaps the U.S. government’s greatest contribution to country programs has been its
ability to ensure a robust, steady, and well-coordinated supply of female condoms. This
is crucial because female condom shortages and stockouts are repeatedly cited as chief
reasons for low demand and program failure. The impact of U.S. commodity support
is further strengthened when U.S. dollars are leveraged alongside assistance from other
donors such as DFID or UNFPA, who tend to put more funds into female condom
distribution and programming. Hence, different donors pay for complementary pieces
of a female condom program, as illustrated by Zimbabwe and Malawi.
USAID’s Commodity Fund has been an invaluable resource for PEPFAR non-focus
countries to procure female (and male) condoms from the U.S. government. All four
countries featured in this report have been able to access the Commodity Fund. USAID
| DELIVER has played an integral role in Zimbabwe and Malawi’s program by offering
technical support with female condom forecasting and supply management. USAID
| DELIVER has been an active player in Zimbabwe and Malawi’s technical working
groups and has ensured that stakeholders receive timely and accurate condom stock
reports. In fact, USAID/Zimbabwe cites “a good logistics system” as one of the key
factors that has enabled the country to be a female condom success story.
Collaboration and Alignment with other Donors, Governments, and Stakeholders
USAID field staff in Zimbabwe and Malawi are involved in numerous technical working
groups that address female condoms. These working groups are composed of country
government officials, donors, civil society, NGOs, and the private sector. For example,
USAID/Malawi actively participates in the reproductive health technical working
group, donor coordination meetings, drugs and medical supplies working group, and
the condom coordination group. According to one USAID official in Malawi, USAID
has recently taken “an active role in ensuring that condom programming will be
integrated into priorities of the HIV prevention and broader HIV technical working
groups.”177 This collaboration opens the door for USAID to offer technical assistance for
procurement and programming when needed by partners, such as PSI.178
Support for Social Marketing
The U.S. government has played a leading role in supporting female condom social
marketing and programming efforts through financial support to international NGOs
such as PSI and local NGOs like PROSALUD in Bolivia. Indeed, PSI/Zimbabwe points
to ample support from USAID and DFID for female condom programming as crucial
for smooth and sustained operations.179
U.S. Weaknesses
Insufficient Funding for Programming
Many stakeholders rightly recognize and applaud the U.S. government for being a vital
partner in making female condoms available and affordable in developing countries,
Part Four: Impacts and Challenges in the Field: Country Case Studies
yet some believe there is more the U.S. can do, especially regarding programming.
According to Lucie van Mens of UAFC, who coordinates the initiative’s efforts in
Cameroon, “We would like to see the U.S. government integrate female condom
programming into its financing of activities on HIV prevention… and to invest not only
in procurement but also in programming.”180 UAFC operates female condom programs
in Cameroon and Nigeria and is hoping to expand efforts to Mozambique, and has
done this largely without U.S. support. However, these are pilot programs that are in
need of a longer-term funding source. The U.S. government could play an important
role here.
Similarly, Sandra Mapemba of UNFPA/Malawi echoed the need for more U.S.
investment in programming, stating that “funding [from USAID] committed to one
portion of the female condom program would assist widely.”181 Yet this message has not
been fully communicated with the USAID Mission in Malawi. According to an official
USAID/Malawi, “UNFPA has been taking the lead in female condom programming
for the country and has not requested additional support since demand has not been
there in the past.”182 Now that demand is indeed growing in Malawi, additional U.S.
support for programming can be crucial to meet the need and bolster demand among
consumers.
Lack of Female Condom Oversight or Program Tracking
An underlying issue regarding financial support for programming in the field is that
there is no clear tracking mechanism or oversight at OGAC or USAID headquarters
for female condom programming. OGAC’s database does not have the sophistication
or level of detail to determine in which countries it supports female condoms and how
financial support is allocated across commodities and programs.183 It is also difficult
and cumbersome for implementing organizations like PSI to establish how much or
what percentage of U.S. government funding goes to procurement or programming.184
PSI explains that because its female condom programs are usually part of larger
condom social marketing programs funded by multiple donors, it would have to review
multiple budgets for each of its countries with female condom programs to break down
USAID’s financial support for procurement and programming. The result is that U.S.
government officials do not have a clear picture of U.S. support for female condom
programming. This absence of information complicates OGAC’s and USAID’s resource
allocation planning and evaluation efforts, and makes it more difficult for recipient
governments, other donors, and NGOs in the field to advocate for increased investment
in programming.
U.S. government officials do not have
a clear picture of U.S. support for
female condom programming.
Limited USAID Mission Outreach to Civil Society
Another challenge that surfaced in each country is the limited outreach from the
USAID Missions to civil society and NGOs on female condoms. When asked if it
reaches out to civil society organizations for input on U.S. support for female condoms,
the USAID Mission in Zimbabwe says it does through “various meetings and
forums.”185 In spite of this, organizations like Women’s Action Group Zimbabwe—a
longstanding women’s rights organization engaged in advocacy and programming on
female condoms—have never met or spoken with the Mission about female condoms.186
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As Bolivia illustrates, U.S. foreign policies
like the Global Gag Rule can have a
lasting negative impact on civil society
engagement with the U.S. government.
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
USAID/Malawi concedes that it does not directly reach out to civil society organizations
but that it does work with them through funded partner organizations such as PSI.187
Cameroon is at a particular disadvantage for civil society engagement because the
country no longer has a USAID office; USAID coordinates its activity in Cameroon
through the West Africa office based in Ghana.188 And Bolivia has its own set of unique
challenges including the lack of a robust female condom program in the first place and
delicate relationships between the U.S. and Bolivian governments. As Bolivia illustrates,
U.S. foreign policies like the Global Gag Rule can have a lasting negative impact on civil
society engagement with the U.S. government.
Civil society communication and advocacy with USAID Missions on female
condoms are important for several reasons. First, procurement decisions ultimately
rest with USAID Missions. While it should not be up to civil society to prove demand
for female condoms, if Missions do not hear or witness demand for female condoms,
they will be less likely to procure them. Another issue is that U.S. foreign assistance is
shifting toward a model of country ownership under the GHI, meaning that countries
themselves will determine priority areas and lead the response. However, advocates
worry that the priorities of civil society, especially women at the margins—women
living with HIV and AIDS, incarcerated women, refugee or migrant women, sex
workers, young women, or drug users—will not be heard or reflected in critical policy
or program discussions. It therefore behooves the U.S. government to find ways to
meaningfully involve civil society in decision making about how U.S. foreign assistance
will be spent, with female condoms included in this discussion.
Ingredients of an Effective Female Condom Program
Best practices and lessons learned from female condom programs in developing
countries offer insight into the building blocks for an effective program. As these
country case studies show, effective female condom programs are complex.
Commodities, while straightforward, are just one piece of a program. Successful models
of female condom programs contain most or all of the following elements:
„„ Support of the national government. Commitment and support from the
national government is critical; it lays the foundation for all other aspects of a
female condom program. When government ministries coordinate, oversee,
and fund female condom efforts, it helps institutionalize and legitimize the
program.
„„ Sustained resources from donors. Robust and sustained funding from bilateral
and multilateral donors is essential. Many existing programs are funded by
multiple donors because it can be difficult for one donor to pay for all the
necessary programmatic components. While it makes sense for donors to put
money into their own areas of specialty (i.e. USAID funding commodities or
UNFPA funding programming), more money overall and more overlapping
and flexible funding is needed.
Part Four: Impacts and Challenges in the Field: Country Case Studies
„„ Multisectoral female condom strategy. Effective female condom programs
have a well-thought out female (and male) condom strategy guiding
efforts. These strategies are often borne out of landscape analyses or market
research that informs stakeholders of the female condom gaps and strengths.
Female condom strategies should take into account public and private
sector approaches, and they should harmonize with existing HIV/AIDS or
contraceptive plans.
„„ Well-functioning supply chain and distribution. Programs not only need
sufficient quantities of female condoms, they also need strong supply chains
and smooth logistics. This is a major strength of U.S. government involvement
through its USAID | DELIVER Project. Countries with USAID | DELIVER
offices that are looking to program female condoms should strongly consider
reaching out to USAID | DELIVER for its involvement and expertise.
Distribution plans should take into account public, private, and interpersonal
channels. These channels could include government health clinics, schools and
universities, pharmacies, hotels, bars, NGOs, and peer-to-peer mechanisms.
„„ Attention to provider bias. Health provider bias against female condoms
presents a significant challenge to distribution and programming and is a fairly
ubiquitous issue. HIV prevention and family planning program designers
should incorporate regular training for doctors, nurses, and counselors about
the female condom and how to discuss and distribute the product with
accurate information and a nonjudgmental demeanor.
„„ Comprehensive and rights-based education. In order to facilitate increased
female condom use and uptake, women, men, and young people need
comprehensive education on female condoms. At minimum, trainings should
provide accurate information about female condoms properties, use, benefits,
and drawbacks; opportunities to practice insertion on oneself or using
pelvic models; discussion around realistic expectations with use; lessons in
condom negotiation with sexual partners; and information on female genital
anatomy. Trainings should also consider lessons on female condoms and anal
intercourse, gender roles and self esteem, and intimate partner violence.
„„ Innovative social marketing. Creative social marketing of female condoms
is an important complement to “traditional” service provision. Hair salon
and barber initiatives, in particular, have proven to be effective ways to reach
women and men with education about the female condom and product
provision in some African countries. Mass media is also an important
component of social marketing that helps raise awareness and generate
demand.
„„ Male involvement. A comprehensive female condom program takes into
consideration the perspectives and needs of men. While female condoms are
designed for women to initiate and wear, men also initiate and use female
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
condoms for vaginal and/or anal sex. Men should be involved in female
condom program design and message testing, and they should also be targeted
for female condom education and distribution.
„„ Coordination among stakeholders. Effective female condom programs
benefit from coordination and collaboration among a variety of stakeholders
through regular meetings or technical working groups. Stakeholders include
government officials, donors, civil society, NGOs, and representatives from the
private sector. Information-sharing and transparency allows stakeholders to
continually improve upon the program, identify potential gaps or weaknesses,
and stay abreast of developments.
„„ Civil society participation. Civil society must be involved in all levels
of a female condom program, from strategy development to program
implementation. NGOs and civil society have important perspectives on the
issues and circumstances confronting women and men at the community
level and are well-positioned to reach marginalized populations. The voices of
women—especially women living with HIV and AIDS—must be included in
these processes.
„„ Monitoring and evaluation. It is very important to monitor and evaluate the
female condom program. Program planners and implementers need evidence
of what works and does not work to further refine and tailor programs.
Information on “typical” users, reasons for using female condoms, and actual
utilization rates are important to capture if possible—especially to report back
to donors and governments.
Comprehensive condom programming civil society champions from Swaziland, Zimbabwe, Malawi,
and Zambia attend a December 2009 female and male condom advocacy workshop led by
CHANGE and the Centre for Population and Development Activities for the UNFPA Civil Society
Advocacy Working Group.
PART FIVE
Findings & Recommendations
Finding: OGAC has identified a serious “condom gap” affecting several high HIV
prevalence countries in Africa. Yet, OGAC is not allocating enough funding to support
female condom procurement and programming, especially for former focus countries,
which cannot access female and male condoms through the Commodity Fund. These
countries must pay for female and male condoms out of their prevention budgets,
which negatively impacts procurement of female condoms, as male condoms are
cheaper and Missions tend to purchase the cheaper product.
Recommendation: OGAC should centrally finance female and male condom
procurement to help close the condom gap. OGAC should allocate funds directly to the
Commodity Fund so that all countries can be eligible to access this account to procure
female condoms. In addition, OGAC should also allocate robust resources to support
female and male condom programming, especially for former focus countries.
Finding: Communication and coordination between OGAC and USAID officials
on female condoms is limited, contributing to female condoms being overlooked in
decision making on funding priorities. In addition, there is no clear mechanism or
oversight at OGAC or USAID regarding financial and technical support for female
condom programming.
Recommendation: OGAC and USAID should form an interagency task team to
engage in strategic thinking and resource allocation planning on female condoms
and the broader condom gap. OGAC and USAID should also conduct an evaluation
of PEPFAR support for female condom programming, and develop a system to track
financial and technical support for female condom programs.
Finding: Whether the U.S. procures female condoms in a given country is highly
dependent on the personal biases of USAID Mission staff. Some Washington- and
field-based U.S. officials lack awareness of the female condom or hold negative attitudes
about it, in part because there is currently no guidance explaining the importance and
relevance of female condoms in HIV prevention and family planning programs.
Recommendation: OGAC and USAID should expedite the issuance of guidance to
U.S. global health personnel in the field highlighting the evidence on female condom
efficacy, acceptability, availability, and cost-effectiveness. The U.S. should also include
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
the female condom in GHI guidance as an important example of integrated, womancentered programming. OGAC and USAID should fund training for PEPFAR- and
USAID-funded doctors, nurses, and counselors about the female condom and how to
discuss and distribute the product with accurate information, in a nonjudgmental way.
Finding: The U.S. government continues to release requests for applications (RFAs) and
requests for proposals (RFPs)—such as the March 2010 U.S. Department of Health and
Human Services Request for Applications for Nigeria—that focus on failed stand-alone
abstinence and fidelity programs for HIV prevention. This contradicts PEPFAR’s new
Five Year Strategy that espouses comprehensive and evidence-based prevention, and
hampers comprehensive programming including female and male condoms.
Recommendation: U.S. government RFAs and RFPs should call for integrated,
comprehensive, and evidence-based HIV prevention programming, including female
and male condom programming. Funding announcements should explicitly mention
female and male condoms, as opposed to “condoms,” to provide further incentive for
programs to include female condoms.
Finding: OGAC’s Next Generation Indicators (NGI) Reference Guide does not
disaggregate female and male condom service outlets in PEPFAR data collection
efforts and does not even require countries to report on the number of male condom
distribution outlets. The USAID-funded MEASURE DHS does not collect data on
female condom use, contributing to the dearth of national level data on female condom
use.
Recommendation: OGAC should revise the NGI Guide to disaggregate female and
male condoms and require countries to report on female and male condom distribution
outlets. USAID should disaggregate female and male condom use in the MEASURE
DHS HIV/AIDS Survey Indicators on condom use.
Finding: The 2008 reauthorization of PEPFAR included a requirement that the Global
AIDS Coordinator issue justification to Congress if PEPFAR programs in countries
with generalized epidemics spend less than 50 percent of PEPFAR HIV prevention
funds on programs that promote abstinence, delay of sexual debut, monogamy, fidelity,
and partner reduction. In addition, OGAC has not issued new guidance on prevention
and condoms, and female and male condom distribution is still restricted to individuals
15 years of age and older.
Recommendation: Congress should remove all funding directives for abstinence and
fidelity prevention programs and fund comprehensive, integrated, and evidence-based
HIV prevention programs that include female condoms. OGAC should issue new
guidance on prevention that ensures that all women, men, and young people have
access to female and male condom education and distribution in PEPFAR-supported
programs. In such guidance, OGAC and USAID should consider female condoms’
contributions to the GHI’s principles of a comprehensive, integrated, and womancentered approach.
Part Five: Findings and Recommendations
Finding: At the country level, the U.S. government has no mechanism to involve civil
society in female condom procurement, distribution, and programming decision
making.
Recommendation: The U.S. should actively include civil society, especially women’s
health and rights groups, in stakeholder meetings and encourage financing mechanisms
that increase government-civil society collaboration in female condom programming.
Finding: The U.S. excels at assisting countries in female condom procurement and
logistics.
Recommendation: The U.S. should expand technical assistance for female condom
logistics and procurement to additional countries to increase HIV prevention efforts.
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NOTES
WHO, Women and Health: Today’s Evidence, Tomorrow’s Agenda (Geneva: WHO,
2009).
2
UNAIDS and WHO, AIDS Epidemic Update: 2009 (Geneva: UNAIDS and WHO,
2009).
3
UNAIDS, UNAIDS Report on the Global AIDS Epidemic: 2010 (Geneva: UNAIDS,
2010).
4
Susheela Singh et al., Adding It Up: The Costs and Benefits of Investing in Family
Planning and Maternal and Newborn Health (New York: Guttmacher Institute and UNFPA,
2009).
5
WHO, Trends in Maternal Mortality: 1990 to 2008: Estimates developed by WHO,
UNICEF, UNFPA and the World Bank (Geneva: WHO, 2010).
6
“Caprisa 004,” AVAC—Global Advocacy for HIV Prevention, accessed August 20, 2010,
http://www.avac.org/ht/d/sp/i/28226/pid/28226.
7
AVAC—Global Advocacy for HIV Prevention, What PrEP Is and What PrEP is Not
(New York, AVAC, 2010).
8
AVAC—Global Advocacy for HIV Prevention, The Thai Way Forward (New York:
AVAC, 2010).
9
Global Campaign for Microbicides, Male Circumcision: What Does it Mean for Women?
(Washington, DC: Global Campaign for Microbicides, 2009).
10
Gowri Vijayakumar et al., “A Review of Female Condom Effectiveness: Patterns of Use
and Impact on Protected Sex Acts and STI Incidence,” International Journal of STD & AIDS,
no. 17 (2006): 652-659.
11
UNDP/UNFPA/WHO/World Bank Special Programme of Research on Human
Reproduction, The Female Condom: A Review (Geneva: WHO, 1997).
12
Heather Cecil et al., “The Female Condom: What We Have Learned Thus Far,” AIDS
and Behavior 2, no. 3 (1998): 241.
13
Diana K. Lara et al., “Acceptability and Use of the Female Condom and
Diaphragm among Sex Workers in Dominican Republic: Results from a Prospective
Study,” AIDS Education and Prevention 21, no. 6 (2009): 548.
14
Susan Kalckmann et al., “Evaluation of Continuity of Use of Female Condoms among
Users of the Brazilian National Health System (SUS): Longitudinal Analysis in Units in the
Metropolitan Region of São Paulo, Brazil,” Rev Bras Epidemiol 12, no. 2 (2009): 1.
15
James Trussell et al., “Comparative Contraceptive Efficacy of the Female Condom and
Other Barrier Methods,” Family Planning Perspectives 26, no. 2 (1994): 66.
16
Ibid.
17
PATH and UNFPA, Female Condom: A Powerful Tool for Protection, Second Edition
(Seattle: PATH, UNFPA, and UNAIDS, forthcoming).
18
Johns Hopkins Bloomberg School of Public Health, USAID, and WHO, Family
Planning: A Global Handbook for Providers (Baltimore: INFO Project, 2007).
19
Ibid.
20
Sue Napierala et al., “Female Condom Uptake and Acceptability in Zimbabwe,” AIDS
Education and Prevention 20, no. 2 (2008): 121.
21
Mack et al., “Introducing Female Condoms to Sex Workers in Central America,”
International Perspectives on Sexual and Reproductive Health, 36, no. 3 (2010): 152.
22
Edinah Masiyiwa (Executive Director of Women’s Action Group Zimbabwe), personal
communication with author, March 9, 2010.
23
Center for Health and Gender Equity (CHANGE), Saving Lives Now: Female Condoms
and the Role of U.S. Foreign Aid (Washington, DC: CHANGE, 2008).
1
55
56
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
24
Kyung-Hee Choi et al., “The Efficacy of a Female Condom Skills Training in HIV Risk
Reduction among Women: A Randomized Controlled Trial,” American Journal of Public
Health 98, no. 10 (2008): 1841.
25
CHANGE, Saving Lives Now, 2008.
26
Natasha Mack et al., Formative Research on Female Condom Promotion in Central
America (Washington, DC: USAID, 2008).
27
CHANGE, Saving Lives Now, 2008, 16.
28
Population Council and Liverpool VCT, Care & Treatment, Female Initiated Prevention:
Integrating Female Condoms into HIV Risk Reduction Activities in Kenya (Nairobi:
Population Council, 2009), 18.
29
Mack et al., “Central American Sex Workers’ Introduction of the Female Condom to
Different Types of Sexual Partners,” AIDS Education and Prevention, 22, no. 5 (2010): 466.
30
Serra Sippel, “Uganda to Reintroduce Female Condoms,” RH Reality Check, June 29,
2009, http://www.rhrealitycheck.org/node/10572
31
Mags Beksinska (Investigator, Maternal, Adolescent and Child Health (MatCH),
Department of Obstetrics and Gynaecology, University of Witwatersrand), personal
communication with author, February 13, 2011.
32
CHANGE has witnessed this firsthand at meetings between civil society advocates
and donor/government officials, for example, in Uganda in June 2009. CHANGE has
also uncovered this dynamic in countries ranging from Guatemala to Botswana through
secondary research and personal communication with stakeholders.
33
UNAIDS, Global AIDS Epidemic, 2010.
34
UNFPA, Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2009
(New York: UNFPA, 2010).
35
Reproductive Health Supplies Coalition, Contraceptive Projections and the Donor Gap:
Meeting the Challenge (Brussels: Reproductive Health Supplies Coalition, 2009).
36
Ibid.
37
WHO, WHO Model List of Essential Medicines, 16th List (Geneva: WHO, 2009).
38
Peters et al., “The Female Condom: The International Denial of a Strong Potential,”
Reproductive Health Matters 18, no. 25 (2010): 119-128.
39
UNFPA, “Empowering Women to Protect Themselves: Promoting the Female Condom
in Zimbabwe,” UNFPA, July 1, 2010, http://www.unfpa.org/public/News/pid/3913
40
Lucie van Mens (Coordinator of UAFC Joint Programme), personal communication
with author, August 17, 2010.
41
UNFPA, Towards a Unified Approach: UNAIDS Inter-Agency Task Team on
Comprehensive Condom Programming (New York: UNFPA, 2010).
42
Choi et al., “Female Condom Skills Training,” 2008.
43
UNFPA, “Partnering with Men to Promote the Female Condom,” Condom
Programming in the Caribbean 1, no. 2 (2009): 1.
44
Weeks et al., “Multilevel Social Influences on Female Condom Use and Adoption
among Women in the Urban United States,” AIDS Patient Care and STDs 24, no. 5 (2010):
307.
45
Doris Anderson (Program Analyst, Contraceptive Commodity Procurement Team,
Office of Population and Reproductive Health, USAID), personal communication with
author, June 23, 2010.
46
Ibid.
47
Mary Ann Leeper, Overview of the FC2 Female Condom (Chicago: Female Health
Company, 2009). This is an unpublished document.
48
Yasmin Madan (PSI Vietnam Country Director), as cited in CHANGE, Saving Lives
Now, 2008.
Notes
49
Population Services International (PSI), Annual Cost Effectiveness Report 2008
(Washington, DC: PSI, 2009).
50
David W. Dowdy et al., “Country-Wide Distribution of the Nitrile Female Condom
(FC2) in Brazil and South Africa: A Cost-Effectiveness Analysis,” AIDS 20, no. 16 (2006):
2091.
51
PSI, Cost Effectiveness Report, 2009.
52
FSG Social Impact Advisors and Elliot Marseille and James G. Kahn, Smarter
Programming of the Female Condom: Increasing Its Impact on HIV Prevention in the
Developing World (Seattle: FSG, 2008).
53
Doris Anderson, personal communication, 2010.
54
USAID, Fact Sheet: The U.S. Government’s Global Health Initiative (Washington, DC:
USAID, 2010).
55
UNFPA, Donor Support for Contraceptives, 2010.
56
Ibid.
57
Gatson Farr et al., “Contraceptive Efficacy and Acceptability of the Female Condom,”
American Journal of Public Health, no. 84 (1994): 1960-1964.
58
CHANGE, Saving Lives Now, 2008.
59
PEPFAR, The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy
(Washington, DC: OGAC, 2009), 15.
60
PEPFAR, The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Annex:
PEPFAR’s Contributions to the Global Health Initiative (Washington, DC: OGAC, 2009), 6.
61
Ibid, 6-7.
62
PEPFAR, FY 2010 Country Operational Plan (COP) Guidance: Programmatic
Considerations (Washington, DC: OGAC, 2009), 151.
63
PEPFAR, FY 2011: Country Operational Plan Guidance Appendices (Washington, DC:
OGAC, 2010), 13.
64
RHInterchange, http://rhi.rhsupplies.org/rhi/index.do?locale=en_US, accessed July 1,
2010.
65
Ibid.
66
Ibid.
67
Bidia Deperthes (HIV/AIDS Technical Advisor for Comprehensive Condom
Programming, UNFPA), personal communication with author, February 22, 2011.
68
Simone Martins (former Program Advisor for Latin America and Caribbean,
SUPPORT Worldwide), personal communication with author, January 21, 2011.
69
Ibid.
70
Anderson, personal communication, 2010.
71
David Sarley (Activity Director for USAID | DELIVER, JSI), as cited in CHANGE,
Saving Lives Now, 2008.
72
Lois Todhunter (Director of Supply Operations for USAID | DELIVER, JSI) personal
communication with author, June 18, 2010.
73
Krishna Jafa (Director, HIV, TB, and Reproductive Health, PSI), interview with author,
April 23, 2010.
74
Jeff Spieler (Senior Technical Advisor for Science and Technology, Office of Population
and Reproductive Health, USAID), interview with author, March 23, 2010.
75
CHANGE, Saving Lives Now, 2008.
76
“About AIDSTAR,” USAID, accessed August 31, 2010, http://ghiqc.usaid.gov/aidstar/
about/index.html
77
Jafa, interview, 2010.
78
Silvia Gurrola Bonilla (GHARP II Chief of Party, Management Sciences for Health),
personal communication with author, September 1, 2010.
57
58
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
79
George Sinyangwe (Senior Health Advisor, USAID/Malawi), personal communication
with author, September 7, 2010.
80
PEPFAR, The U.S. President’s Emergency Plan for AIDS Relief Five-Year Strategy Annex:
PEPFAR and the Global Context of HIV (Washington, DC: OGAC, 2009), 5.
81
Beth Deutsch (Senior HIV Prevention Advisor, USAID/Malawi), interview with author,
April 8, 2010.
82
Caroline Ryan, “Overview of PEPFAR Prevention,” (power point presented at the
PEPFAR Scientific Advisory Board Meeting, Washington, DC, January 7, 2011).
83
Ibid.
84
PEPFAR, Fiscal Year 2009: PEPFAR Operational Plan (Washington, DC: OGAC, 2010).
85
Nick Wadhams, “The Battle in Uganda over Condoms,” TIME.com, August 30, 2009,
http://www.time.com/time/world/article/0,8599,1919311,00.html
86
U.S. Department of Health and Human Services (DHHS), Providing Quality
Comprehensive HIV/AIDS Prevention, Care, and Treatment Services in the Federal Republic of
Nigeria, Under the President’s Emergency Plan for AIDS Relief (PEPFAR) (Washington, DC:
DHHS, 2010), 10.
87
PEPFAR, Next Generation Indicators (NGI) Reference Guide (Washington, DC: OGAC,
2009), 3.
88
Ibid, 27.
89
“MEASURE DHS HIV/AIDS Survey Indicators Database,” MEASURE DHS, accessed
February 23, 2011, http://www.measuredhs.com/hivdata/ind_tbl.cfm.
90
UNFPA, UNFPA Female Condom Global Initiative: 2006-2007 Progress Report (New
York: UNFPA, 2007).
91
Daisy Nyamukapa (condom programming specialist formerly with UNFPA/
Zimbabwe), e-mail message to Implementing Best Practices e-Forum on Female Condoms,
May 1, 2008.
92
Kumbirai Chatora (Deputy Country Director, PSI/Zimbabwe), interview with author,
April 28, 2010.
93
CHANGE, Saving Lives Now, 2008.
94
Ibid.
95
UNFPA, Female Condom Global Initiative, 2007.
96
Nyamukapa, e-mail message to Best Practices, 2008.
97
Ibid.
98
UNFPA, UNFPA Global Condom Initiative—Scaling Up Male and Female Condom
Programming: Zimbabwe January-December 2009 (Harare: UNFPA, 2009).
99
RHInterchange, 2010.
100
Peter Halpert (Health and Education Team Leader, USAID/Zimbabwe), interview with
author, April 23, 2010.
101
Nyamukapa, personal communication with author, February 22, 2011.
102
PEPFAR, 2009 Country Operational Plan: Zimbabwe (Washington, DC: OGAC, 2009),
20.
103
Nyamukapa, personal communication, 2011.
104
Halpert, interview, 2010.
105
UNFPA, Global Condom Initiative Zimbabwe, 2009.
106
Global Health Technical Assistance Project, Zimbabwe HIV/AIDS Partnership Project
& Behaviour Change Programme: A Joint USAID/DFID Assessment (Washington, DC: Global
Health Technical Assistance Project, 2008).
107
UNFPA, Global Condom Initiative Zimbabwe, 2009.
108
Ibid.
109
Halpert, interview, 2010.
110
Ibid.
Notes
111
Kathryn Bice, “Female Condom Popular in Zimbabwe,” Kubatana.
net, August 6, 2010, http://www.kubatanablogs.net/kubatana/?p=3518&utm_
source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+kubatana+(Kubat
ana.net+speaks+out+from+Zimbabwe
112
Ibid.
113
Ibid.
114
UNFPA, Global Condom Initiative Zimbabwe, 2009.
115
Ibid.
116
PlusNews, “Malawi: High Hopes for Female Condom,” PlusNews, July 29, 2008, http://
www.irinnews.org/report.aspx?ReportID=79506.
117
Countdown 2015 Europe, Female Condoms Now! How European Governments Can
Help to Increase Access to Female Condoms for Women in the Developing Countries (Brussels:
Countdown 2015 Europe, 2009).
118
Ibid.
119
Hunger Project Malawi, Position Paper on the Availability and Access to Female
Condoms in the Prevention of HIV Infections and Other Reproductive Health Services
(Blantyre: Hunger Project Malawi, 2006).
120
Deutsch, interview, 2010.
121
Sandra Mapemba (Condom Programme Coordinator, UNFPA/Malawi), interview
with author, April 6, 2010.
122
Ibid.
123
Ibid.
124
Deutsch, interview, 2010.
125
Countdown 2015 Europe, Female Condoms Now!, 2009.
126
Sandra Mapemba, “Breaking Down the Barriers to Achieve Gender Equity—The
Female Condom Programme in Malawi” (power point presented at USAID, Washington,
DC, November 19, 2009).
127
Countdown 2015 Europe, Female Condoms Now!, 2009.
128
UNFPA, UNFPA Global Condom Initiative—Scaling Up Male and Female Condom
Programming: Malawi Jan-Dec 2009 (Lilongwe: UNFPA, 2009).
129
UNFPA, “Empowering Women,” 2010.
130
Mapemba, “Breaking Down the Barriers,” 2009.
131
Countdown 2015 Europe, Female Condoms Now!, 2009.
132
Ibid.
133
UNFPA, Global Condom Initiative Malawi, 2009.
134
Nestor Ankiba (Executive Director, ACMS), interview with author, April 26, 2010.
135
RHInterchange, 2010.
136
Ankiba, interview, 2010.
137
RHInterchange, 2010.
138
Ankiba, interview, 2010.
139
van Mens, interview, 2010.
140
Ibid.
141
Gislaine Ada Ngaska (Programme Advisor for Central and South Africa, SUPPORT
Worldwide), personal communication with author, August 23, 2010.
142
Ibid.
143
RHInterchange, 2010.
144
Ada Ngaska, personal communication, 2010.
145
Jafa, interview, 2010.
146
Ibid.
147
Ankiba, interview, 2010.
148
ACMS, Le Préservatif Féminin s’Insère au Cameroun (Yaoundé: ACMS, 2010).
59
60
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
149
van Mens, interview, 2010.
ACMS, Préservatif Féminin, 2010.
151
van Mens, interview, 2010.
152
UNAIDS, Global Directory of Condom Social Marketing Projects and Organizations
(Geneva: UNAIDS, 1999).
153
Ibid.
154
Health Systems 20/20, “Bolivia: Strengthening PROSALUD,” Abt Associates Inc.,
accessed August 20, 2010, http://www.healthsystems2020.org/section/where_we_work/
bolivia.
155
PROSALUD, “Mercadeo Social de Productos,” PROSALUD, accessed August 20, 2010,
http://www.prosalud.org/mercadeosocial.html
156
USAID, Country Profile: HIV/AIDS Bolivia (Washington, DC: The Synergy Project,
2004).
157
Diddie Schaaf (HIV/AIDS Officer, UNFPA/Bolivia), interview with author, June 15,
2010.
158
Ibid.
159
RHInterchange, 2010.
160
Ibid.
161
Ibid.
162
Teresa Lanza (Executive Director, CDD/Bolivia), interview with author, May 25, 2010.
163
Ibid.
164
Stanley Blanco (Health Development Specialist, USAID/Bolivia), interview with
author, May 20, 2010.
165
Schaaf, interview, 2010.
166
Blanco, interview, 2010.
167
Schaaf, interview, 2010.
168
Martins, personal communication, 2011.
169
Martins, personal communication, 2010.
170
Ibid.
171
Lanza, interview, 2010.
172
Schaaf, interview, 2010.
173
Schaaf, personal communication, 2011.
174
Lanza, interview, 2010.
175
Ibid.
176
Halpert, interview, 2010.
177
Deutsch, interview, 2010.
178
Chatora, interview, 2010.
179
Ibid.
180
van Mens, interview, 2010.
181
Mapemba, interview, 2010.
182
Deutsch, interview, 2010.
183
Nina Hasen (Technical Advisor, HIV/AIDS Prevention, OGAC), interview with
author, August 10, 2010.
184
Jafa, interview, 2010.
185
Halpert, interview, 2010.
186
Masiyiwa, personal communication, 2010.
187
Deutsch, interview, 2010.
188
Ada Ngaska, personal communication, 2010.
189
Female Health Company, Vision + Partnership, Working Together to Improve Women’s
Health Worldwide: The Female Health Company 2009 Annual Report (Chicago: The Female
Health Company, 2010).
150
Notes
190
Ibid.
Leeper, FC2 Female Condom, 2009.
192
Maya Gokul, “FC2 Female Condom” (power point presented at the XVIII
International AIDS Conference, Vienna, Austria, July 19, 2010).
193
Reproductive Health Supplies Coalition, Female Condom (Seattle: PATH, 2009).
194
Carol Joanis (consultant to UAFC and i+Solutions), personal communication with
author, January 4, 2011.
195
Phil Harvey (Founder and President of DKT International), personal communication
with author, January 5, 2011.
196
Ibid.
197
Patricia Coffey (Senior Program Officer and Woman’s Condom Team Leader, PATH),
personal communication with author, February 16, 2011.
198
Beksinska et al., “Female Condom Technology: New Products and Regulatory Issues,”
Contraception, 83, no. 4 (2011): 316-321. Published electronically September 15, 2010.
199
Ibid.
200
Ibid.
201
Sonia Correa (Associate Researcher, Development Alternatives with Women for a
New Era and Brazilian Interdisciplinary AIDS Association), personal communication with
author, January 4, 2011.
202
Reproductive Health Supplies Coalition, Female Condom, 2009.
203
Patricia Karlin (CEO, Silk Parasol Female Panty Condom), interview with author,
January 4, 2011.
204
PATH and UNFPA, Powerful Tool for Protection, forthcoming.
191
61
62
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65
66
ANNEX A
Female Condom Products Currently Available or
Previously Distributed on Public or Private Markets
FC1 and FC2
FC1 and FC2 female condoms are manufactured by FHC. The
FC1 is a silicone lubricated, polyurethane sheath with flexible
rings located at each end to aid insertion into the vagina and to
hold the condom in place. The FC1 first came on the market
in 1992. However, its production ceased in 2009 shortly after
FHC’s second generation “FC2” female condom received
regulatory approval from USFDA. The FC2 is identical to the
FC1 in design and appearance but is composed of nitrile, a
synthetic latex, which decreases manufacturing costs. The FC2
is currently being manufactured in Malaysia.
FHC began to develop the FC2 in 2003, and product
development finished two years later.189 In 2006, a WHO
technical review committee examined FC2 clinical data
and deemed it acceptable for bulk purchase by public sector agencies such
as United Nations agencies. Shortly thereafter, UNFPA began procuring
FC2 for its reproductive health programs worldwide. Since WHO clearance of FC2,
approximately 40 million FC2 units have been distributed in 105 countries.190
To date, the FC1 and FC2 are the only female condoms that have received regulatory
approval from USFDA. Before female condom products can become available on
U.S. markets, they must undergo rigorous USFDA review to meet safety and efficacy
standards. USFDA approval also has significant implications for U.S. HIV/AIDS and
family planning programs overseas. As mentioned earlier, USAID has only procured
female and male condoms that have USFDA approval to date. USFDA approval of the
FC2 was heralded because the FC2 costs approximately 30 percent less than the FC1.191
The lower unit cost is one important factor that can help increase access to the FC2 both
in the United States and internationally.
The FC2 received USFDA approval in March 2009. This paved the way for USAID
to exhaust FC1 shipments and begin procuring and shipping the less expensive FC2
to its programs worldwide. In the fall of 2009, the FC2 became available to U.S. public
sector programs. It is now available in some retail outlets, such as CVS drugstores in
Washington, D.C., and Walgreens pharmacies nationwide. FC2 is currently available in
more than 120 countries worldwide.192
FC2 Female Condom
67
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
VA w.o.w. Feminine Condom or “Reddy” Female Condom
The VA w.o.w. (“worn-of-women”) female condom, also known under brands like
“Reddy” or “L’amour,” was developed by Medtech Products Ltd of India. This product is
made of latex, comes lubricated with silicone, and uses a sponge to secure the condom
in a woman’s vagina. The VA w.o.w. does not have USFDA approval or WHO clearance
for bulk procurement by public sector agencies. However, it carries the CE mark for
sale in Europe. The VA w.o.w. has been distributed in many countries including India,
Brazil, Portugal, South Africa, and the United Kingdom, and approximately 5 million
pieces were sold commercially between 2003 and 2007.193 They are also currently being
distributed by UAFC’s program in Cameroon.
VA w.o.w. Female Condom
Although VA w.o.w. female condoms are still available in some countries,
manufacturing has ceased due to closure of the Medtech factory.194, 195 The cause of
the closure is unclear. The Indonesia office of DKT International, a social marketing
organization that has procured VA w.o.w. female condoms in the past, reports that
Medtech failed to fill outstanding purchase orders in 2010.196
Closure of the Medtech Products Ltd factory does not mean that the VA w.o.w. is a
failed product. On the contrary, this female condom is just as efficacious as other female
condom models and has been shown to be acceptable by diverse users. Discussions
among Medtech stakeholders are currently underway to allow the product to continue
to be manufactured.
Woman’s Condom
Woman’s Condom
The Woman’s Condom, developed by PATH and manufactured by the Dahua Medical
Apparatus Company in China, received the CE mark at the end of 2010 and is newly on
the market in some places. The novel design of the Woman’s Condom was created in
consultation with women and couples from around the world to identify features that
promoted comfort and ease of use. The Woman’s Condom is a polyurethane pouch that
is partially enclosed in a capsule to aid insertion. The capsule dissolves in the vagina
which releases the pouch, and foam pads secure the condom within the vagina. This
product is not pre-lubricated; couples must apply lubricant to the inside of the condom
pouch before use. The Woman’s Condom does not have USFDA approval or WHO
clearance for bulk procurement by public sector agencies. The National Institute of
Child Health and Human Development is now conducting a contraceptive efficacy trial
that will lead to a USFDA application for market approval.197
Cupid Female Condom
The Cupid female condom, though it has similarities with the VA w.o.w., is a new design
that is manufactured in India and available there and in some European countries. It
is made of latex, comes lubricated with silicone, has an octagonal frame, is available in
natural and pink colors, and uses a sponge to secure the condom in the vagina.198 Cupid
does not have USFDA approval or WHO clearance for bulk procurement by public
sector agencies. Cupid holds the CE mark and is registered by the India Drug Authority
Control.199
Cupid Female Condom
ANNEX A
Phoenurse Female Condom
The Phoenurse female condom is produced and distributed in China. It is made of
polyurethane and comes with an insertion tool, a water-based lubricant, sanitary towel,
and disposable bag. The Phoenurse does not have USFDA or WHO clearance for bulk
procurement by public sector agencies, though it has approval from the Chinese State
Food and Drug Administration for distribution at the provincial level.200
Natural Sensation Panty Condom
The Natural Sensation Panty Condom is in limited supply globally, and evidence
suggests that it is no longer being produced. It was previously manufactured by
Phoenurse Female Condom
Natural Sensation Condoms in Bogota, Colombia, but the company does not list
the product for sale on its website. Profamilia, an International Planned Parenthood
Federation affiliate in Colombia, reports that the product left the market several years
ago.201
Panty female condoms have a distinct design from other female condoms. The
panty contains a condom sheath secured at its base, while the panty itself performs the
same function as the outer ring or frame in other female condoms. The condom sheath
unfurls and encapsulates the penis when penetration occurs. Condom sheaths must
be removed and replaced with new ones after each use. The Natural Sensation Panty
Condom does not have USFDA approval or WHO clearance for bulk procurement by
public sector agencies, though it carries the CE mark.202
Products Still in Development
Silk Parasol Female Panty Condom and Origami Female Condom
Other female condoms in development are the Silk Parasol Female Panty Condom
(U.S.), which is seeking funding to begin phase I clinical trials, and the Origami Female
Condom (U.S.), which is undergoing feasibility and acceptability studies in the United
States.203, 204
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70
ANNEX B
U.S. Female Condom Procurement for International Programs
Units Shipped
Source: RHInterchange. Brussels: Reproductive Health Supplies Coalition, 2011.
15,000,000
12,000,000
9,000,000
6,000,000
3,000,000
0
2003
2004
2005
2006
2007
2008
2009
2010
2011
U.S. Female Condom Shipments, 2003-2011
Data on U.S. international female condom shipments should be analyzed in terms of overall
trends. Shipment quantities vary from year to year because of multi-year procurement cycles.
The data above indicates a clear upward trend for U.S. international female condom shipments.
71
72
Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
U.S. Female Condom Shipments by Country, 2003-2011
Country
Angola
Benin
Bolivia
Burkina Faso
Cameroon
China
Cote d’Ivoire*
Democratic
Republic of Congo
El Salvador
Ghana
Guatemala
Haiti*
Indonesia
Kyrgyzstan
Laos
Lesotho
Liberia
Madagascar
Malawi
Mali
Myanmar
Papua New Guinea
Senegal
South Africa*
Swaziland
Tanzania*
Thailand
Togo
Trinidad & Tobago
Ukraine
Vietnam*
Zambia*
Zimbabwe
Total
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total
0
41,000
0
0
0
0
0
0
0
41,000
0
0
0
5,000
2,000
11,000
14,000
0
0
32,000
0
60,000
0
45,000
68,000
76,000
23,000
0
0
272,000
70,000
0
0
0
0
0
0
0
0
70,000
60,000
138,000
60,000
46,000
1,000
7,000
0
0
0
312,000
0
0
0
0
0
40,000
26,000
5,000
0
71,000
20,000
0
0
0
0
0
0
0
0
20,000
455,000
300,000
400,000
24,000
104,000
570,000
0
1,817,000
2,000,000
5,670,000
0
0
0
0
0
0
50,000
0
0
50,000
0
0
0
0
0
0
0
40,000
0
40,000
25,000
50,000
0
50,000
50,000
0
0
0
0
175,000
45,000
0
35,000
85,000
235,000
0
338,000
0
0
738,000
0
0
0
0
0
500,000
0
0
0
500,000
0
0
0
0
0
85,000
0
0
0
85,000
0
0
0
0
40,000
10,000
624,000
0
0
674,000
55,000
0
0
0
999,000
0
0
0
0
1,054,000
0
0
0
0
0
35,000
40,000
0
0
75,000
0
0
0
0
88,000
44,000
44,000
49,000
44,000
269,000
0
0
0
0
0
0
1,500,000
1,500,000
2,000,000
5,000,000
0
75,000
50,000
0
0
0
0
60,000
0
185,000
0
0
0
0
0
200,000
0
200,000
250,000
650,000
0
0
0
0
0
15,000
0
0
100,000
115,000
240,000
57,000
183,000
0
232,000
126,000
70,000
0
0
908,000
10,000
0
0
300,000
0
0
600,000
250,000
446,000
1,606,000
5,000
0
0
0
28,000
0
0
0
0
33,000
100,000
190,000
180,000
1,056,000
549,000
1,074,000
1,032,000
0
0
4,181,000
0
0
0
0
15,000
0
248,000
100,000
345,000
708,000
24,000
30,000
71,000
62,000
0
0
0
0
0
187,000
0
0
0
0
0
2,000
90,000
40,000
0
132,000
0
0
0
0
0
0
0
250,000
0
250,000
0
0
5,000
20,000
20,000
0
40,000
0
0
85,000
0
0
0
495,000
275,000
0
0
1,100,000
0
1,870,000
0
1,000,000
300,000
2,475,000
6,125,000
5,503,000
9,937,000
0
4,813,000
30,153,000
1,109,000
1,941,000
1,284,000
4,663,000
8,831,000
8,298,000
14,676,000
5,411,000
9,998,000
56,211,000
*Former PEPFAR Focus Country
Source: RHInterchange. Brussels: Reproductive Health Supplies Coalition, 2011.
ANNEX C
UNFPA and UNAIDS Inter-Agency Task Team 10-Step Strategic
Approach to Scale Up Comprehensive Condom Programming at the
National Level
Development Phase
STEP 1: ESTABLISH A NATIONAL CONDOM SUPPORT TEAM
Assemble a team from an existing reproductive health commodity security working
group and/or HIV prevention committee. The team should include representatives
from:
„„ Line ministries (such as health, finance, gender, education, and tourism)
„„ Institutions working in family planning and sexual and reproductive health
„„ National AIDS council
„„ Local condom ‘champions’
„„ Regulatory authorities responsible for local standards and quality assurance
„„ Donor community
„„ Civil society (including people living with HIV, young people, faith-based, and
nongovernmental organizations)
„„ Social marketing organizations
„„ Private sector and business coalitions
The purpose of the team is to provide guidance and support to government in
developing and monitoring the national CCP strategy and operational plan. The team
should have clearly designated roles and responsibilities.
STEP 2: UNDERTAKE A SITUATION ANALYSIS
Undertake a desk review of documents, reports, and research pertaining to HIV
and sexual and reproductive health to gain background information on the various
components of the CCP framework (leadership and coordination; demand, access, and
utilization; supply and commodity security; and support).
Where information from the desk review is insufficient, collect data from the field
(see the CCP Rapid Needs Assessment and Strategic Planning Tool).
Convene a stakeholders meeting to share findings from the situation analysis, build
consensus and support, and agree on a concrete roadmap for scaling up condom
programming efforts.
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
STEP 3: DEVELOP A COMPREHENSIVE AND INTEGRATED NATIONAL STRATEGY FOR MALE AND FEMALE CONDOMS
Identify responsible agencies and/or stakeholders to implement and oversee
coordinated activities in each of the following areas and, if possible, link them
programmatically. The national strategy should reflect the components of the CCP
framework:
Leadership and coordination
„„ Coordination of partnerships
„„ Advocacy
„„ Policies and regulations
„„ Resource mobilization
Demand, access, and utilization
„„ Market research
„„ Total market approach
„„ Targeted distribution
„„ IEC and behaviour change communication strategies
„„ Social mobilization
Supply and commodity security
„„ Forecasting
„„ Procurement
„„ Quality assurance
„„ Warehousing and storage
„„ Distribution to supply chains
„„ Logistics management information system
Support
„„ Advocacy
„„ Social, behavioural, and operations research
„„ Capacity and institutional strengthening
„„ Monitoring and evaluation
„„ Documentation and dissemination
ANNEX C
STEP 4: DEVELOP A MULTI-YEAR OPERATIONAL PLAN AND BUDGET
For each component of the national condom strategy, including integration with
other programmes and the steps outlined below, ensure that the operational plan
specifies:
„„ Activities
„„ Division of labour for each partner
„„ Time frame
„„ Cost
„„ Process indicators
Most importantly, ensure the buy-in of key stakeholders, including ‘gate-keepers’, by
including them in important programme decisions.
Implementation Phase
STEP 5: LINK THE MULTI-YEAR OPERATIONAL PLAN WITH THE NATIONAL COMMODITY SECURITY PLAN
Link the operational plan, where possible, to the existing logistics system for essential
drugs and reproductive health and HIV-related commodities, including systems for
forecasting, procurement, distribution, and warehousing.
If there is no reproductive health commodity security committee, the national
condom support team should advocate for the establishment of one.
STEP 6: MOBILIZE FINANCIAL RESOURCES
Based on the operational plan:
Identify available, committed, and potential resources at the local, national, regional,
and global levels in the areas of HIV prevention, treatment, care and support, and
sexual and reproductive health, to scale up CCP.
Determine funding gaps in the operational plan.
Advocate and secure funds for implementation of the operational plan.
Develop a reporting system to provide routine feedback about programme
implementation to donors.
STEP 7: STRENGTHEN HUMAN RESOURCES AND INSTITUTIONAL CAPACITY
Identify human resource capacity strengths and gaps and determine how these can
be utilized or filled.
Identify institutional capacity strengths and gaps and determine how these can be
utilized or filled.
Develop, obtain, or adapt existing training materials (such as manuals, guidelines,
and demonstration models).
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Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s Health
Train trainers, drawing from the public and private sectors, civil society, and social
marketers. Ensure standards are met and support is maintained.
Cascade training to service providers at different levels (for example, at the
provincial, district, and community level) and ensure quality of training.
STEP 8: CREATE AND SUSTAIN DEMAND FOR CONDOMS
Conduct formative research, including market research, on preferences, target
audience segmentation, and values and perceptions that influence the use of male and
female condoms.
Develop a communication strategy that includes key messages, target audiences, and
channels for stimulating and sustaining demand.
Employ creative and nontraditional outlets for promoting and distributing condoms
(such as condom dispensers, hair salons, and youth centres).
Stimulate social mobilization of communities to ensure a supportive environment for
male and female condoms.
STEP 9: STRENGTHEN ADVOCACY AND ENGAGE THE MEDIA
Initiate policy and regulatory analysis and dialogue.
„„ From the situation analysis, identify policy issues that require advocacy for
change.
„„ Hold a stakeholders meeting to review policy issues and start the dialogue
process.
Identify and strengthen condom ‘champions’.
„„ Champions may be found in government, civil society, and among
those providing reproductive health/family planning or HIV services or
implementing related programmes.
„„ Strengthen technical and advocacy skills of condom champions through
training.
Build coalitions and partnerships (through networking and engagement with civil
society and other segments of society).
„„ Identify a wide range of stakeholders interested in working to improve the
policy environment.
„„ Establish a common goal, mission statement, roles and responsibilities, and
communication process.
„„ Develop and implement the advocacy plan.
Coordinate media outreach and capacity-building.
Develop a communication strategy to engage the media.
Provide sensitization and skills-building for journalists and members of the mass
media.
ANNEX C
STEP 10: MONITOR PROGRAMME IMPLEMENTATION ROUTINELY, CONDUCT RESEARCH, AND EVALUATE
OUTCOMES
Incorporate the CCP monitoring & evaluation framework into the national M & E
framework.
Review and update operational plan indicators.
Identify research areas and conduct research to support programme
implementation.
Establish baselines.
„„ Identify milestones and intended targets.
„„ Update baseline data indicators and undertake a baseline study, as necessary.
Monitor programme implementation.
„„ Collect and analyse routine data on programme delivery among target
populations (risk groups) and the various public-health interventions in which
condom programming has been integrated.
„„ Hold regular review and planning meetings with the national condom support
team.
„„ Share feedback from the review with implementing partners.
„„ Ensure that feedback is used by implementing partners to adapt, readjust, and
improve programme implementation.
Evaluation
„„ Conduct annual, mid-term, and end-of-term evaluations.
„„ Provide feedback from evaluations to implementing partners.
„„ Evaluate overall impact of the national strategy.
Source: UNFPA. Towards a Unified Approach: UNAIDS Inter-Agency Task Team on Comprehensive
Condom Programming. New York: UNFPA, 2010.
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79
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Acknowledgments
The Center for Health and Gender Equity (CHANGE) would like to express gratitude
to all those who worked on this report and the many people who were interviewed and
provided critical information. This report was written by CHANGE staff. Kimberly Whipkey
conducted research and wrote the report; Mary Beth Hastings provided editing support. We
thank staff at the U.S. Agency for International Development (USAID) and Office of the
Global AIDS Coordinator (OGAC) who were very generous with their time and shared
information. CHANGE is grateful to the following individuals for their review of this
document: Bidia Deperthes, Sandra Mapemba, Clemens Benedikt, Bruce Campbell, Daisy
Nyamukapa, Diddie Schaaf, Patricia Coffey, Theresa Hoke, Mags Beksinska, Mark Rilling,
and Erin Balch.
About the Center For Health and Gender Equity
The Center for Health and Gender Equity (CHANGE) is a U.S.-based nongovernmental organization
whose mission is to ensure that U.S. international policies and programs promote sexual and reproductive
health within a human rights framework for women and girls worldwide. CHANGE advocates for
effective, evidence-based policies, and increased funding for critical programs. CHANGE believes that
every individual has the right to basic information, technologies, and services needed to enjoy a healthy
and safe sexual and reproductive life free from coercion and preventable illness.
About the Prevention Now! Campaign
Prevention Now! is a global campaign to increase access to existing prevention methods, especially female
and male condoms, in order to stem the spread of HIV/STIs, reduce unintended pregnancy, and improve
the sexual and reproductive health of women, men, and young people worldwide. Through education
and advocacy, the Prevention Now! Campaign seeks to ensure that governments and donor agencies
provide the funds and policy needed to dramatically increase access to female condoms. Prevention
Now! achieves its goals through network and capacity building, engagement of key decision makers and
policy makers, and media outreach in the U.S. and internationally. To join the campaign, please visit
www.preventionnow.net
Center for Health and Gender Equity (CHANGE)
1317 F Street NW, Suite 400
Washington, DC 20004 USA
tel +1 (202) 393-5930 fax +1 (202) 393-5937
Email: [email protected]
www.genderhealth.org
This report was developed and published by the Center for Health and Gender Equity (CHANGE).
Please cite as:
Center for Health and Gender Equity. Female Condoms and U.S. Foreign Assistance: An Unfinished Imperative for Women’s
Health. Washington, DC: Center for Health and Gender Equity, 2011.
© 2011 by Center for Health and Gender Equity. All rights reserved.